Hygiene Promotion for Household Water Treatment and Safe Storage in Emergencies | Water Purification | Hygiene

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  Hygiene promotion for HWTS December 2012 1 Introduction It is now well accepted that despite source water being safe, water can be contaminated during transportation and storage and the hygienic handling of water during transport, storage and use is an important aspect of hygiene promotion in all WASH interventions. In an emergency, it may not always be possible to ensure that the source water is clean (within the existing budget or time constraints) and household treatment of water is an important response option. As with the introduction of any hardware, this will only succeed if the users are considered in the selection, operation and maintenance of the treatment option and intensive hygiene promotion will be required to encourage correct and consistent use. The promotional aspects of the following water treatment methods that are most commonly used in emergencies will be considered: 1. Boiling 2. Chlorination (including tablets or liquid) 3. Flocculation/disinfection sachets (including PuR® and WaterMaker®) 4. Natural filtration and flocculation methods (sedimentation, cloth filtration, moringa seeds, alum) 5. Ceramic filtration (including pot- and candle-style filters) 6. Membrane filtration  An existing technical brief (TB4) provides information on the technical household water treatment and safe storage (HWTS) options but has limited detail on the promotional aspects that are required. This short briefing paper is aimed at hygiene promoters and engineers who are working with communities on HWTS. It may also be useful for managers to understand how to ensure the effectiveness of HWTS interventions. It should be read in conjunction with TB4. Safe water collection and storage Household water treatment will not always be required if it is possible to provide an alternative safe water supply for consumption, but promotion will always need to consider how water will be transported, stored and used in the household. Even if household drinking water is treated, it may still become recontaminated through storage in dirty or uncovered containers or through contact with dirty hands and utensils. Chlorination can help to reduce recontamination if residual chlorine levels are kept at a reasonable level and it is important to try to understand how long people store drinking water in the household when providing chlorine. All other household water treatment methods (HHWT) risk recontamination. Handwashing Improved handwashing can help to ensure that water does not become contaminated and must form an important aspect of any hygiene intervention. Current recommendations suggest that it is better to simplify the promotion as much as possible by focusing on only two key times for handwashing (before eating and after defaecation) and promoting a simple message such as „wet, lather, rub and rinse‟ rather than including too many steps in the handwashing process 1 . An Oxfam briefing paper is available on handwashing. 1  See  http://tinyurl.com/7xdl6lt  for more information   Hygiene Promotion for HWTS in emergencies Figure 1: Contamination of water in household  Hygiene promotion for HWTS December 2012 2 Collection and storage containers Sphere recommends that “each household has at least two clean water collecting   containers of 10-20 litres, plus enough clean water storage  containers to ensure there is always water in the household.” The containers should either have a lid or be narrow necked to limit environmental contamination. If containers are not clean then consideration could be given to distribution or to regular mass cleaning of the containers. This is usually carried out at water collection points but could also be done in neighbourhood groups. The steps for cleaning are 2 : 1. Drain the container 2. Scrub the inside of the container using an abrasive (soft bristles or small stones) and a cleaning agent (solution of chlorinated water or soap and water). 3. Clean the exterior of the container with a cloth and soap or chlorine solution, paying particular attention to the area around the neck and lip of the container 4. Rinse container with clean drinking water to remove cleaning agent residue In addition to regular cleanings, in camps or densely populated settings, Oxfam recommends periodic super chlorination of all receptacles, an example of which is presented in the box opposite. In some cultures large water containers (20 litres or more) are rolled along the ground. This poses no risk of contamination if the lip of the container does not touch the ground and avoids the backbreaking work of hauling water back to the household. Using / drawing water in the household It is important to avoid contaminating drinking water with hands when using a cup or scoop. Ideally water should be drawn from a tap or spigot that is kept off the ground. If this is not 2  Taken from Technical Briefing Paper Number 4 available then water should be poured from the storage container or a separate, dedicated scoop or cup should be used.  Again this must be kept off the ground. Promotional methods for HWTS Whilst the mass media (e.g. television, radio and leaflets) can be used to promote a specific household water treatment method, it is important that interpersonal methods such as training and demonstrations are also used, especially in emergency settings where the risks to health are high and people need to be enabled to act quickly. If a specific household water treatment is to be introduced, try it out yourself before designing the promotional materials. Then if possible test your materials on a small number of participants to obtain feedback and adapt them before large-scale promotion. Case study 1: Chlorine disinfection campaign in Darfur In June 2004, an outbreak of shigellosis was confirmed in Abou Shouk camp in the Northern Darfur province of Sudan. As water testing at the source showed no contamination, it was assumed that post-collection contamination was happening. The decision was taken to launch a programme of mass disinfection of all water containers in order to break the contamination cycle. Five percent chlorine solution was used to clean containers. Approximately 100  – 150 millilitres were added to every container, along with some small stones. The container was shaken vigorously if it was closed or scrubbed with a local straw broom if open. Diarrhoea figures from the clinics showed a fall in cases following the disinfection campaign. Although it is difficult to collect statistically rigorous data, it does appear that the campaign had an impact on the prevalence of watery and bloody diarrhoea. Source Walden 2005   Successful uptake of HWTS is less likely if there are any more than 2 steps in the instructions. Think twice before introducing more complex treatment methods. Figure 2: Oxfam bucket with spigot  Hygiene promotion for HWTS December 2012 3 Key messages and information for each treatment method are provided in the respective section. Interpersonal Methods Interpersonal methods allow participants to ask questions and clarify misconceptions and, where populations can be accessed safely, these methods should always be included in the response. However, interpersonal methods are resource and time intensive and scaling up will require the identification, training and support of outreach networks. Demonstrations Demonstrations can be carried out at distribution or water points or in small local gatherings. Volunteers can be trained to carry out the demonstrations within their communities. It is a useful strategy to be prepared to sample the clean water produced in front of the audience so that they are convinced of its safety  –  especially when using packaged products such as PuR® or WaterMaker®. Training Training will need to be kept short and should focus on the practical skills required for water treatment, making use of both demonstrations and the opportunity to practice the skills learned. Volunteer networks and community leaders can be trained to train others in the use of the water treatment method. Training of trainers should include an action plan detailing what will happen after the training and how many people will be reached by future training. Follow up for ToT participants will need to be scheduled so that they can discuss any problems they face in training others. Discussion groups HWTS can be included in discussions with a variety of groups but should identify and prioritise those responsible for carrying out the water treatment or care of drinking water. This will usually be women or young girls. Discussion groups can include demonstrations but should also aim to explore any barriers to use.  A new approach to selecting HWTS methods known as SDM (structured decision making) 3  could also be used in a simplified form. This approach encourages participants to identify the key criteria for using a specific water treatment method (or other practice) such as ease of use, cost (time), taste, colour, safety etc. and to compare different water treatment methods such as boiling water or using PuR® using these criteria. Symbols can be used for the different criteria selected and a voting system using stones or seeds could be used to score each method. The benefit of using such a method is that it can generate discussion and analysis and help to identify the specific concerns of users. In emergencies, it could be adapted and used when monitoring the intervention. Other visual aids using pictures or symbols could also be used to generate discussion. Home visits Networks of volunteers or mobilisers can visit households to provide information on treatment methods. There may already be outreach workers attached to the local hospital or health centres and the involvement of local health staff to identify and support such outreach workers will be critical. Follow up home visits are crucial in ensuring that the water treatment method is being used effectively. 3  See http://onlinelibrary.wiley.com/doi/10.1111/j.1539-6924.2011.01675.x/full Figure 3: Criteria used to rank different HWTS methods Follow up home visits by community mobilisers are a vital part of promoting the optimal use of household water treatment methods.  Hygiene promotion for HWTS December 2012 4 Motivational interviewing techniques can be used to encourage uptake in households where resistance is high. This entails using specific person centred counselling techniques. Open-ended questions, affirmations and summarising techniques are used to encourage the person to consider their own internal motives for change and the facilitator „ nudges ‟  them towards engaging in „change talk‟ and action 4 . Mass media Mass media can reach large numbers of people quickly and can therefore be very useful in an emergency. However the use of the mass media will need to be combined with more interactive methods to be effective. Where possible interaction that gives people a chance to ask questions should be encouraged. Television and radio Whilst television and radio can reach large numbers of people, it must be remembered that the specific target audience may not have access to such media. For example the household may own a radio but only the male head of household listens to it or the radio slot may be broadcast at a time when the participant groups are busy doing other things. Ensure that any broadcasts are organised in co-ordination with the government and other agencies working in the area. The government may be entitled to free airtime from the broadcasting company. Leaflets It is important to consider the literacy level of the target audience and the language(s) used in the leaflet. Existing leaflets may be available from previous social marketing campaigns on HWTS. The provision of a leaflet is not a substitute for demonstrations of use. Remember to  : 1. Consult and collaborate with WASH experts and government bodies. 2. Ensure that discussion with communities has taken place to determine acceptability and the most user friendly instructions e.g. type of container to be used, type of chlorine 4  See http://mi.fhi.net/ for more information (e.g. household bleach, pre-packaged solutions etc.), potential problems with acceptability 3. Provide clear steps and illustrations where possible (see example leaflets) 4. Carry out a rapid pretesting of the leaflet 5. Monitor subsequent household use It is also useful to translate back into the srcinal language (using a second translator) in order to identify misunderstandings. Posters and leaflets Posters can be useful reminders of how to do something or when to do it. The instructions on how to use a household treatment method should be distributed with the product in leaflet or poster form, with the suggestion that these are put on the wall near to where the treatment is being carried out. They could also be stuck on the sides of water containers. Preparing posters or instruction leaflets from scratch can take some time but existing instructions for some products may already exist and will just need adapting. Mobile Phones In recent years more interest has been shown in using mobile phones for hygiene promotion. Instructions for water treatment methods can be sent on the phone and people can even have their questions answered. This method shows great promise especially for remote populations or where insecurity prevents access. Social marketing in an emergency   Other ideas for promotion o  Labels with instructions for treating water or maintaining the filter can be stuck on storage containers o  Calendars or small posters with information about keeping water clean to hang near to where water is stored o  Comics or games that focus on keeping drinking water clean for use with children or in schools
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