Hygiene Promotion Campaigning in Urban Settings

Systematic and participative planning approaches are needed to implement effective hygiene promotion campaigns for refugees and Internally Displaced People (IDPs) and their host communities (THE SPHERE PROJECT 2011, UNHCR 2015a). They promote positive behavioural change around household, food and personal hygiene and can facilitate meeting the Sphere Project Minimum Standards (UNHCR 2015a, THE SPHERE PROJECT 2011, GWC 2009). Careful planning, execution, monitoring and evaluation of hygiene promotion campaigns ensures that the affected populations have the knowledge, resources, willingness and practice to prevent WASH-related disease transmission of concern in rural settings (HARVEY 2015, WHO AND WEDC 2011).

The Challenges for Hygiene Promotion in Urban Settings

Due to the diverse nature of the needs of refugees and IDPs in Urban Settings, it is often challenging for humanitarian actors to provide WASH assistance in a structured and timely manner (HARVEY and COLONI 2015). In addition, the large disparities (regarding WASH services, health, nutritional status, as well as regarding poverty and housing) in urban areas complicate meeting the minimum standards for hygiene (UNICEF 2012). Moreover, inherent crowding in cities means that the risk of disease outbreak related to poor hygiene is a strong concern (UNICEF 2012). To meet the diverse needs and varying levels of service, hygiene promotion activities in urban areas should focus on mobilising the community and building capacity of the affected population to take charge in preventing and/or mitigating WASH-related diseases.

Coordination and Collaboration

The primary goal of WASH interventions in urban settings is to provide access to national hygiene-related services (such as health services, nutrition planning strategies and policies, programs for hygiene promotion etc.) and to improve services if necessary (THE SPHERE PROJECT 2011, UNICEF 2012b, UNHCR 2015a). To provide access and to address potential causes of waterborne diseases, it is vital that humanitarian actors, local stakeholders, municipal authorities and service providers collaborate from the start and plan the campaign in a way that local stakeholders can take over with time to ensure sustainability of the campaign (UNHCR 2015a, HARVEY and COLONI 2015).

Humanitarian actors operating in urban areas should be aware that they may affect the power dynamics of municipal authorities or population groups/neighbourhoods. For example, repairing water and sanitation networks can directly benefit rich population groups or neighbourhoods as opposed to slum dwellers’ (where refugees and IDPs may reside) who must continue to rely on private water vendors to get water (REDR 2014). A good understanding of where refugees and IDPs are located or housed within urban areas is important to ensure that the assistance reaches the target population.

In urban settings, where the displaced and the host communities live side-by-side in concentrated areas, mass media can be an effective means to disseminate information on hygiene promotion. Existing infrastructure like media and newspaper outlets, radio stations and television stations should be utilised (HARVEY 2015). However, hygiene promotion should also take up an interactive approach as much as possible, using methodologies such as drama, songs, the street theatre or dance.

In urban settings, community consultation is key to hygiene promotion and to delivering messages to the affected population. Children are more prevalent in urban areas than in rural settings and since they can be very efficient in disseminating information to their families, schools can present a particularly successful avenue for hygiene promotion in urban settings (REDR 2014).

Regardless of the communication strategy chosen, humanitarian actors should always consider the obstacles to an effective intervention (such as language and literacy barriers) and should adjust their hygiene promotion campaigns accordingly. Before selecting communication methods, an assessment should be conducted to identify of the cultural norms of the refugee/IDP population as well as the host communities.

Urban settings often have direct access to local markets, which means that hygiene items can be made available to the affected population through local businesses rather than just distributing them. As such, hygiene practices should be marketed through effective communication strategies, to create demand for hygiene items and thereby support the adoption and maintenance of good hygiene practices. Cash transfer programs and market-based tools have a potentially vital role to play in supporting the local economy and in giving refugees and IDPs the choice to determine their own ways of maintaining hygiene. To do this, refugees and IDPs will often require monetary assistance such as cash, grants, vouchers as well as material incentives to cover costs of hygiene kits, cleaning or the maintenance of water and sanitation structures (REDR 2014, UNHCR 2015a). The UNHCR vulnerability criteria should be applied to prioritise the provision of WASH assistance (i.e. WASH non-food items, money vouchers, construction materials for sanitation upgrades) to the most vulnerable refugees and IDPs that are renting or staying with hosting families (HARVEY 2015).

The USAID Hygiene Improvement Fund illustrates an innovative approach to facilitate demand creation for proper hygiene practices: they provided privately owned pay-per-use toilet and shower facilities and managed them through public-private partnerships. Additionally, USAID designed bank loans specifically for sanitation and hygiene stores or for product lines in order to to make hygiene items readily available (USAID 2011).

Having communities participate in hygiene promotion allows humanitarian actors to obtain a good understanding of how the public health can best be protected. Programmes for promoting hygiene awareness should be participatory, focused and specific, but not alarmist (WHO 2002).

Hygiene Committees or Health Clubs

Interventions should aim to mobilise neighbourhoods or specific groups within urban areas that share an interest in taking charge of their own hygiene promotion and health protection initiatives (HARVEY 2015). One way this can be done is by supporting the formation of hygiene committees or health clubs that are developed and run in cooperation with the refugee and IDP population and the host communities (UNHCR 2015a). All programs should have a gender-balanced and representative committee responsible for promoting hygiene and implementing hygiene promotion campaigns. In urban settings, Community-Led Total Sanitation and Participatory Hygiene and Sanitation Transformation (PHAST) are good approaches to community mobilisation (UNICEF 2012).

Mobilising the community for hygiene promotion is best done in a phased approach that is adapted to the level of development of the urban area as well as phase of the humanitarian crisis (HARVEY AND CONOLI 2015). In the immediate emergency phase, hygiene promotion should focus on (HARVEY AND CONOLI 2015):

• Ensuring necessary resources are provided to the refugee population to carry out proper hygiene.
• Mobilising the community to act on actions to address WASH related problems.
• Mobilising the community to act concerning the design, use, management of WASH services.
• Ensuring that the refugee population has the basic knowledge to prevent disease.

In the medium- to long-term post-emergency phase, hygiene promotion should follow an approach more in line with development settings, involving continuous assessment, analysis, design, implementation, monitoring and evaluation of risks (a concept commonly referred to as Linking Relief, Rehabilitation and Development LRRD) (HARVEY 2015).

Defining the Campaign Strategy

A strategy needs to be put in place that justifies “WHY hygiene promotion is important in the specific context, HOW the key hygiene risk practices have been identified, WHO are the priority at-risk groups and WHY, WHAT are the most effective hygiene promotion approaches and activities and WHY, HOW the target activities for each at-risk group will carry out and HOW the effectiveness of the plan will be monitored’’ (HARVEY 2015). In urban areas, the context-specific hygiene promotion strategy should be based on a strong urban social marketing strategy that maximises inclusion of the refugees and IDPs (see above) (UNHCR 2015a). The following components should be addressed by the strategy and prioritised according to the risk assessment: community and individual action, use and maintenance of facilities, selection and distribution of hygiene items, monitoring, community participation and communication with WASH stakeholders (see graph below). 

Planning and Preparation

The assessment and preparation steps for developing a hygiene promotion campaign should be applied according to the following steps (adapted from GWC 2009 and HARVEY 2015) according to the following steps:

Step 1: Assessment

• Identify key risk practices and get an idea of the level of knowledge, the practices and level of understanding of WASH;
• Determine which practices allow for diarrhoeal microbes or diseases transmission;
• Identify the practices that are the most harmful to human health.

Step 2: Consultation

• As soon as possible, consult men, women and children on hygiene needs and items to include in hygiene kits. Seek to form a close liaison with the urban host community.  
• It is necessary to assess the separate needs of refugee and IDP population residing with host families and those congregating in public areas (HARVEY AND COLONI 2015).

Step 3: Initial planning through definition of goals and objectives

• Define the aim of the entire campaign based on the unique needs that were revealed in the needs assessment (see WASH Needs Assessment factsheet).
• Set one or two purpose objectives referring to the wider objectives of the campaign, targeting specific hygiene practices. Select these based on which practices have the greatest potential impact on public health and which are achievable. Also, consider what can be done to enable change of risk practices;
• Determine two to four outputs that should be achieved;
• Select measurable indicators and means of verification for each objective (such as those in the Sphere Project Hygiene Promotion);
• Identify potential areas for intervention (e.g. on the hardware side such as water systems or hygiene items, or on the software side such as education or advocacy).
• Set out action plans for achieving the objectives.
• Priority actions for urban settings should be approached in the following order (adapted from HARVEY AND COLINI 2015):
  • Ensure that urban refugees and IDPs are living in conditions where they have adequate access to sufficient and safe water of sufficient quantity.
  • Ensure that urban refugees and IDPs have received key hygiene messages and essential WASH non-food items (e.g. soap, water containers, and menstrual management materials).
  • Ensure living conditions with adequate access to sanitation and toilet facilities.
  • Ensure living conditions free from excreta or other hazardous wastes.
  • Ensure living conditions free from high-risk disease vector populations

Step 4: Planning through Identifying target audiences and stakeholders

• Decide on which segments of the refugee/IDP population will be targeted by the campaign, based on an assessment of risky hygiene practices.
• Determine important stakeholders who influence the people that employ these risky practices (teacher, community leaders, etc.).
• Recognise that reaching the target groups in urban areas may require careful planning and adjusting of strategies since urban refugees and IDPstend to be highly mobile and dynamic. Although they at times manage to recreate their communities, the social fabric is often not intact in urban areas (REDR 2014).

Step 5: Planning communication campaigns and modes of intervention

• Decide on initial key messages (such as WHO`s Facts for Life). In early stages, mass media is effective, as 60% of people have radio (although they are often only used by men);
• Define the initial mode of intervention for media campaigns (see Media Campaigns - Radio (DC) and Creating Information Material (DC) factsheets) as well as for other means that the target audiences’ trust (women`s discussion groups, traditional healer). Also, define locations where to best reach target groups (consider gender).
• Determine advocacy and training needs for stakeholders (see Recruiting and Training of Hygiene Promotion Facilitators factsheet).

Step 6: Recruitment, identification and training of workers and outreach system

• Base recruitment and training on the capacities (systems, skills and approaches) that already exist among the active humanitarian actors (see Recruiting and Training of Hygiene Promotion Facilitators factsheet). In urban areas, this could also be achieved by strengthening local capacities.

Implementation and Continued Assessment (see also Project Implementation factsheet)

• Implement the defined actions (e.g. distribution of hygiene kits or carrying out media campaigns).
• Hold meetings/ interviews with key informants and stakeholders to initiate an interactive approach.
• Conduct ongoing assessments to understand the motivation factors behind positive behavioural change around hygiene.
• Obtain quantitative data and carry out a systematic data collection in a participatory manner and in coordination with other sectors.

Monitoring (see also Participatory Monitoring and Evaluation factsheet)

• Monitor the hygiene promotion activities (e.g. distribution of hygiene kits, installation of toilets) and people’s level of satisfaction.
• Monitor and evaluate hygiene promotion campaigns against hygiene-related indicators on safe access to quality sanitation and on satisfactory living conditions (UNHCR 2015b). The relevant indicators for urban settings (referred in standards as out of camp settings) include:
  • ≥ 90% of households have soap present in the house (which can be presented within 1 minute),
  • ≥ 60% (emergency stage)/ 80% (post emergency stage) of households can name 3 of the 5 circumstances in which it is critical to wash hands

Adaptation

• Define the campaign based on the changing situation and move towards more interactive methods of communication and participation in comparison towards later emergency stages.
• Rapidly adapt the intervention and campaign based on monitoring outcomes and empower the communities to maintain their longer-term hygiene promotion structure (e.g. committees).
• Continue training and monitoring and adapt approaches as necessary.

To ensure that the hygiene promotion campaign promotes practices among refugees and IDPs in urban areas that can be sustained in the long term, the following points should be considered (IA 2014):

• Use multiple communication methods and make use of hygiene promoters, schools, women’s groups, youth groups and mass media;
• Carry out multi-sector planning and delivery together with health, child protection, livelihoods and non-food items sectors;
• Increase participation and decision making of beneficiaries;
• Use a child-centred approache;
• Approach disease monitoring and awareness campaign in an integrated health and education manner;
• Support and strengthen WASH committees and health clubs;
• Monitor and conduct impact assessment and use the information gathered in programme planning and adapting hygiene promotion campaigns;
• Ensure systems are in place for operation and maintenance of facilities to enable maintaining good hygiene (see Ensuring Appropriate Operations and Maintenance Services factsheet).

Hygiene promotion campaigns are to be completed within the first three months of the arrival of refuges and IDPs and then redesigned every six months based on the monitoring (HARVEY 2015).

The guidance is applicable to Urban Settings for refugees and IDPs with individual accommodation, residing within host families, or residing on public land or collective centres within urban areas.