Lessons Learned in Water, Sanitation and Environmental Health
BANGLADESH (English)
BANGLADESH
The Sanitation and Family Education (SAFE) Project
BACKGROUND
CARE-Bangladesh, with technical assistance from the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), developed and implemented the Sanitation and Family Education (SAFE) project starting in May 1993. It followed a Water and Sanitation/Hygiene (WASH/CARE) cyclone relief project implemented in the coastal belt of southeastern Bangladesh. The objectives of the WASH/CARE project included the repair of damaged tubewell platforms, provision of tubewells, and latrine construction with a limited hygiene education component. The SAFE project built on the earlier experience, but emphasized hygiene education rather than infrastructure development. Specifically, the SAFE project compared two models of outreach. Model 1 was based on courtyard education sessions with the tubewell caretakers, their spouses, and tubewell users. Model 2 included additional outreach activities such as school programs, child-to-child approaches, and the involvement of key opinion leaders in the community. The purpose of this comparison was to see whether a more intensive outreach program would have a greater influence on hygiene behaviors.
PROJECT LOCATION
SAFE was implemented in a coastal area near Chittagong in southeastern Bangladesh. Chaturi Union of Anwara Thana and Saidpur Union of Sitakunda Thana were chosen as the project areas. Chaturi had a total of eight communities, which averaged 1,800 households each, and Saidpur nine communities averaging 2,500 households each. The major occupation of the project population was agriculture with very few engaged in business or service. The majority of the population was Muslim, although there were some Hindus and Buddhists.
OBJECTIVES
The SAFE project had the following objectives:
- To develop effective and replicable hygiene education outreach strategies to promote behavior change.
- To develop and assess different models for health and hygiene education outreach.
- To design and implement a behavior-based monitoring system for the hygiene education program.
- For achieving these objectives, community participation was considered the key strategy and was followed in every aspect of the SAFE project.
The central features of the SAFE approach were the following:
- The development of hygiene education interventions was based on information collected in small qualitative and quantitative research activities, rather than depending on stock messages and materials. Interventions focused on reinforcing existing behaviors (where beneficial) or developing specific, appropriate alternatives to existing behaviors.
- An incremental approach to improving hygiene behaviors was used. Rather than promoting a large number of 'perfect' hygiene behaviors, SAFE sought to identify those behaviors most strongly associated with diarrhea in children and to target these priority behaviors with locally appropriate interventions.
- A behavior-based monitoring system was used to identify problems and opportunities for improving the intervention, for analyzing the problems and developing solutions with community members, and for adjusting and improving SAFE activities continuously.
- Participation of community members in every aspect of the project was emphasized. This included program design, outreach activities, monitoring the identification and analysis of problems, and evaluation.
- The interventions for the SAFE project were based on the conceptual model of fecal-oral transmission of diarrhea and baseline information from the intervention areas, including findings from both baseline surveys and qualitative studies. The interventions were further refined based on dialogue with community members and information from monitoring surveys. Based on the data, priority behaviors for interventions were identified in six areas: (1) clean water, (2) latrine use and feces disposal, (3) environmental cleanliness, (4) hand washing, (5) food hygiene, and (6) diarrhea management. The interventions were developed and refined to address specific behaviors. Thus, SAFE interventions were focused on behavior change rather than message retention.
- Two different models of extension were used in the SAFE Project. Model1 was more limited and conventional, working only through caretakersessions. Model 2 was an expanded model, involving, in addition to sessions with caretakers, school sessions, child-to-child sessions for non-school children, and sessions with key community persons. The interventions were implemented by 13 field extensionists. Their role was primarily to facilitate discussion during the sessions, providing technical input when required. Outreach methodologies varied by target group, but included group discussion, demonstrations, participatory action learning exercises, flash card displays, folk songs, role playing, comic story sessions, and games. All communication materials and approaches were developed step-by-step, and carefully field-tested at the community level to ensure that both message content and dissemination channels were relevant and appropriate for the local context.
KEY FINDINGS
After one year of pilot implementation, dramatic improvements were seen in all areas of intervention, for all targeted behaviors, and by all measures - knowledge, reported behavior, demonstrated practices, and observations (see Tables 1 and 2). In addition, an estimated two thirds reduction in diarrhea prevalence was seen in SAFE intervention areas. These results provide strong evidence that the SAFE approach can be effective in improving hygiene behaviors and reducing the incidence of diarrhea in children.
In comparing the two models, it appears that Model 2 performed better than Model 1 by most measures, in all areas of behavior studied. Nonetheless, the difference between Model 1 SAFE intervention areas and Model 1 control areas was significant. Thus, caretaker sessions alone (Model 1) were worthwhile and had important benefits. Model 1 was a very good intervention; Model 2 (with multiple channels of communication) was a slightly better intervention. The dramatic differences between the intervention and control areas found in both models suggest that the key elements of a successful hygiene behavior change program may be those that are similar in both models. The similarities include focusing on a few, key behaviors, community participation in all aspects of the project, participatory extension methods, and a system of continuous monitoring and improvement of the interventions.
Table 1: Model 1 Results
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Table 2: Model 2 Results
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LESSONS LEARNED
Insights regarding the intervention process should be gained primarily through qualitative investigations. Quantitative surveys can provide information on what happened, but offer little on why it happened.
Recognizing that behavior change is a long-term process, CARE must make provision for long-term interventions in communities, either through direct CARE activities, or through facilitating the development within the community of sustainable systems for continued hygiene improvements. The SAFE pilot intervention extended for a period of nine months in each community.
Means to devolve responsibility for organizing hygiene behavior change activities to the community need to be sought. Many avenues may be explored, from continuing similar sessions with a community person in charge, to evolving away from initial, group sessions to other means of communication and community action.
Group sessions similar to those that work well with women may not be appropriate for men. The differences between men and women in social activities, communication patterns, and daily schedules should be taken into account when developing means to reach men. For example, SAFE reached men at various levels: tubewell caretakers individually, group sessions at tea stalls, and on-the-spot informal sessions with young males. For priority setting in project interventions, those behaviors that are already adequate in nearly all households should be reinforced, but may receive less emphasis and reiteration than behaviors which need a considerable amount of refinement. Just as priorities need to be set to reduce the number of behaviors targeted, setting priorities in the amount of time and effort spent among the targeted behaviors may improve program efficiency.
Interventions should continue to evolve in order to realize continued success. As new challenges arise, additional rounds of problem analysis and development of alternatives are needed. Projects have to be dynamic in order to be effective.
The SAFE interventions took place in the context of a high profile national latrine promotion campaign. The lack of increase in hygienic latrine coverage in control areas suggests that a national campaign alone will have limited impact in the short run. On the other hand, the dramatic increase in hygienic latrine coverage in the SAFE intervention areas may in part be due to the combination of the national campaign and SAFE's community-based approach.
The SAFE project was conducted in areas where community members have access to tubewells. The success of the interventions was dependent, to some extent, on access to safe water supplies. In areas where water is less accessible, integration of water supply interventions withhygiene education activities will be important.
SAFER
The success of the SAFE project represented an important opportunity to extend experience from the project to others in order to facilitate the broader implementation of successful hygiene behavior change programs. Thus, in July 1995, CARE Bangladesh began implementation of the five-year Sanitation and Family Education Resource (SAFER) project in Chittagong. The main approach of the SAFER project is to provide technical assistance and training to Bangladeshi NGO's on planning and implementing high quality sanitation and hygiene education programs. Six NGO's, which already implement water and sanitation programs, will receive intensive, tailored, on-site technical assistance and a further 160 interested NGO's will be made aware of the concepts and basic principles of hygiene behavior change.
FOR FURTHER INFORMATION CONTACT
Bangladesh
G.P.O. Box 226
Dhaka 1209
Bangladesh
Tel: (880) 2 814195-8 / 2 814207-9
Fax: (880) 2 814183
E-mail: carebang@bangla.net
This case study is based on an article prepared by Raquiba Jahan, Massee Bateman, Sumana Brahman, Sandra Laston, Sushila Zeitlyn, Dee Jupp and Florence Durandin and published in Learning for Health, Issue 8, Oct 1995 - Mar 1996.
A number of reports describing the SAFE project in more detail have been published, including:
Sanitation and Family Education Pilot Project (SAFE): Don't Just Say It Do It! by D. Jupp, CARE Bangladesh, 1995.
Prevention of Diarrhea Through Improving Hygiene Behaviors: The Saniation and Family Education (SAFE) Pilot Project Experience, by O. Massee Bateman, Raquiba A. Jahan, Sumana Brahman, Sushila Zeitlyn, Sandra L. Laston, CARE Bangladesh and ICDDR,B, 1995.
"Lessons Learned in Water, Sanitation and Environmental Health" is a series of short case studies designed to identify best practices in water, sanitation and environmental health through the lessons learned in projects implemented by CARE and others. The series is edited by Jon Macy and Peter Lochery.
March 3, 1997
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