Technical brief

Sanitation and hygiene
approaches
Part of a series ofWaterAid technology
briefs.
Available online atwww.wateraid.org/
technologies
January 2013

Introduction
There are different ways to develop
and implement a hygiene promotion
programme. It is now understoodthat ‘educating’ people about
health benefits is, in many cases,
not sufficient to change people’sbehaviour. Therefore, hygiene
promotion activities need to insteadbuild on drivers such as status,
nurture or privacy.
Generally, hygiene promotion
approaches are divided into twogroups:• Participatory, community-based
approaches• Marketing approaches
Different elements of each approach
can be combined to suit a particular
context.
This technology brief gives anoverview of some of the main
sanitation and hygiene promotion
approaches used by WaterAid andother organisations. More detailed
information on these methods, andothers, can be found in the references.

Technical brief

Sanitation and hygiene approaches

Participatory, community-based
approaches
Participatory, community-based
approaches to hygiene promotion
allow organisations and governments
to work with communities to arrive atsustainable solutions to development
problems. They build self-esteem
and a sense of responsibility, while
placing the decision-making process
at community level.
SARAR
The aim of SARAR is to encourage
people to think through problems
and develop their creative abilities
in problem-solving, planning andevaluation. SARAR stands for thefollowing principles:• Self-esteem – built through active
participation of local people.
• Associative strength – local people
develop the ability to work towards
a common vision.
• Resourcefulness – local people areresourceful in taking initiative andfinding solutions.
• Action planning – local people thinkcritically and are creative in taking
action.
• Responsibility – local people
identify and commit to taking
responsibility for the outcomes.
Strengthening these attributes
is intended to lead to better selfdirection and management, andenhance participation among all
stakeholders. SARAR has beenused successfully in both rural andurban settings; however, its successdepends upon skilled facilitators.

PRA
Participatory rural appraisal (PRA)
uses techniques such as observation,
participation, interviews, shortquestionnaires, mapping and rapid
report writing in a participatory
manner to ensure community
ownership. Some of the most common
PRA tools include matrix scoring,social and resource mapping andmodelling, wellbeing (‘wealth’)ranking, and sorting/ranking cards
or symbols. PRA is similar to SARAR,with the skill of the facilitator beingof critical importance. This means
the approach can be human-resource
intensive and require time from
community members; however,the participation of all community
members, and interactive tools
enabling participation regardless ofliteracy levels, make PRA an inclusive,
cost-effective and efficient method.
PHAST
Participatory hygiene and sanitationtransformation (PHAST) is the main
methodology of hygiene promotion
for many organisations. It is basedon the idea that as communities
gain awareness of their water,
sanitation and hygiene situation
through participatory activities,
they are empowered to develop
and carry out their own plans toimprove their situation. PHAST uses
local languages, situations andperceptions in seven steps. Each stephas between one and four activities,
enabling groups to improve theircommunity planning on sanitationand hygiene. PHAST requires skilled
and experienced facilitators as wellas in-depth training of communityworkers. Although this is timeintensive, community workers canbecome lasting assets to a programme
and the community. It is importantthat PHAST has the full support of acommunity before being implemented.

2Technical brief

Sanitation and hygiene approaches
CLTS
Community-led total sanitation(CLTS) is a ‘no hardware subsidy’
approach to rural sanitation thathelps communities to recognise theproblem of open defecation and takeaction to become ‘open defecation
free’ (ODF). It uses activities suchas community mapping, walks andthe use of the local equivalent of
the word ‘shit’ – to generate disgust
about open defecation, with theaim of ‘triggering’ a community intoaction. While CLTS has been very
successful in Asia, it has had to bemodified in certain parts of Africa
as it has been seen as ‘too blunt’. In
some cases, communities have beenless responsive to CLTS where there
have been previous subsidies. Local
context is therefore very important.
Skilled facilitators are essential in
carrying out triggering exercises incommunities. A modified version ofCLTS, which incorporates features of
PHAST and PRA, has been trialled by
WaterAid Tanzania. This new method,
called ‘Mtumba’, is outlined in thecase study on p5.

A community
mapping their village
with coloured dye,using the CLTS
approach in Akkelpur
village, Mohanpur,Bangladesh.

CHC
Community health clubs (CHCs)
are voluntary and free communitybased membership organisations
that aim to improve the community’s
health. The approach is based on

regular meetings, facilitated byhealth extension workers who havebeen trained in participatory healthpromotion activities. They are open
to anyone and encourage members
to practise what they have learned athome through homework assignments
and monitored home visits. CHCs
are sociable and competitive. They
increase learning and raise social
status. They do not require literacy,
and strengthen the position of women
within the family and the community.
They also reduce workloads for healthextension workers and provide animportant institutional link between
members and government.
CtC
The child-to-child (CtC) approachis based on the belief that children
can be effective agents of change.
Children are often responsible forcaring for younger siblings, tending
to animals, collecting water, andcleaning, and therefore there isconsiderable potential for children toraise awareness about hygiene. The
CtC approach facilitates children’s
understanding of healthy behaviour
and allows them to identify health/development priorities in a fun,challenging and interesting way.
CtC approaches are often integrated
into broader WASH programmes, andthey have had a particular impact
as part of health education andpromotion in schools.
Despite its noted success, there
has been some concern that CtC isteacher-centred and could lead tothe exploitation of children insteadof encouraging their empowerment;
therefore, facilitators must be properly
trained with this in mind.

Marketing approaches

WaterAid/Juthika Howlander

Marketing approaches combine
enterprise approaches with demand
stimulation, and assume that people
both want and are able to change
3Technical brief

Sanitation and hygiene approaches
after contact with faeces. It uses
radio, theatre groups and face-toface domestic visits to communicate
its messages. The focus on a small
number of practices means a small
number of messages, which increases
the likelihood of users picking up andchanging behaviour. It relies on a mixof different types of promotion, frommass media to house-to-house visits,
which makes monitoring relatively
resource-intensive and requires
trained field workers.
WaterAid/GMB Akash/Panos

Debashish, son of
the WASH committeepresident, plays ahygiene education
board game with hisfriends, Lakatoorah
tea garden, Sylhet,
Bangladesh.

their behaviour. It focuses on thefollowing:• Product (eg a handwashing facility,service or behaviour)• Price (eg price of soap may have an
impact on how much people use)
• Place (eg products need to be easilyavailable)• Promotion (eg to encourage
adoption of certain behaviours)

Latrine options at the
newly establishedsanitation centre,
Mwakashanhala
village, Nzega
district, Tanzania.

Marketing approaches may facechallenges if no strong enterprise
culture exists, and they may notalways reach the poorest people
without sufficient resources to invest.
SaniyaSaniya is a hygiene communicationcampaign focused on handwashing

PPPHWS
Public private partnership forhandwashing with soap (PPPHWS)
combines the marketing expertiseand consumer focus of the soap
industry with the institutional strengthand resources of governments. The
approach targets those most at risk
(particularly mothers and children)and brings together the skills of theprivate and public sectors as well as
various development partners. Whilerequiring significant resources to
run large handwashing campaigns,
public private partnerships can beslow to show results, and there can beresistance to the involvement of theprivate sector.
TSSM
Total sanitation and sanitation
marketing (TSSM) focuses on
generating demand and increasing
supply of sanitation products andservices, and creates drivers for goodhygiene behaviour through marketinghygiene-related products such assoap. It is designed to complement
community methods like CLTS byenabling community members to
upgrade their latrines over time.
TSSM supports public financing formarketing to achieve public healthgains, as well as private investment in
latrines for private gain. A challenge
for the TSSM approach is that it may
not reach the very poorest people.

WaterAid4

Technical brief

Sanitation and hygiene approaches

A note on menstrual hygiene
management
Research on menstrual hygiene
management indicates that
inadequate facilities for cleaningand disposing of menstrual hygienematerials can have significant health
implications for women and girls,
and affects school attendance rates.
Hygiene promotion programmes
should therefore include a focus oneasy and affordable access to sanitarynapkins and facilities for safe anddignified disposal after use.

References
WaterAid (2013) Hygiene framework.
WaterAid, London, UK. Available at:www.wateraid.org/publications
Peal A, Evans B and van der Voorden
C (2010) Hygiene and sanitation
software – An overview of approaches.
Water Supply and Sanitation
Collaborative Council (WSSCC).
Available at:www.wsscc.org/node/745
House S, Mahon T and Cavill S (2012)
Menstrual hygiene matters. WaterAid,London, UK. Available at:www.wateraid.org/mhm

Useful websites
The World Bank analyses a numberof hygiene promotion approaches
as part of a Sanitation, hygiene andwastewater resource guide. These canbe accessed at:
http://water.worldbank.org/shwresource-guide/promotion/hygienepromotion-approaches

5Technical brief

Sanitation and hygiene approaches

Case studyReferenc The Mtumba approach‘Mtumba’ is a hybrid of CLTS, PHAST
and PRA piloted by WaterAid. Rural
areas of Tanzania have very low
basic sanitation coverage, with little
improvement being noticed in the last
decade. The Mtumba sanitation andhygiene participatory approach wascreated in Mtumba village, Dodoma
region, and has been successfully
trialled in other areas of Tanzaniabetween 2008 and 2011. It focuseson improving latrine quality andquantity, while ensuring equitable
access to latrines and safeguarding
sustainability. Key actions included
training and empowering artisans andcommunity animators, constructing
sanitation demonstration centres,
capacity building for district
sanitation teams, and lobbying
the district health department foradequate sanitation budgeting.
Evaluation by the National Institutefor Medical Research observedthat during the pilot programme
the number of households lacking
latrines significantly declined, whileconstruction of latrines (particularlyimproved pit latrines) greatly
increased. Key changes noticed byparticipants included: a decline
in open defecation, safe disposalof children’s faeces, and proper
handwashing. There has also beena dramatic decline in the occurrenceof diarrhoea and other water-related
illnesses, particularly in the laterstages of implementation.
Since the pilot, Mtumba has
been replicated in other areas of
Tanzania, being enthusiasticallyreceived by several district councils,
and will now be scaled up as partof a national sanitation campaign.
However, there is still a shortfall interms of hardware availability, withthe transportation of construction
materials to rural areas proving
problematic. Mtumba has proved
successful in raising demand for
improved sanitation, but markets
must be able to meet that demandin order for the full benefits of the
programme to be realised.

Endanyawish village,
Mbulu district,Tanzania

WaterAid Tanzania

6Technical brief

Sanitation and hygiene approaches

WaterAid transforms lives by improving accessto safe water, hygiene and sanitation in the world’s
poorest communities. We work with partners andinfluence decision-makers to maximise our impact.
Registered charity numbers:
Australia: ABN 99 700 687 141
Sweden: Org.nr: 802426-1268, PG: 90 01 62-9, BG: 900-1629
UK: Registered charity numbers 288701 (England and Wales) and SC039479 (Scotland)
US: WaterAid America is a 501(c)(3) non-profit organization

7