Hygiene Promotion Strategy

Hygiene Promotion Strategy (draft)Cholera Response Haiti

December 2010

Hygiene Promotion sub-Cluster

Table of contents

1. Introduction

2. Goal and objectives3. Hygiene Promotion sub-Cluster priority areas

4. Hygiene promotion methods and approaches

4.1 Priority hygiene areas for cholera response4.2 Hygiene promotion in earthquake affected areas4.3 Hygiene promotion in non-earthquake affected areas

4.4 Stigmatisation of cholera affected persons4.5 Training of community mobilisers4.6 Communication channels for promoting hygiene

5. Enabling factors for HP6. Monitoring7. CoordinationAnnexesAnnex 1: Table of HP activities

Annex 2: Goal, objective, effects and outputs and indicators

Annex 3: Terminologies and definitions Annex 4: Essential skills and knowledge required by facilitators Annex 5: HP contexts and proposed channels of communication Annex 6: Responsibilities and accountabilities matrixAnnex 7: Glossary of terms

Gaps identified during monitoring and assessment activities have necessitated a review of the hygiene promotion (hereafter HP) strategy developed in November. The revision seeks to improve coordination among HP partners by providing a guiding framework and standards for HP approaches and methods in earthquake and non-earthquake affected areas. The strategy also sets forth principles for enhancing coordination with both WASH and non-WASH stakeholders.

The goal of cholera response HP activities is to reduce mortality, transmission and impact of the cholera epidemic. The specific objective is to ensure children, women and men are aware of the cholera health risks and are mobilised and enabled to take action, to prevent or mitigate outbreak risks by adhering to safe hygiene practices. A table outlining the goal, objective, effects, outputs and indicators is attached as Annex 2.

Non-earthquake affected areas should be prioritised as there is limited or no WASH actor presence or programmes (exception is Artibonite). The North East, Grande Anse, Nippe and Sud Departments should be prioritised for all HP and mobilisation activities. Earthquake affected areas generally have WASH or other actor presence. In addition to non-earthquake affected areas, HP activities should also prioritise earthquake affected areas where there has been no WASH or other actor present. The following indicators should guide HP interventions: Areas with reported and confirmed cases or neighbouring areas with reported cholera cases. Areas with that rely on surface water or water from shallow unprotected wells. Low lying areas (eg along rivers) that are subject to flooding, and with low water and sanitation coverage

High population density areas with low water and sanitation coverage and poor hygiene (eg. slums, IDP camps, markets, bus stations) Areas that are difficult to access due to geophysical conditions, having limited access to mass media and are far from existing treatment centres/units and ORS posts Hygiene promotion principles 1. In view of conflicting definitions of the various activities being carried out across different Clusters, a definition of hygiene promotion and underlying principles is presented for clarity.2. Hygiene promotion refers to a range of approaches that systematically seek to stimulate and facilitate people to practice water and sanitation - related hygiene behaviours, by building on what people know, do and want.

3. HP provides a practical way to facilitate community participation and accountability in emergencies. It starts with systematic data collection to find out and understand what different groups of people know about hygiene, what they do, what they want and why this is so.4. Understanding what people know, do and what physical, social, cultural or economic constraints influence their behaviour requires competency in participatory methodologies eg. transect walks, history line, focus group discussions. HP facilitators should be trained in participatory methodologies.5. Information obtained is used to set objectives and to identify and implement activities that enable the different groups to measurably reduce risky conditions and practices and to strengthen positive situations and behaviours.6. Unlike educational methods, which seek to impart knowledge, the focus of promotion is to change behaviour while taking into account that people are not empty vessels.

1. Priority (prevention) activities will focus on treating and reducing contamination of drinking water at household level, handwashing at critical moments and safe excreta and vomit disposal. The HP sub-Cluster will support Health case management activities through demonstrations on preparation and administration of ORS at household level, as well as encourage sick persons to present themselves at health facilities.2. Hygiene promotion might need to focus on different aspects of the priority activities, depending on context, identified transmission routes, key risk behaviours and misconceptions (eg. where people have access to treated water, emphasis on safe storage and handling, not on treatment. Or people wash hands after defecation before eating but not after contact with excreta or vomit of sick persons).3. However, only a few risk practices should be targeted for effectiveness whatever the situation. The priority messages for the HP sub-Custer are given below based on the assumption that all Departments are now affected by cholera:PreventionManagement and Referral

Areas affected by cholera1. Only use water that is treated. Water containers need to be kept covered to keep the water clean. Drawing water from the container in an unhygienic way can contaminate the water.2. All family members, including children, need to wash their hands thoroughly with soap and water after contact with faeces, after contact with faeces or vomit of sick persons, before touching food, and before feeding children.

3. All excreta, and especially excreta and vomit of sick persons should be disposed of safely.

1. Taking ORS at the first sign of diarrhoea greatly reduces dehydration and saves life.

2. Go to the nearest health facility at the first sign of diarrhoea even after taking ORS

Camps Promotion of aforementioned cholera response messages has been ongoing since May. The HP sub-Cluster Rainy Season Plan focused on these messages in anticipation of diarrheal disease outbreak during the rainy season (June-August). Activities should focus on reinforcing messages and ensuring maintenance and use of available latrines. Safe excreta management in camps is a priority as not all camps had achieved minimum latrine coverage during the earthquake response. Close collaboration is needed with the Sanitation sub-Cluster to ensure safe excreta disposal for the duration of the epidemic. Agencies working in camps should especially ensure handwashing facilities are provided in all camps according to the standards defined for the earthquake response. Regular distribution of key hygiene supplies, especially to the vulnerable should continue, while ensuring the minimum standard of 1:500 community mobilisers is achieved. There should be close collaboration with CCCM/IOM to ensure coverage of camps with no WASH actors. Health campaigns and distribution of key supplies should be carried out initially (Phase I), while identifying and recruiting community mobilisers for HP training. Markets

In metropolitan Port au Prince, HP activities will be carried out in collaboration with the solid waste group focal point (public works ministry), under whose docket markets fall under. Public works shall identify key HP focal points for each market that will be trained through HP sub-Cluster support. These focal points will work in close collaboration with promoters from agencies carrying out HP activities in markets. The HP sub-Cluster will work closely with the Sanitation sub-Cluster to ensure provision of basic enabling services in markets, especially where markets can be connected to the Camep distribution network for water supply to enable hygienic practices. Basic WASH services will consist of bucket chlorination, and provision of handwashing facilities where possible. The HP sub-Cluster will advocate for HP/WASH actors to adopt markets located in their areas of activity to ensure widespread HP coverage of a key transmission route. The Public Works focal person will avail a list (or map) of markets and their location in the Port au Prince metropolitan area for this purpose.Neighbourhoods (around camps) Strategic approaches are needed for HP in neighbourhoods given the limited (human) resources within agencies. Well planned mass media and information campaigns targeting specific audiences should be a key communication option. These should be supported by interpersonal communication using community mobilisers from surrounding camps. Agencies are encouraged to dedicate some of their camp-based resources to target the communities around the camps where they are working. A minimum of 1 day a week should be dedicated to neighbourhood HP activities. The radius should be determined based on available resources, including community mobilisers and hygiene promoters. Identification of vulnerable groups where household visits should be carried is essential. Planning should be done to ensure home visits to vulnerable groups are accompanied with distribution of basic supplies to support adherence to key hygiene practices. Existing neighbourhood committees should be identified and targeted including providing basic orientation/training on HP to assist in mobilising neighbourhood communities.

Schools

Schools are an important medium for change through children. Support to schools should be ensured through hygiene promotion sessions with teachers and pupils, distribution of key hygiene supplies (aquatabs, soap) and provision of water supply. Distribution of child-friendly posters/brochures, painting hygiene messages on walls, drama and song are methods that can be used to effectively reach children. WASH in schools activities should be coordinated with the Education Cluster. Rural

This includes areas bordering and outside the Port au Prince metropolitan zone, sometimes mountainous in characteristic. These are characterised by little or no WASH actor presence. In addition to strategic mass campaigns, partnership with local actors and existing community networks will be indispensable to effective hygiene promotion. CAZECz, AZECs and other local authorities will have information on existing community organisations in their areas of jurisdiction.

With the exception of Artibonite, the number of operational WASH actors is still very low with some areas having no WASH actors almost 3 months after the cholera outbreak. Building local capacity (NGOs, local authorities, community associations and volunteer networks) for hygiene promotion, through training, should be a key strategy for HP activities in non-earthquake affected areas. Public places, such as markets and bus stops, and schools should be primary targets for HP in non-earthquake affected areas. Sensitisation through mass media will be significant in the initial phase of the response, in areas with no WASH or other actors. However, interactive community mobilisation for behaviour change should be undertaken as early as possible if HP objectives are to be achieved. Volunteer networks are crucial in the initial phase as there will be little time to recruit and train dedicated HP facilitators. These can be identified through local authorities, churches, community health workers, local NGOs and national societies (Haitian Red Cross). However, community mobilisers should be identified and trained as soon as possible. Involving community organisations and local partners in sensitisation activities will increase compliance and coverage in areas with no WASH or other actors. Assistance should be sought from local authorities and partners in mapping existing community networks. Collaboration with the Health and Agriculture Clusters will also help in identifying and engaging community networks and sub-national officers for sensitisation activities, especially in rural areas. Agencies having both WASH and health (or other sector) programmes in these areas should coordinate internally to effectively use existing programmes and networks for HP activities. Joint planning meetings at sub-national level will help determine the best approaches for non earthquake affected areas.

In view of the stigma currently associated with cholera, establishment of cholera support groups to provide community support structures to sick persons and their families is recommended. These groups would be composed of 2 or 3 neighbours. They would have basic orientation on cholera prevention measures, early basic treatment (ORS) and referral measures. Their role could be to assist sick neighbours get to hospital and provide moral support to affected families. They could also serve as focal points for prepositioning of ORS in communities without access to ORPs. Having a contact list of numbers of motos or tap-tap drivers that could transport sick persons to hospital and nearest CTCs/CTUs is an example of practical support these groups could provide. They could be part of the trained community outreach workers. Information campaigns should be launched to address misconceptions in relation to cholera. A technical working group (TWG) on Cholera Stigma has been formed, enjoining HP and Health partners that include psycho-social actors. The TWG will produce a guiding paper on the subject that will include approaches and messages to deal with it.

Effective HP will require well-trained and supported hygiene promoters and community mobilisers. Community participation approaches rely on well trained and confident workers, to encourage and facilitate behaviour change through action planning and follow-up. A total of 18,000 community mobilisers and hygiene promoters are needed in order to achieve nationwide coverage based on the 1:500 minimum Sphere standards (or 1:300 where households are far apart). There are currently about 5,000 community mobilisers and hygiene promoters working in the earthquake affected areas. An additional 13,000 are needed to ensure coverage of all cholera affected populations. Training in basic promotion techniques and key (cholera) preventives messages approved by MSPP can be provided initially. Other topics for good facilitation skills can be added gradually in follow-up trainings. Additional/refresher trainings are recommended beyond the initial phase of the response and should be factored in agency plans. Essential skills and knowledge required by facilitators are presented in Annex 4. Recruitment and training of community mobilisers and hygiene promoters should target priority areas first and ensure all Departments/Communes/Sections Communales are covered. Initially mapping of existing community mobilisers per commune should be carried out to determine gaps and identify potential mobilisers to train. As it will not be possible to achieve total coverage immediately, realistic targets should be set for the different phases of the response. Coordination of the various trainings planned by the WASH and Health Clusters is crucial to avoid duplications, ensure priority areas are targeted first and the entire country is covered by joint efforts. A meeting between WASH and Health donors/agencies supporting the trainings is recommended. A common cholera-specific training curriculum including tools and manuals should be agreed on, in order to promote common standards and approaches between actors in cholera preparedness and response. A review of training curricula being developed, as well as relevant pre-existing trainings (eg Global WASH Cluster HP training, MSPP/WHO training, UNICEF (ESARO) Cholera/AWD EP & R training) is necessary. The review will help to identify what is most appropriate for Haiti, including a possible mix of available trainings. Joint trainings within the HP sub-Cluster, and with Health partners are encouraged to enhance coherence in approaches and standards. Remuneration of community mobilisers will require discussion and agreement given the different approaches currently employed by actors. A joint Health and WASH working group should be constituted to identify the best approach on the issue.

Communication is at the heart of making people aware of right hygienic practices and the benefits of investing in them. Identifying target audiences for the messages will be crucial in determining the best channels to use. Target audiences are either primary (those carrying out risk practices), secondary (those supporting or hindering primary audience behaviour) or tertiary (decision makers, leaders and people whose support is needed for the success of HP porgrammes). Channels of communication can be divided into three types: One- to- one eg. household visits Group eg. meetings, video and film presentations, hygiene campaigns, community events, drama and theatre, focus group discussions Mass eg. radio broadcasts, TV, posters, billboards, public address systems such as meagaphones Finding out how target audiences communicate is important in defining a good communication plan. For example, if targeted women are housewives with little contact with channels of communication outside their homes, then household visits will be required. Radio might be a popular means of communication but if men carry the radios with them, then targeting men not women - through radio might be better. A mix of channels that balance maximum reach and effectiveness with minimum cost should be selected. Mass communication, such as radio, reaches more people cheaply, but has lower capacity to affect behaviour because there is less opportunity for dialogue. One-to-one communication is highly effective in getting a message across but is time consuming and requires many promoters. An intermediate solution would be to address groups of target audiences at meetings, special events or video showings. Additionally, literacy levels of targeted audiences will affect the choice of channels used. A good communication plan is needed to ensure that whatever channels are identified should give the same messages, reinforcing one another. A summary of the different HP contexts and proposed channels of communication is attached as Annex 5.Table 1: Sample target audiences and how they could be targetedTarget AudienceWhoWhereChannels of CommunicationObjective

Primary Poor mothers, children, care givers Home, markets, fields, churches, schools Weddings, home visits, street theatre, school lessons, video, women meetings

Change hygiene practices

Secondary Fathers, mother-in-law, teachers, neighbours, etc Neighbourhood, work places, meeting places, bars, churches, sports Radio, TV, meetings, newspapers, leaflets, video projections, special events Support the changes in hygiene practices

Tertiary Religious, community and political leaders Offices, churches, temples, capital Radio, TV, leaflets, seminars, print media, ceremonies, meetings Support the hygiene promotion programme

An important hygiene promotion principle in communication is not to overload targeted audience with too much information at one time and to focus on a few practices at a time. A maximum of 3 is best. Prioritisation of messages should be guided by specific context and situation needs. An inter-Cluster communication working group should define a common communication plan for a standardised approach across Clusters. The group should also review existing communication material for appropriateness and propose common materials for use by all actors. Printed materials such as brochures, pamphlets and posters should be designed bearing in mind that about 60% of the urban population and 63% of the rural cannot read or write easily. All materials must be validated by MSPP before use for any hygiene promotion activities.

4.6.1Communication materials for HP activities

All materials for HP activities must be approved and validated by MSPP. No materials should be used for HP activities if they have not been approved by MSPP. An updated list of all validated materials will be made available to HP sub-Cluster members. Materials for HP requiring validation include:

Training manuals for hygiene promoters and community mobilisers

Tools and aids for promoters and facilitators eg. Boites a images, posters

Mass communication materials eg. posters, fliers, leaflets, videos,

HP activities need to be supported by provision of WASH services to enable effective behaviour change. Provision of WASH services (including infrastructure) has been ongoing in earthquake-affected areas since January, mainly in camps. Activities outside camps have been limited to rehabilitation of community wells and construction of family latrines in a few areas outside the Port au Prince metropolitan. Agencies working in earthquake-affected areas should ensure that WASH services meet agreed minimum standards. Joint planning with the sanitation sub-Cluster is necessary to identify feasible, impact-evidence actions to improve access to WASH services in non-earthquake affected areas. Examples are water supply to schools, bucket chlorination and handwashing facilities (with soap) at markets. These should be linked with longer-term initiatives such as the community led total sanitation initiative currently being piloted in the West, North East and South West Departments. Systematic distribution of key hygiene supplies to affected populations should be carried out in the first phase of the emergency. Distribution in IDP camps should continue throughout all phases of the emergency. The most vulnerable groups should be identified and also targeted for regular distribution in all affected Departments. Key supplies should meet Sphere minimum standards and include the following:

Soap Aquatabs, Gadyen Dlo or other locally appropriate chlorination product Cholorox, jif for disinfection Storage containers for household water treatment and storage. Containers should have narrow necks and caps or have lids and taps from which to draw water ORS (HP sub-Cluster advocates only for prepositioning of ORS with community focal points in areas with no access to ORPs) Distribution of hygiene supplies needs to be accompanied by sensitisation activities on proper use of items and mobilisation of hygiene promoters to accompany distributions needs strategic planning. Joint planning meetings with all actors to coordinate distributions at sub-national are indispensable to success of distribution activities in non earthquake affected areas. All planned agency distributions should be coordinated with ongoing DINEPA distributions to avoid duplications. DINEPA has a distribution coordinator for every Department and agency plans should be communicated to the coordinators. Existing non-WASH programmes, local authorities and community networks should be targeted to support distribution activities in areas with no WASH actors. Best practices and lessons learned will need to be captured in order to determine the most effective way to reach targeted populations.

Monitoring will be carried out at two levels: i) Progress monitoring to measure achievement of targets set for different phases and ii) Impact monitoring to evaluate behaviour change as a result of interventions. Monitoring and evaluation of hygiene behaviour change will focus on a limited set of indicators.

In order to enhance coordination of HP activities, the following principles are proposed: Standardized approaches in response delivery for the following areas: training of hygiene promoters and community mobilisers. Joint trainings are encouraged; Information, communication and education (IEC) materials, including training manuals and facilitator tools; Establishment of a clear sharing of roles and responsibilities between the WASH/HP sub-Cluster and Health Cluster, in order to improve inter-cluster collaboration and coordination Identify and maximise opportunities for synergies between all actors through joint planning at Department/Commune level, particularly at sub-national hubs. Joint planning should ensure clear definition of partner activity zones for HP to avoid overlaps. The Municipal Coordination Mechanism (Port au Prince) WASH activity zoning principle should be applied, especially in non earthquake affected areas. The principle involves demarcation of activity zones for agencies and nomination of a focal agency for each Commune. Work in coordination and support of government authorities at all levels using existing systems to implement response where possible. Definition of priority focus areas for HP in non earthquake affected areas should be determined at sub-national hubs. Sub-national level hygiene promotion working groups exist in a few Communes. Where these already exist, they will identify priority focus areas for HP activities, ensure joint planning with other key actors, map existing community mobilisers and identify needs/gaps in capacity and resources for their respective areas. The groups should ensure coordination with other forums in their respective areas, as well as with the national level HP sub-Cluster. Focal HP points will be appointed for priority Departments/Communes to ensure feedback of achievements, needs and gaps to the national level HP sub-Cluster.Annexes 1: Table of HP activities

ActivityGeographical areaWhereWhoPhase

Non-WASH partner involvement

123

Assessment and monitoring

Rapid assessment to identify risk practices and get an initial idea of what people know, do and understand about WASH and cholera WASH Priority areas/hot spotsCommunity, marketNGOsHealth

Baseline surveys/pre- intervention KAP surveysAll affected Departments, beginning with hot spotsCamps, communities, marketsNGOs, CDAC, CDCCDAC

Progress monitoring of achievement of set targets All affected Departments/WASH priority areasCamps, communities, markets, schoolsNGOs, DINEPA, community outreach workers, community

Impact monitoring (Post KAP surveys)All affected Departments/WASH priority areasCamps, communities, markets, schoolsCDC, CDAC, NGOs, community outreach workers, community

Planning

Identify capacities, needs and gaps, and development of joint HP response plansWASH priority areasSub-national hubsSub-national WASH Clusters/Hygiene promotion working groups, local authoritiesHealth,

Identify viable, high impact, low cost WASH services for implementation, to enable hygienic behaviour WASH priority areas/hotspotsMarkets, communities, public places, schoolsHP sub-Cluster and Sanitation sub-ClusterEducation

Map existing community mobilisers and community organisations/networks to identify trainees for hygiene promotionAll affected DepartmentsCommune levelHP sub-Cluster coordinator, sub-national WASH Cluster coordinators, local authoritiesHealth

Identify and review of existing IEC materials for appropriatenessHP sub-Cluster MSPP/CDAC

Identify market focal points for HP trainingPAP metropolitanmarketsPublic Works ministry focal point

Implementation

Training of hygiene promoters and community mobilisersWASH priority areas/hotspotsCommunity, NGOsNGOs, Donor agencies and facilitative agencies (USAID, WHO, UNICEF)Health

Training of market focal pointsPAP metropolitan and eventually all affected CommunesmarketsHP sub-ClusterPublic Works

Development of training materials and facilitator aidsNGOs, MSPP (CDAC/MSPP for validation of materials)Health

Provision of basic WASH servicesWASH priority areas/hotspotsMarkets, schools, public placesNGOs, Sanitation sub-Cluster, Public Works ministryEducation

Distribution of basic hygiene supplies (distribution to most vulnerable groups in all affected Departments)WASH priority areas/hotspotsHouseholds (camps, community), markets, schoolsNGOs, DINEPAHealth, Education

Prepositioning of ORS with community focal pointsWASH priority areas/hotspotsCamps, community, schoolsNGOsHealth, Education

Hygiene promotion campaign

Define target audience and priority focus (eg primary care givers)All affected Departments/CommunesCommunity, camps, markets, public places (eg bus stops)HP sub-Cluster CDAC

Audiovisual mass media campaign (radio spots, TV, video/film)All affected DepartmentsCamps, community, NGOsCDAC

Traditional media (dances, drama and theatre, song)All affected DepartmentsCamps, community, schoolsNGOs, community outreach workersEducation

Public broadcasts (megaphones)All affected DepartmentsPublic places, markets campsNGOs

Print media (posters, pamphlets, cholera/publications, bill boards) with simple, few messages and emphasis on graphic illustrationsAll affected DepartmentsSchools, public places, camps, communityNGOsHealth, CDAC, Education

One-to One (face-to-face) and group (focus group) communication with distribution of simple pamphlets with graphic illustrations on use of key hygiene suppliesWASH priority/ hotspotsHousehold level (camp, community), community and camp meetings, markets, teachersNGOs, community outreach workersHealth, Education

Setting up of community cholera support groupsAll affected Departments beginning with WASH priority areasCommunity, campNGOs, community outreach workersHealth

Printing of IEC materials for HP activitiesNGOs

Coordination

Organise and facilitate HP coordination meetings (Joint meetings with Health and other sub-national forums where there are no HP working groups)All affected DepartmentsNational and sub-national hubsHP sub-Cluster coordinator, sub-national HP working groupsHealth

Produce who, what where thematic maps on HP activities All affected DepartmentsWASH Cluster IM

Agency reports on HP activities (using agreed format)All affected DepartmentsNGOs

Annex 2: Goals, objectives, outputs, indicatorsOVERALL OBJECTIVE/GOAL

Reduce mortality, transmission and impact of the cholera epidemic

SPECIFIC OBJECTIVE

Children, women and men are aware of the cholera health risks and are mobilised and enabled to take action to prevent or mitigate outbreak risks by adhering to safe hygiene practices.

Outcomes Increased hygiene awareness and adaptation at household and community levels Increased community participation and representation

Indicators (impact) 70 % of men, women and children washing their hands correctly after contact with faeces/vomit and before handling food Adequate water handling practices to treat and minimise contamination practised by at least 70% of households At least 70% of households in camps and communities safely dispose of faeces and vomit Majority of community members, including the most vulnerable, have been consulted and are satisfied with HP interventions

Outputs

Competent and functioning hygiene promotion teams at NGO and community level Better informed and organised communities

Improved access to safe drinking water People enabled to practise the target hygiene behaviours

Indicators

% of households with at least one or more persons who have participated in consistent, participatory HP sessions % of every household having at least one person who knows 3 key ways to prevent cholera and what to do in case of symptoms % of communities with cholera support groups

Basic hygiene supplies are available at 70% of households, schools and camps

Activity target indicators

Activity targets Phase 1

Activity Targets Phase 2

Activity Targets Phase 3

Training of 3,000 mobilisers (ratio: 1,125) 80% of HH reached through mass media

40% of population in WASH priority areas reached through one to one and group communication

70% of households in affected areas have received basic hygiene supplies (vulnerable populations, cholera patient families) Training of 5,000 mobilisers (ratio 1:700) 100% of HH reached through mass media

60% community reached through one to one and group communication

80% of households in affected areas have received basic hygiene supplies (vulnerable populations, cholera patient families) Training of 5,000 mobilisers (ratio: 1:500) 100% of HH reached through mass media

70% community reached through one to one and group communication

100% of households in affected areas have received basic hygiene supplies (vulnerable populations, cholera patient families)

While a cascade outreach system is currently being favoured, carefully planning is needed for several reasons:

Level of education of targeted mobilisers 60% of the population cannot read or write easily. Training courses and approaches must take this into account and will require skills in participatory methodologies

Training in use of participatory methodologies requires skilled trainers

The cascading approach results in the dilution of training effectiveness. Every time a trainee becomes a trainer some of the information is lost. Ensuring quality of training being passed on from trainer to trainer will require monitoring and support of mobilisers by hygiene professionals

Ensuring trained mobilisers are committed, have time to devote to activities and actually use their training.

Complexities of ensuring effectiveness of this approach means training of many people might not be possible as huge resources will be required to monitor for effectiveness.

The difference between health campaigns and hygiene promotion is:

health campaigns are top-down communication and educational activities that mainly address the link between good hygiene and better health

Hygiene promotion is a bottom-up approach based on evidence that providing information on health (knowledge) alone is not sufficient to change peoples practices. Privacy, convenience, dignity, security, disgust, peer pressure and livelihoods are key motivational factors for behaviour change

Hygiene/health education may be part of this methodology; however, hygiene promotion includes additional elements

Hygiene promotion builds upon the knowledge, behaviour and beliefs that people already have

Emphasis of hygiene promotion is on enabling people to take ACTION to mitigate health risks (by adhering to safe hygiene practices) rather than simply raising awareness about the causes of ill health

Hygiene Promotion also involves ensuring that optimal use is made of the water, sanitation and hygiene enabling facilities that are provided

Additional information on the principles of hygiene promotion, as well as differences between HP and hygiene/health education is provided in Annex 3.

Linking messages with livelihoods is recommended as people often do not see health benefits as the primary reason for improving their hygiene. Cholera is a livelihoods issue in Haiti and this should be capitalized on for effective behaviour change. Example, a message to market vendors could be women will lose their livelihoods if they dont stay safe by drinking treated water. If theyre sick and stay home, they cannot go to the market to sell!

5. Enabling factors for HP

4.6 Communication channels for promoting hygiene

4.5Training of community mobilisers

4.4 Stigmatisation of cholera affected persons

4.3Hygiene promotion in non-earthquake affected areas

4.2Hygiene promotion in earthquake affected areas

4.1Priority hygiene areas for cholera response

1. Introduction

4. HP methods and approaches

2. Goal and objectives of HP activities

3. HP sub-Cluster priority areas

6.Monitoring

7.Coordination