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1. What is the HEP?

Why assess hygiene practices?
Who is this handbook for?
Is this a participatory handbook?

The Hygiene Evaluation Procedures (HEP) handbook was conceived of as a field companion to Actions Speak: the study of hygiene behaviour in water and sanitation projects (Boot and Cairncross, 1993), a resource book prepared primarily for project managers and decision-makers. In contrast, the HEP's main focus is on the practical concerns of field personnel in water supply, sanitation, and health/hygiene education projects who want to design and conduct their own evaluations of hygiene practices.

This handbook was developed through processes of consultation with a number of field-level project staff working in Eastern Africa (rural Kenya, Tanzania, and selected urban areas in Ethiopia). Each consultation process involved a hygiene evaluation study designed and conducted by project staff with coordination, training, and supervision support from researchers whose backgrounds include anthropology, community development, and public health. Practical insights gained from these studies reflect the needs and concerns of the primary intended users. The draft HEP was field tested in India and Afghanistan prior to peer review and finalization.

The emphasis of the HEP is on how to gather, review, and interpret qualitative information. In line with related manuals and handbooks designed to provide technical/methodological support to health practitioners (see, for instance, Simpson-Herbert, 1983; Scrimshaw and Hurtado, 1987), the HEP handbook is designed to make qualitative research skills accessible to practitioners with little or no previous training in the social sciences. It is not for quantitative researchers who want to use statistical analysis. Qualitative information is gathered, analyzed, and interpreted differently from quantitative information, but this does not mean that the two types of information cannot be gathered and analyzed side-by-side to enable a fuller understanding of the issues under study.

The quality of information collected is critical in the systematic assessment of hygiene practices. A number of problems have been identified in relation to the quality of questionnaire-based data due to the limitations of the questionnaire as the sole instrument for information gathering (see Gill, 1993 for a concise analysis). The problems are more pronounced where sociocultural information is sought. However, qualitative information collected with the aim of designing good questionnaires for specific topics of enquiry can improve the effectiveness of questionnaires. This handbook was developed as a practical solution to the limitations of using a single method or instrument for information gathering, especially when trying to investigate sociocultural aspects of human behaviour that do not easily lend themselves to quantifiable measurement.

Like previous works on the subject of assessing hygiene practices, the HEP explores alternatives to the questionnaire-based survey design by examining other tools for the systematization of gathering chiefly qualitative information. We do not discourage you from using questionnaires. Many projects use and will continue to use questionnaire based surveys on which to base their decisions. However, we advocate the use of trustworthy qualitative information with which to design your questionnaire, and the use of other tools to complement your questionnaire. The triangulation of sources and methods is advocated as the best way to obtain a complete set of information on the issues under study.

In order to emphasize practicality, we have included:

• a variety of methods and tools from which you can choose and combine;

• appraisals of individual methods and tools to help you select the most appropriate combination(s) of methods for your purposes;

• examples from field experience including common mistakes and pit falls to provide insight into what a hygiene evaluation study may involve.

Why assess hygiene practices?

For a long time, project planners have appreciated the value of improving water supply and sanitation facilities. Improved facilities reduce contamination of drinking water and of the environment, and reduce diarrhoeal disease transmission and worm infestations. Even so, World Health Organization and World Bank statistics show that as many as three million children still die from intestinal infections every year, and a third of the world's population is still infected with parasites. The main reason for this is not that too little has been invested in technological improvement of facilities, but that the facilities are often inappropriate, unaffordable, or unacceptable to the intended users. All of these result in no use, limited use, or inappropriate use of facilities.

For example, pit latrines are widely promoted in both urban and rural regions in many parts of the world, in order to prevent faeces from contaminating the environment. However, having the facility does not in itself guarantee the isolation of faecal contamination. Even where pit latrines are in use, faecal contamination can get into drinking water and food and thereby into the mouth, or directly from fingers into the mouth. Various routes of transmission, such as fingers, flies, soil, and water, may require different barriers if the spread of contamination is to be cropped. This makes the prevention of diarrhoea and worm infections complex, as shown in Figure 1.

This diagram, often called the F diagram, clearly shows the different transmission routes whereby pathogens can get from the faeces of an infected person through fluids (mainly drinking water), fields (soil), fingers, and food. Some of the most effective primary and secondary (behavioural) barriers are indicated. You can see that there are at least nine barriers/facilities associated with hygiene practices. Clearly, numbers 1 and 2, pit latrines and Ventilated Improved Pit (VIP) latrines respectively, are very important physical barriers. If they are constructed and used properly, they can prevent faeces from contaminating water sources, soil, and food. The rest of the barriers relate to hygiene practices such as the protection of water sources (4) irrespective of the existence of latrines; hand-washing at critical times - after defecation, after cleaning children's bottoms, before handling food, and before eating and/or feeding (5); protection of food by safe storage (6); safe handling (7); protection of water in transit and in the home (8); and, washing raw foods before eating them (9).

FIGURE 1. Faeco-Oral Routes of Disease Transmission

Do improved hygiene practices really make a difference to health? Research shows that hygiene-related practices such as the safe disposal of faeces and hand-washing after contact with faecal material can reduce the rates of intestinal infection considerably. Consider the following figures:

Hand-washing with soap and water can reduce diarrhoeal disease by 35% or more. Hand-washing can also help to reduce the prevalence of eye infections such as conjunctivitis and trachoma.

Safe disposal of faeces serves as a primary barrier to prevent faeces from contaminating the environment. It is particularly important to isolate the faeces of people with diarrhoea, most of whom are usually young children. Pit latrines, when used by adults and for the disposal of young children's stools, can reduce diarrhoea by 36% or more.

Protection of water from faecal contamination can also reduce diarrhoea, because some diarrhoeal infections are water-borne. Water quality in the home can be improved by using only a protected water source for drinking purposes; by keeping water storage vessels clean, covered, and out of the reach of young children and domestic animals; by boiling water where practical; or by putting water in clear plastic containers and exposing them to sunshine for several hours. In the special case of guinea worm, filtering with a cloth filter can provide complete protection. Improved water quality can be associated with up to a 20% reduction in diarrhoea. However, increased quantity of water used, which results from better access to water, can bring about still greater reductions.

However, much remains to be learned about the links between improved water supply and sanitation facilities, and well-designed and implemented health/hygiene promotion and health. What is clear is that good hygiene practices are necessary for maintaining good health.

Who is this handbook for?

This handbook was developed primarily for field level personnel in water supply, sanitation, and hygiene education projects. These include water and/or sanitary engineers, public health technicians, community workers, health educators, communication specialists, health workers, and other public health practitioners as well as project planners, managers, and trainers. If you are one of these, and want to design your own assessment of hygiene practices in your project site, this handbook is for you. This handbook may also be useful to students and researchers in public health and other academic institutions interested in interdisciplinary enquiries into health behaviour.

Successful systematic investigations are seldom done by one person or with one perspective alone. The skills and experiences of engineers, health workers, and community development workers are all relevant when trying to investigate and analyze activities around water supply and sanitation. You will need to involve in your assessment your colleagues and other people who know and understand the local social and cultural norms. This handbook provides examples of a variety of tools designed to make the participation of local people in your assessment effective. Therefore it is also aimed, indirectly, at those whose hygiene practices are to be assessed.

Is this a participatory handbook?

One of the issues encountered during the development of this handbook was the question of whether or nor outsiders (researchers and/or project staff) should do all the investigation and analysis in hygiene evaluation studies, without involving the people studied. No assessments of hygiene practices can be done by outsiders alone, without the participation of the people studied. The problem is that the term participatory is used widely to mean different things to different people. Researchers working in the fields of agriculture as well as water supply and sanitation projects have identified several uses of the term participation or community participation. White (1981) has identified ten and Pretty (1994) seven different types of participation. Box 1 provides an outline of three main types of participation.

BOX 1: Three Types of Participation (Adapted from Pretty, 1994)

People participate by answering questions posed by researchers using questionnaire surveys of similar approaches. People do not have the opportunity to influence proceedings as the findings of the research are neither shared nor checked for accuracy .

People participate by being consulted and external agents listen to views. These external agents define both problems and solutions and ma! modify these ill the light of people's responses. [Such a consultative process does not concede an! share in decision-making and professionals are under no obligation to adopt people's views.

People participate in joint analysis, which leads to action plans and the formation of new local institutions or the strengthening of existing ones. It rends to involve interdisciplinary methodologies that seek multiple perspectives and make use of systematic and structured learning processes. These groups take control over local decisions. and so people have a stake in maintaining structures or practices.

You must decide which of these types of participation coincide with your project's ethos and approach. The purpose of this handbook is not to prescribe any particular brand of participatory approach. Our aim is to show how combining methods and tools from participatory and conventional, or nonparticipatory ways of investigation can produce good quality information, and therefore a better understanding of the issues under investigation

In conclusion, how participatory you may want to make your hygiene evaluation study may largely depend on your answers to the following two main questions:

• To what extent have local people been involved in the planning, design, and implementation of your project? For instance, if the provision of protected water sources and getting individual households to acquire latrines are part of your project activities, to what extent did you involve members of your target population in discussions of your project aims and objectives? To what extent have your project plans taken into account local needs, beliefs, and priorities?

• What institutional mechanisms are there to put the findings of your hygiene assessment to immediate use? For example, do you foresee the possibilities of changing the direction of project activities if that is what the findings of your assessment suggest? Who would take responsibility for any necessary changes to be put into effect and how?

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