CHAPTER 4: Health and Sanitation Education: New concepts and approaches
In the early 1980's, under CWSSP Helvetas developed an Integrated Health and Sanitation Education Package which included creating awareness of the transmission routes of waterborne diseases, motivation for private latrine construction, demonstration of and motivation for the use of smokeless stoves, and personal and environmental sanitation activities. These sanitation and health education activities were combined with the aim of involving women in the planning and implementation of drinking water facilities.
Selective and Intensive Approach
Because the CWSSP approach was very comprehensive, it could only be implemented with intensive input. Since so many subjects were covered in a relatively short time, the actual overall behavioural change was minimal. Realising that it is easier to change behaviour in only a few fields at a time, SRWSP developed a Selective and Intensive Approach for health and sanitation education. Emphasis was on hand washing practices and motivation for construction, use and maintenance of latrines. Other issues were only covered if there was a clear request or an observed need for it.
The Gender-Balanced Process Approach for Sanitary Change
The extensive Participatory Self Assessment (PSA) and External Evaluation (EE) held in 1997 found that a broader health package would enhance the awareness of latrine construction and use. Also, the growing awareness regarding gender roles, and the impact that drinking water and sanitation activities could have on the role and responsibility of men and women in the community, encouraged SRWSP to develop its present approach: The Gender-Balanced Process Approach for Sanitary Change. Now, a broader HSE package is offered to the community (as explained in chapter 3), but, more importantly, men are now also involved in the various activities.
The community facilitators of SRWSP and its partner NGOs conduct various HSE activities, but it is the WSMC, the VMW and the WTC who regularly follow up to ensure that the health and sanitation message is well understood and that improvements are made accordingly.
Direct pit latrines (where the pit is directly below the squatting place) and offset pit latrines (where the pit is indirectly connected to the slab through a closed drain) are most appropriate for the Nepalese rural environment. Cement slabs are only used in areas where no flat stones are available.
All costs for a latrine are borne by the people, except for the very poor who may receive a subsidy for a cement slab. SRWSP has observed that in most cases subsidies are not needed to encourage people to build a latrine. 80% of the households covered by a drinking water system have constructed a latrine. After a period of three to five years, 65% (2 in 3) of the constructed latrines are still in use and in acceptable condition. Some people remain reluctant to build a latrine. On average, 20% never build one. When analysing this phenomenon, the following reasons seem most plausible:
• HSE has the greatest impact when started at the project's very beginning and integrated in all activities throughout the entiry process.
The reason for combining HSE with drinking water is well understood by programme planners. Communities, however, first demand better drinking water facilities. The reason why HSE activities are included must, therefore, be made very clear. In the beginning, villagers show a keen interest to take part in the various participatory activities. Newly gained insights activate people's eagerness to improve their living environment. SRWSP makes positive use of this momentum in motivating the people to construct and use latrines. Intensive supervision is provided during the time of latrine construction to guarantee high quality workmanship according to approved designs. Motivation for sanitation requires repeated efforts over an extended period of time, especially when the whole community is targeted. HSE should also be an integral component of other activities, including the more technical training programmes. To sustain the sanitation facilities, HSE should continue during the operation and maintenance phase.
The impact of such HSE activities is greatest when sanitary behaviour is practised by the whole community. In heterogeneous communities this is more difficult to achieve. Different ethnic and/or caste groups have their own cultural and religious beliefs and habits. Special, sometimes tailor-made awareness-raising activities are necessary to address these. Those of lower economic status who live on a survival strategy need to be given special consideration to motivate them to participate in the community efforts.
• To reach the whole community, HSE activities should be gender sensitive.
Generally, sanitation activities are directed at women, assuming that they have the most influence when it comes to improving sanitary behaviour. This is, however, not necessarily true for all communities. Moreover, women and men may have different interests and needs when it comes to sanitary change. Analysing these first and then conducting the HSE activities accordingly will address both needs. (see also chapter 6)
• Proper use of latrines has a high impact on the overall sanitary situation in the community.
HSE is more than just latrine construction. However, as this is the most tangible change, it is easy to monitor and report on. Other changes like hand washing practices are not to be underestimated. Nevertheless, latrine use is very important in changing the living environment of the community. People may also have their own reasons for latrine use which are not always related to improving the health situation. Reasons of convenience or safety can be decisive as well. Lack of technical knowledge keeps people from building a latrine. In some cases providing technical guidance is enough to motivate the people; in others, more motivational activities or even a small push are needed to make people take the first step. SRWSP has observed that in most cases, subsidy is not necessary to encourage people to build a latrine. Only the economically weak might need some support. The most positive observation is still that once people get used to using a good latrine they appreciate it and refrain from open defecation. After the first latrine pit is filled, some people are willing to invest more to build one that lasts longer.
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