By Celia McMichael, Institute for Human Security & Social Change and Department of Social Inquiry, La Trobe University

In order to plan and implement hygiene interventions with sustained impact, we need to better understand what triggers and supports people to sustain hygiene behaviours. There is limited conclusive evidence on hygiene behaviour change, but it is clear that health messaging alone is a poor motivator for change. Further, evidence indicates that hygiene behaviours often drop-away when the focus dissipates at the conclusion of a project.

Nepal is one of the world’s poorest countries, with low levels of development and persistent social inequalities. While there has been significant progress in water and sanitation coverage in recent years, water, sanitation and hygiene continue to present significant challenges to population health in Nepal particularly in remote areas.

Nepal Red Cross Society (NRCS) has implemented water and sanitation activities with the support of partners for over 30 years. A particular focus has been on hygiene behaviour change (e.g. elimination of open defecation, hand-washing with soap) in order to improve health. In partnership with Austrian Red Cross/Austrian Development Corporation, NRCS implemented a water, sanitation and hygiene project in Kotgaun Village Development Committee (VDC) in Rolpa District between 2008 and 2012.  Activities to support hygiene behaviour change in the target communities included: installation of water/sanitation hardware (toilets, handwashing platforms etc.), group/committee formation (e.g. junior/youth Red Cross circles, women’s groups, water user committees), health and sanitation education and awareness raising, street drama, handwashing demonstration, home visits, and campaigns to include women and under-privileged people.

In 2013, Australian Red Cross proposed a research partnership with the Institute for Human Security and Social Change in order to conduct evaluative research to better understand the drivers and barriers to sustained hygiene behaviour change (post-intervention). Funding for this is provided by the Department of Foreign Affairs and Trade’s Australian aid program through the Civil Society Water, Sanitation and Hygiene (CS WASH) Fund and the findings of this evaluation are being used to inform a CS WASH Fund project located in Bajhang District in far-western Nepal (implemented by NRCS in partnership with Australian Red Cross).

In late 2014, two researchers from La Trobe University, Dr Celia McMichael and Dr Priscilla Robinson, visited Rolpa, Nepal, to conduct the evaluative research with the support and input of in-country NRCS and Australian Red Cross staff.

Evidence from the research project suggests that hygiene behaviour change has largely been sustained in Kotgaun VDC. Key reported drivers of  hygiene behaviour change included provision of  partially subsidised wat/san ‘hardware’; involvement of NRCS volunteers in project delivery, education and creation of new norms around hygiene behaviours; community engagement including establishment and renewal of women and children’s groups and their inclusion in hygiene promotion activities; local motivations to conform with social norms and enhance community status; civic pride related to transformation of WASH conditions and ODF status; shaming as a triggering tool for behaviour change (a common strategy in Community-Led Total Sanitation, that has promoted substantial debate); desire to prevent illness and to promote good health; and establishment of conditions that support routine/habitual hygiene behaviours.

 Key reported barriers included periodic water shortages from new/renovated water  schemes (associated with climate  change/seasonal rainfall variability/deforestation/ inter-  ward tensions);  lack of ongoing hygiene education and awareness raising post-project;  lack of clarity about structures/institutions responsible for post-project  hygiene promotion;  sense of exclusion among some members of the  community, particularly disadvantaged  people (i.e. Dalit families); and  cost of constructing sanitation hardware (e.g. latrines) in  the post-project phase.

 The Nepal Red Cross Society were central to the implementation and  success of the  project, building on existing practices, knowledge and  relationships in Kotgaun VDC.
They  ensured that activities were  culturally compelling (e.g. street drama, healthy baby  competitions). NRCS volunteers are part of the community, and they provided peer  support and influenced community norms,  triggering hygiene behaviour change in homes and villages. Further, the project provided a supportive environment for the  development of leadership roles among NRCS volunteers, which encouraged local responsibility for sustained hygiene behaviour  change. This highlights the importance of Doing Development Differently, in which many players – in this case local government,  IFRC, NRCS staff and volunteers, community members – work together to achieve progress in complex situations.

In complex public health promotion programmes the effects of individual intervention activities are difficult to identify. This evaluation indicates that there were multiple contributing and inhibiting factors to sustained hygiene behaviour change: (partially-subsidised) construction of sanitation hardware; renovation and construction of water schemes; contribution and engagement of NRCS staff and volunteers; use of diverse hygiene behaviour change messaging. Importantly, health messaging was one of a broad suite of educational messages, with particular focus on creation of new norms and civic pride related to personal and environmental cleanliness. As one young woman said:

 We learn many things, clean the water, clean the toilet. This VDC is now very nice to visit.  Before people felt it was dirty coming to Kotgaun because there was a lot of defecation on  the road, but now when they come they think it is beautiful.

It is the holistic and multi-layered nature of the intervention that appears to have been  central to its successes. The evaluation has highlighted the importance of adaptive  programming that responds to local contexts and builds on the strengths of communities,  including the commitment of existing NRCS chapters, sub-chapters and volunteers.

The WASH project, jointly undertaken by the Institute, NRCS and Australian Red Cross, was funded by DFAT.