Chapter 5: Health Promotion - Hygiene, Sanitation, and AIDS

Chapter 5: Health Promotion - Hygiene, Sanitation, and AIDS 5.0 Introduction RWSSP is more than a water supply project. It is a health improvement project, covering water supply, hygiene, sanitation, and HIV/AIDS. Water supply alone will not improve health. Studies show, for example, that improvements in sanitation will have a bigger impact on health than water supply improvements. This chapter will look at: 1 Definitions 2 Background Situation 3 Community Strategies 4 The Role of the District 5 Schools WASH Programme 6 HIV/AIDS Promotion 5.1 Definitions 5.1.1 What is Sanitation? Sanitation is a process where people demand, develop, and sustain a hygienic and healthy environment for themselves by erecting barriers to prevent the transmission of disease. (UNICEF, 1997) It includes the development of facilities such as latrines, handwashing facilities, bath shelters, dish racks, refuse pits, water storage containers, soakaways, etc. 5.1.2 What is Hygiene? Hygiene is the practice of keeping oneself and one s surroundings clean in order to prevent illness or the spread of disease. It includes the proper use of water and sanitation facilities and practices to prevent the transmission of diseases, in our case water and sanitation related diseases. These practices include such things as using potable water (rather than contaminated sources) and keeping it clean; using latrines; washing hands at critical times, etc. 5.1.3 What is AIDS? What is HIV? AIDS (Acquired Immune Deficiency Syndrome) is a set of diseases, which are caused by a virus which affects the body s immune system, making it liable to infections and cancers to which it would normally be resistant. This virus is known as the Human Immunodeficiency Virus (HIV). 67

5.2 Background Situation 5.2.1 Sanitation There is a high coverage of household pit latrines (over 80%) but many of these latrines have been built for the wrong reasons - in response to force or fines. As a result many latrines are poorly built, maintained and used. They are unsafe to use. High water tables in some areas results in latrines filling up quickly or collapsing. Appropriate technologies for latrine improvements, including the use of sanplats and materials to line pits, are generally not known in the rural areas. Women have more demand for latrines, due to concerns about privacy and safety. Men have less problem using the bush so they have less interest in using latrines. Women often depend on men to finance latrines, dig the pits, and build the roof. There are varying levels of coverage of other sanitation facilities - washing slabs - XX%; handwashing facilities - XX%; solid waste disposal - XX% 5.2.2 Hygiene There is limited demand for hygiene - people don t see the effort involved in improving hygiene practices as important. Basic knowledge about hygiene is relatively high but practice tends to be poor. Handwashing before eating is common (81-97%) but handwashing at other critical times is relatively uncommon (after defecation - 33%; before preparing food - 17%) Children s stools are seen as harmless so people take little care in handling them. Washing hands after cleaning a child s bottom or after using the latrine are viewed as difficult because there is often not enough water available in the house. People know many of the basic messages on hygiene but lack the resources to apply them eg to buy the necessary things (eg soap) or improve their toilets. Another big obstacle to improved hygiene is women s heavy workload. Women are often so busy that they don t have the time to do things hygienically. Men s control over household resources blocks hygiene practices at home. 5.2.3 HIV/AIDS Knowledge, attitudes and practice related to HIV/AIDS is generally low. Many people don t see themselves at risk of HIV infection or recognise the seriousness of the HIV epidemic. They don t feel personally involved. They see it as somebody else s problem (eg people living in town, commercial sex workers), so they have no commitment to changing their own behaviour. Other people are aware of the risks involved but feel they are powerless to do anything. They feel they are totally dependent on government or health officials to make changes and can do nothing themselves to prevent, control, or live with AIDS. Young women are particularly at risk, due to poverty and limited control over sexual decision-making. Poverty forces some young women into commercial sex. Other factors contribute to the spread of HIV including: excessive drinking, multiple sexual partners, and customs (eg widow inheritance, polygamy, circumcision) People do not know their HIV status and are reluctant to be tested. People find it difficult to talk about AIDS, which is closely associated with immoral sexual behaviour. It is also difficult for parents to talk with children about AIDS. There is a lot of secrecy surrounding AIDS and stigma towards people with HIV/AIDS. People point fingers at others and fail to see that we are all at risk. Women in AIDS affected households have a big workload, including increased water collection (because of high diarrhoea) and increased home care for affected people

5.3 Community Level Strategies 5.3.1 Integration. Hygiene, Sanitation, and AIDS action will be promoted as an integrated package along with water supply, rather than as separate components. They will be promoted through the same process (described in the project cycle) and by the same players (Facilitation Teams, Watsan Committees, and Animators). 5.3.2 Equal Attention to Hardware and Software. RWSSP will promote both hardware - construction of water and sanitation facilities; and software - promotion of new habits and behaviours. For example, households will be encouraged to improve their latrines while at the same time improving their hygiene and AIDS related practices. The overall aim is to improve their health and quality of life. 5.3.3 Build a Demand. One of the basic aims will be to get villagers to see Hygiene, Sanitation, and AIDS action as a serious issue in their lives and something they are committed to and capable of acting on. At present they see Hygiene and Sanitation as something imposed by outsiders and not as a survival need like water. In the case of AIDS they see it as someone else s problem or something they are powerless to deal with. There is no sense of responsibility or commitment to these issues, or in the case of AIDS a sense that they can actually do something to stop HIV infection. To build commitment and a sense that they can do something will require a new approach. 5.3.4 Stop Telling. The old approach was a message delivery approach - field workers told the community what to do through talks. They talked and talked and talked and delivered lots of information, but allowed little time for discussion. Villagers were expected to listen passively, swallow the messages, and put them into practice - and their own ideas and experience were ignored. The messages were a set of rules to be blindly followed, not a set of actions which they had planned themselves. This approach failed to create real understanding and a commitment to change. People, for example, built latrines because they were told to, but did not use them nor maintain them. 5.3.5 Use Participation. The new participatory approach will adopt a new Golden Rule - STOP DOING FOR VILLAGERS WHAT THEY CAN DO FOR THEMSELVES. It will move villagers out of a passive role into an active role of discussing and analysing their health situation, deciding what needs to be done, planning the changes, taking action, and then monitoring their action. They will discuss why poor faeces disposal or certain sexual behaviours are risky to their health, how this affects their lives, and what they can do practically to minimise these risks - affordable and appropriate solutions. Since they are coming up with their own solutions, decisions, and plans based on their own understanding, they will be more committed to taking serious action. The new approach builds self-motivation for change, rather than relying on external pressure. They analyse problems, they find solutions, they decide, they plan, and they act. A participatory process encourages households to: ANALYSE their own situation and key problems DECIDE what things need to be improved PLAN how they are going to do it ACT!

5.3.6 From Awareness to Action. The old approach focussed on the delivery of messages and information, rather than behavioural change. Information and knowledge alone will not bring about change. The new approach will focus on knowing and DOING - helping communities and households find solutions which are do-able - practical, realistic, and affordable. It will not only raise awareness; it will also help people think through the practical steps in taking action, including constraints which are blocking action (eg cost of soap or latrine building materials, workload constraints, etc.) 5.3.7 Household at the Centre. Behavioural change will depend on the commitment and initiative of each household who will decide what forms of change they want to make and how they are going to do it. Each household, for example, will decide on the type of latrine they want to build or how to improve their existing latrine based on costs, willingness and ability to pay, preferences, soil types, etc. 5.3.8 Community Support for Household Action. While households will make their own decisions (eg type of latrine) they will be supported by the community. The educational process will involve peer group discussions where neighbours analyse problems and work out solutions. The discussions will produce common thinking and commitment to action and individuals will get encouragement and support from friends. 5.3.9 Empower the Community. The old approach was a provider approach, creating a dependency on external solutions and players. It was lead by the field worker who targeted Hygiene, Sanitation, and AIDS to individuals and failed to build the capacity of the community to take action. The field worker conducted the meetings and everything depended on him/her. The new approach will turn the whole process into a community controlled process where the community meet, discuss, plan, and decide together what needs to be done. The process will build ownership and responsibility on the part of the community and the self-confidence to do things on their own. 5.3.10 Watsan Committee Takes the Lead. In the past Water Committees focused primarily on water issues and had little interest in hygiene and sanitation. In the new approach the Water Committee s role has been broadened to include hygiene, sanitation, and HIV/AIDS - and it is now called the Water and Sanitation (Watsan) Committee. The challenge will be to build a strong commitment to these tasks and get Watsan to see these activities as an important part of the job (along with water supply). 5.3.11 New Roles, Skills, and Attitudes for Field Workers. The new approach will require a different role for field workers - a facilitating and capacity building role, rather than a telling role. Their job will be to train Watsan and Animators to facilitate this process themselves. Once these community leaders have developed the skills and confidence, the field workers will take a backseat, monitoring and support role. To implement this new approach, field workers will need to learn new skills and attitudes, including respect for villagers ability to solve problems, make decisions, plan, and act. 5.3.12 No Blanket Solutions: No single set of solutions will be uniformly imposed. The contexts vary widely and different solutions are needed in different areas. Blanket solutions imposed from the top will not bring about effective change. Each community and each household will choose the sanitation option they can afford and manage, given the resources available. This approach moves away from a narrowly defined sanitation with a single target and allows everyone to participate, even with limited resources. This concept is represented in the Sanitation Ladder.

The Sanitation Ladder is based on the idea of helping households to improve their sanitation on a GRADUAL, ONGOING BASIS. For example a household who have no latrine might start by building a traditional latrine. Later, when funds permit, they may improve it by adding a sanplat. At a later stage, they may build a VIP latrine - and add a handwashing facility. 5.3.13 Empower Women and Involve Men. Women have the most to gain from H&S&A action and are often more receptive to these changes than men; but women often need the cooperation of men to take action eg releasing funds to buy latrine materials and providing labour for digging and construction; or in the case of AIDS agreeing to safe sex practices. Men in the past have been left out of discussions on hygiene and reproductive health. There is a need to involve both men and women in planning and decision-making for these improvements and behavioural changes. 5.3.14 Reduce Women s Workload. Because of their heavy workload in the house and at the farm women have little time to apply hygiene practices. There is a need to promote analysis of gender roles in relation to hygiene and sanitation and advocate for changes in work division within the household as a way of improving hygiene. 5.3.15 Focus on Schools: Targeting schools at the same time as communities helps to reinforce household action. Schools provide an excellent opportunity to encourage positive behaviour change. Children can learn new habits and then set examples at home. The programme will support the development of water & sanitation facilities in schools and practical education on hygiene, sanitation, and HIV/AIDS. 5.3.16 Bye-laws and Codes of Conduct will also help to reinforce behaviour change. These rules or laws, which are introduced by community leaders and politicians, are aimed at promoting exemplary behaviour and stopping worst practices. 5.3.17 Community based monitoring can also help to motivate large-scale change. The community keeps a record of those households who have, for example, built latrines. This public record motivates others to follow this example. Most water and sanitation related diseases can be prevented by improving the following behaviours: Sanitary disposal of faeces Handwashing after defecation and before touching food Keeping drinking water free from faecal contamination

Participatory Tools Community Mapping: Participants use whatever materials are available to create a map of their community showing its water sources and sanitation facilities. This helps people visualise their overall situation. This can be done on the ground with a stick or written on a large sheet of paper. Participants then use the map to discuss water, sanitation, and health problems facing the community. Water and Health Walk (Guided or Transect Walk): Participants (eg members of a Watsan Committee) walk through the village observing water sources, sanitation facilities, and health practices and problems, and discuss them as they walk. For example they may visit the water point, observe how water is being collected and talk to women. The walk makes things real and practical. Three Pile Sorting: Participants sort pictures of hygiene or sanitation behaviours according to whether they are considered good, bad, or in-between. Then participants discuss 2-3 good behaviours they want to promote; and 2-3 bad behaviours they want to discourage. Transmission Routes and Blocking The Routes: These are two linked tools. Transmission Routes is a set of pictures showing different ways in which faecal-oral contamination can occur. Participants arrange the pictures to show how they see faecal matter is spread. Blocking The Routes shows how to stop this oral faecal contamination. Participants select pictures of barriers (eg latrines, handwashing, etc) and place them on the original diagram to show how to stop the spread of faecal matter. Participants then discuss each of the barriers and how they can practice them in their own lives. Sanitation Ladder: This technique uses a set of pictures showing different sanitation options. Participants arrange them on a scale from worst to best, like steps on a ladder. They identify their own situation and look at advantages of moving up the ladder and the feasibility of different choices. This tool helps households choose the type of latrine which suits their income level. Gender Task Analysis: In this activity participants sort a set of pictures which depict household and community tasks on the basis of who would normally perform them - a man, a woman, or a man and a woman jointly. People assess the way tasks are distributed by gender. The exercise helps men recognise the heavy workload faced by women and to renegotiate the division of labour. Story with a Gap: This activity uses two pictures - one showing a before scene (a problem situation) and one showing an after scene (improved situation or solution). The pictures stimulate discussion on the steps to move from the before to the after situation. In this way they fill the gap in the story. This helps to simplify the planning process by breaking it down into a series of steps.

5.4 The Role and Tasks of the District While direct action will take place at the community level, the District Council will play an important planning, coordinating, and backup support role, including: H&S&A planning - incorporated into the District Water & Sanitation Plan Training facilitators and monitoring and supporting their work in the field Advocacy and building commitment by politicians and officials Development of supportive policies and bye-laws Technical backup for the construction of latrines Contracting the private sector and NGOs The strategies and activities to be applied at the district level include the following: 5.4.1 Data Collection and Planning: DWST will collect baseline information on H&S&A, and use this to develop a district water/sanitation/hygiene/aids plan. The plan should include an assessment of the targets for change, the major obstacles to H&S&A improvement, and strategies and resources to overcome them. 5.4.2 Advocacy and Creating Demand: The plan needs to be more than a paper plan. It needs to be owned by all the major stakeholders at the district level, including Councillors, ward and village leaders, religious leaders, and NGOs. So there is a need for advocacy workshops and joint planning at the district level, using the same participatory process and tools. 5.4.3 H&S&A Policies and Byelaws. In addition to the plan, the district needs to show its commitment in other ways. The Council could, for example, put its own funds/budget into H&S&A action; and develop relevant policies and bye-laws. For example Council should not approve a new school until it has sufficient latrines. 5.4.4 Doing It! District leaders will be encouraged to promote H&S&A action. They can talk about these issues in their speeches and model the new behaviours, showing their leadership by example. All politicians and officials should have sanitary latrines, demonstrate hygienic practices, and serve as role models in AIDS related behaviour. 5.4.5 Train Field Workers in Participatory Approaches. Field workers will need to learn the new skills and attitudes for facilitating participatory discussion and planning and the use of PHAST tools. The DWST will be trained first in these approaches. Once they have learned these methods, they will organise the training of field workers. 5.4.6 Supervise and Support. After being trained field workers need to be supported and supervised through visits and debriefing meetings. 5.4.7 Establish Monitoring Systems. There is a need for monitoring at all levels, including the community level. People will define indicators to show improvements, collect data on a regular basis, and use the information to make improvements. 5.4.8 Involve Private Sector. DWST will contract work out to the private sector and NGOs eg facilitation, latrine construction, sanplat making. Where possible districts should select local contractors, as they will be more responsible to the community.

5.5 Schools WASH Programme 5.5.1 Programme Aim. The aim of the school WASH programme will be to promote good hygiene and sanitation practices in school and AIDS prevention practices with the aim of improving the health of students and their families. 5.5.2 Schoolchildren as Agents of Change. Children can be powerful change agents within their homes through their knowledge and use of H&S&A practices learned at school. They can help to promote and support hygiene action at home. 5.5.3 New Facilities Planned, Constructed and Managed by Schools. RWSSP will support the development of water facilities and latrines in schools on a demand driven basis. The School Committee will apply for these facilities, making a commitment to manage them and organise a hygiene and AIDS programme. The community will contribute finances and labour for the construction of these facilities. 5.5.4 Orienting the Leaders. The District Education Officer, who is a member of DWST, will coordinate the schools programme. As a starting point s/he will organise: Orientation and advocacy workshops for stakeholders, including: Ward Education Coordinator, headteachers, teachers, School Committees, Watsans Training workshops for headteachers and teachers on hygiene, sanitation, and HIV/AIDS and PHAST and Child-to-Child methods All stakeholders will be encouraged to be role models, practising what they preach. 5.5.5 School Promotion. At the school hygiene, sanitation, and AIDS action will be integrated into all school activities, both in the class and extra-curricula activities: Students will learn about hygiene, sanitation, and AIDS prevention not only as examinable, school subjects but also as practical habits for daily living. Students will learn new habits (eg washing hands after using the latrine) and be encouraged to demonstrate and promote these new habits at home. Students will be encouraged to clean and maintain the water & sanitation facilities. School health clubs will promote hygiene habits and safe sex practices and take on practical activities eg making simple handwashing facilities and mosquito traps and organising community health surveys. 5.5.6 School-Community Link. The school programme will be closely linked to the community water and sanitation programme: The School Committee will work closely with the Watsan Committee in planning and developing the new W&S facilities. The plan for new school facilities will be incorporated into the community FMP. The school health club might be asked to conduct a health survey as part of the planning process; or help with the building of household latrines.

5.6 HIV/AIDS Promotion HIV/AIDS is a new component within the water sector. Its promotion will use similar approaches to those used for Hygiene and Sanitation, but it will also need its own strategy, which is described below: 5.6.1 Prevention and Care. While the main focus will be to promote HIV prevention, the programme will also work in support of the MOH s home based care programme. For example the Watsan Committee and Animators will promote support for AIDS affected households, including exemptions on water fees (where appropriate). 5.6.2 Start with Leadership Training. The programme will start by training Watsan and Animators on how to facilitate AIDS awareness, planning, and action. 5.6.3 Collect Data and Develop a Plan. After being trained, one of the first steps will be to collect data on community high risk practices related to the spread of HIV, community perceptions on AIDS, and services available (eg condoms, counselling, testing). Based on this data the Watsan Committee and community will develop a plan for HIV/AIDS education and action, which will be incorporated into the FMP. 5.6.4 Organise Participatory Meetings. The Watsan Committee and Animators will organise a series of community and peer group meetings (women, men, and youth) using participatory methods and tools to: Build awareness that AIDS exists and people are at risk of getting it Build commitment to do something about it Personalise the risk of HIV infection and share information on modes of transmission and ways people can protect themselves Analyse barriers to AIDS prevention (eg lack of access to condoms) and factors which promote HIV transmission eg drinking, migrant labour, unemployment forcing young women into commercial sex, cultural practices (eg widow inheritance). Decide on what can be done individually and collectively to minimise risks. Analyse the needs of AIDS affected households (eg effect on production and household workload) and advocate against exclusion or isolation Decide on what can be done to support AIDS affected households eg giving exemptions from water tariffs (where they are unable to pay) Implement the plan and organise monitoring and followup support 5.6.5 Advocate New Ideas. Watsan and community leaders will promote: Recognition that AIDS exists and everyone are at risk Empowerment - a feeling that people are not powerless, that people can do something to reduce the risk of HIV/AIDS Collective action and mutual support - a commitment to work together to support each other and support AIDS affected households. Openness to talking about sex and HIV/AIDS Stamp Out Stigma (SOS) - break the exclusion, isolation, and stigmatisation practised against AIDS affected households. 5.6.6 Schools Programme. AIDS awareness will be included in schools program so that young people have the knowledge and confidence to practice safe sex.