Training Manual on Behaviour change in Brick Kilns via Hygiene Promotion

A.Session Plan:
COMMUNITY HYGIENE & SANITATION AWARENESS SESSIONS OBJECTIVES To improve the knowledge of 100% of the target beneficiaries regarding sanitation & hygiene practices trough the implementation of community hygiene & sanitation awareness sessions. And ensure the use and maintenance of filter, latrine and the buckets. PLANNING 6 different topics will be exposed during 2 different sessions. Each session will last approximately an hour and 2-3 topics will be presented per session. Each Commnity Motivator ( Chhimeki) will manage ~200 People ( about 40 clusters) in each brick Kiln . The objective for each day will be to conduct 2 different sessions according to the beneficiaries needs (i.e. morning, noon and evening sessions for men/women/children/moulders/firemans/transporters, etc). Each session will be organized for Max. 30 people. And in one day 3 sessions.. so 20-30 jhyauli per day. ( 1 male, 1 female and all kids will be covered.), for 1st session they will complete 200 Person in 10 days. The TF will also assist the SM in Conducting Community sessions. For the HH visist each TF & SM will visit 10 HH per day and thus 50 HH in a week with planned sessions and keep notes of observations too.

Hygiene Session 1
Planning: 1. Introduce staff, activities, and objectives of Hygiene & Sanitation session: Through improved hygiene practices to improve health status and therefore to improve nutritional status. Personal Hygiene IEC tool: Personal Hygiene based on our hygiene kit 1. Discuss about personal hygiene practices, frequency and reasons. 2. Explain that people should bathe AT LEAST WEEKLY, especially during the warmer months, with soap and all the body. 3. Wash clothes regularly with soap and change clothes regularly. 4. Explain that nails should be kept short and clean since faeces and dirt can easily get under the nails. They then enter our mouths when eating, especially when children put their hands in their mouths.

Topics: 1.

Manual for Behavior change via hygiene promotion in Brick Kilns

5. Explain that it is important to have good teeth until we reach an older age, since we need to be able to eat properly. Brushing our teeth with toothpaste prevents teeth from decaying, and gives us better breath. 2. HANDWASHING 1. Explain the role of handwashing as a barrier on the F-O Diagram. 2. Ask beneficiaries the following questions: When was the last time they washed their hands, and with what? What are the key times they wash their hands? What handwashing materials do they use during those key times? Why do they only use water for handwashing? For those using other materials, what motivates them to wash their hands with these materials? Key times for Handwashing IEC tool: HW Key times with photo of WASH area we have built 1. Explain that the key times for handwashing to remember are: after defecation after contact with children/animal faeces before cooking before eating/handling food or drink Before breastfeeding Emphasize on After Defecation or Contact with Faeces and Before Eating, always With Soap/Ash. 3. WATER SUPPLY/TRANSPORT/STORAGE/FILTERING Using Water from protected Well and Taps IEC tool: Safe drinking water with well and tapstand Poster Photo of filter with its benefit and using steps 1. Ask participants the following questions: Which water sources they currently use for drinking water? What contaminates your water sources? What are the risky hygiene practices at water point/source locations? What can you do to keep the water point clean at all times? 2. Brainstorm all the activities they can do to improve the water source environment. 3. Message: People should drink from protected spring and at use for drinking after filtering only. Contamination of Water during transportation 1. Ask people how do they fetch their water (since they leave house with empty jerrycan until they arrive back home). 2. Explain that water container should be cleaned everyday (wash hands before cleaning it!). Cover container during transportation.

Manual for Behavior change via hygiene promotion in Brick Kilns

 Contamination of Water at Household Level/ Safe Water Storage 2. Ask the participants how they store drinking water in their houses. 3. Explain the importance of putting water pots above ground level on a stool or cupboard shelf, and covering the water pot to avoid pollution from children/animals (chicken, dogs). 4. Explain that the pouring method is better than dipping the cup in the container, since it prevents direct contact with hands. 5. Explain that all materials such as water containers, glasses, cups, jugs, etc. should be washed regularly with ash and water before storing or drinking water. 6. Explain them the function of filter we have provided and use and maintenance steps.

Hygiene Session 2
Planning: In community Session, Start with the refreshing of the content of first session by brainstorming. For HH Visits: First do follow up of last session by taking notes and reminding them the messages of the first session and start providing this session contents. 1. PREVENTION OF DIARRHOEA/Excreta Inhalation 1. 2. Relate Diarrhoea with death. Explanation of Diarrhea F-O Transmission Diagram and barriers. Ask the beneficiaries how diarrhea can be transmitted. Brainstorm ideas. Explain F-O diagram on a participatory way (transmission routes and main barriers). Once filled ask people to explain it.

IEC tool: F Daigram in Nepali

2. Use & Importance of Latrine Including operation & Maintenance Review main 4 F-O routes and emphasize that 3 can be cut by using a proper latrine.

Discuss the advantages of latrine:

Diarrhea reduction. Cleaner-looking compound. People cannot smell or see faeces. Privacy from men and other people Safety at night Colse to house Protection and comfort from rain and snow and wild animals Convenience for young children, sick people, pregnant women and elderly. Save time looking for a place when you are working Could be used for personal hygiene

Manual for Behavior change via hygiene promotion in Brick Kilns

 Disposal of Childrens and Sick peoples Faeces 1. Ask people how young children under 5 years and under 10 years defecate. What do they do with the faeces? How do they wash the children under 5 years? With just water or with ash/soap? 2. Explain to them that childrens faeces can be more harmful than adult faeces and can make them sick. Make sure childrens faeces are disposed of properly and do not defecate in the surroundings. If children are too small, then find different solutions. 3. Sick peoples faeces are also more harmful than healthy peoples.

IEC tool: Why use latrines? Use Latrines daily with our latrine
picture Prestige and clean jhyauli 3. Food Hygiene & Waste Disposal IEC tool: Clean Jhyauli Vs Dirty Jhyauli Including Kitchen Bed 1. Ask people what is food hygiene and is it important (link it to F-O diagram routes and barriers). 2. Cover all food and water from flies and mosquitoes to keep them clean and free from faeces/dirt. 3. Wash hand with ash/soap before cooking and eating!!! 4. Wash fruits and vegetables with safe water properly before eating/cooking. It is best to add salt to water and soak the vegetables for 30 minutes before rinsing them and eating. 5. Explain that all cooking and eating utensils, dishes, cups should be washed properly with ash/soap before use, and stored cleanly away from flies and dust. The utensils will last longer if maintained well. 6. You should reheat food thoroughly before eating. Make sure it is very hot. 7. Children should not eat food chewed by their mothers, it can transmit disease (options like soaking food in water, milk, dal, 8. Discuss with people how do they manage their domestic waste/waste water and why. 9. Explain to participants garbage is full of disease-causing particles which attract flies and animals. 10. Solutions: Discard organic garbage in a compost pit and cover with soil. Burn plastic to reduce flies, insects, and rats. This will keep your compound clean, and keep the children from getting dirty. The village will look much nicer and pleasant to be in. 11. Remember to wash hand with ash/soap after cleaning the house!

Manual for Behavior change via hygiene promotion in Brick Kilns

HP Session #3 Refresher session including all topics and follow up. REPORTING Daily reporting for daily activities (diary keeping). For each Session: #people and names of attendants (ask for signature)/kind (children, male, female, elders, castes)/Topics discussed/Remarks/Problems/etc Objective 3 sessions per day, if not achieved justification. Ideas to improve sessions

Manual for Behavior change via hygiene promotion in Brick Kilns

HOUSEHOLD VISITS HYGIENE & SANITATION AWARENESS SESSIONS OBJECTIVES Once knowledge regarding hygiene practices has been enhanced through the community sessions, the objective of HH visits will be to give practical advice to 100% of the HH beneficiaries in their houses. The idea is to observe the practices of people and to give advice on how to improve in case that these practices are risky. PLANNING At least 3 visits will be done for each HH. VISIT 1. - Introduction of Staff and Programme. - Checking and searching for risky practices in the house. - Give advice in case that risky practices are identified. - To set objectives to improved practices for the main (1-5) risky practices identified. These objectives will be checked in Visit 2. VISIT 2. - Reintroduction of Staff and Programme. - Checking for Objectives planned in Visit 1. - Re-checking and searching for additional risky practices in the house. - To set new objectives in case that former ones achieved and to retake previous objectives in case they were not achieved. These objectives will be checked in Visit 3. VISIT 3. - follow up of session 1 & 2. REPORTING 1 file per HH. For each HH: Village/#people/children/caste/ For each Visit: Date/Risky practices/Objectives/Achievement/Comments/

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B.Knowledge for Trainers

Health promotion to Hygiene Promotion:
Diarrhoea is one among leading causes of child illness in brick kilns. Improvements in water supply and sanitation have helped cut the incidence of diarrhoea/faecal-oral diseases. TDH therefore integrates hyagiene & sanitation awareness activities as part of child protection programme. The most successful approaches to diarrhoea prevention are: 1. Improving Water Quantity (Storage Tanks, Pumping, Water container distribution) 2. Improving Water Quality ( HH filter distribution, Well Protection, Bucket with lids) 3. Improving Safe disposal of Faeces (TDH WASH and Hygiene & sanitation awareness) 4. Handwashing after contact with Faeces (TDH Hygiene & sanitation awareness sessions via chhimeki) Human faeces are the main source of diarrhoea. 1 gram of human faeces can contain = 10 million viruses, 1 million bacteria or 100-1000 parasite eggs!1 They can pass through many routes (See F-DIAGRAM) but they all come from one source: faeces.

F-DIAGRAM : We are trying to reduce Faecal-oral diseases (Diarrhoea) by:

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1. Improving Water Quantity = allows increased washing of hands and food. (5-Fingers and 2. 3. 4.
9-Food on F-Diagram) But if increased amounts of water are still contaminated, it will not prevent diarrhoea. Improving Water Quality= prevents contamination of drinking water. Interventions include water source protection, safe transport and storage techniques, and household level water treatment. But it only targets one way which faeces are ingested. (8- Fluids on F-Diagram) Improving Safe Disposal of Faeces= prevents faeces from contaminating water sources, the environment, and food. (1,2,3 -Fields, Food, Flies on F-Diagram) Improving Handwashing after Contact with Faeces= prevents faeces from contaminating all pathways- water, environment, food, etc. (5- Fingers on F-Diagram)

We cannot target ALL prevention barriers effectively and therefore we are focusing on The primary barriers to prevent diarrhoeal disease or faeces inhalation are: Key Hygiene Practice Impact Handwashing with Soap, ash, etc. after contact reduction in faeces inhalation with faeces (at key times) Using a latrine and disposing of childrens reduction in faeces inhalation faeces in it Using safe water for drinking and cooking reduction in faeces inhalation Promoting proper waste management Reduced pollution Classification of Water/Sanitation-Related Diseases2 Type: Faecal-oral diseases Water-borne (contributes to epidemic diarrhoea) AND Water-washed (endemic/continuous diarrhoea) Only Water-washed= lack of water for washing Only Water-borne= contaminated drinking water. Parasite lives in aquatic host. Water-related vector Examples: Non-bacterial: Dysentery, Giardia, Hepatitis A. Bacterial: Cholera, Soil parasites: Roundworm, Hookworm etc. Scabies, body lice, Trachoma Worms Malaria (anopheles) , Dengue fever, Yellow fever (aedes),

Water Quantity: Increasing access to water allows larger amounts of water to be used for drinking and for washing purposes. Limited amounts of water results in: 1. Lack of drinking water 2. Lack of water for cooking 3. Lack of water for handwashing 4. Lack of water for bathing
2

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5. Decrease in productivity and time for child caring from time spent collecting water 6. Decrease in workers income because of more time spent on collecting water in stead of
brickwork. 7. Increase in chronic diarrhoea.and the list goes on.. Providing an overhead water tank with a pipe distribution system pumping from a well- will: decrease the time spent fetching water decrease the distance to travel increase the liters of water per jhyauli increase accessible to a larger number of jhyauli in brick kiln. Water Quality Water can become polluted through man-made faecal contamination. Water can be contaminated directly or indirectly with faeces through the following factors: 1. Unsafe disposal of faeces/open defecation near well/water sources 2. Direct contact with water 3. Improper transport/storage/handling of water 4. Flooding/ infiltration 5. Animals 6. Flies 7. Wind (open defecation) if container is not covered. Interventions to address the contamination paths include: 1. Protection of wells: a. Well Rehabilitation b. Prevent open defecation by using latrines 2. Proper handling/transport/storage of water from tapstand to point of consumption a. Preventing hands/feet from having direct contact with water. b. Keeping drinking water containers separate from other uses. c. Cleaning drinking water containers regularly. d. Storing water containers/vessels with proper lids (no holes, cracks) 3. Household level treatment: a. Using filter distributed. Safe Sanitation (Stool Disposal) Faeces causes diarrhoea and is transmitted to humans through hands, flies, the environment and water. The only way to contain faeces is to dispose of faeces properly through: 1. using a latrine 2. not open defecating. 3. disposing of childrens faeces in a latrine 4. handwashing after any contact with faeces (after defecating, or cleaning a childs bottom) A well- maintained latrine should have the following criteria: Smell-free No flies Easy to clean Safe- no direct contact with faeces

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Have enough privacy for females Have enough water Have handwashing materials (ash/soap) Child-friendly- safe and easy to get into without falling Sustainable for at least 3 years

Remember that built latrines are useless if they are not used by everyone in the brick kiln. Childrens faeces still need to be disposed in a latrine to reduce contamination in the environment. A motivator is an interpersonal reaction or feeling that pushes a person to perform or to do a safe hygiene practice. As we are human beings, we have our own motivation to do something. For example, I use a latrine not because I immediately think about preventing diarrhea, but because I dont want others to watch me defecate. In this case my motivator is privacy, even though I know very well using latrines will prevent diarrhoea in the long run. It is not realistic to say that I think about preventing diarrhoea each time I look for a latrine! Therefore, Knowing does not mean doing. It is the hygiene promoters job to figure out the real reasons that will motivate beneficiaries to do safe hygiene behaviours. There are some examples of social motivators for using latrines: Convenience- saves time looking for a place to defecate as workers can earn much if they work for much time People cannot smell or see faeces and flies Cleaner brick kiln environment Visual privacy for females More comfortable, avoids exposure to rain Less embarrassing in front of others These motivators can be used as positive messages for promoting latrine use with people. Handwashing Bacteria which live in faeces cannot be seen by the eye, and they cause diarrhoeal diseases. We get faeces on us from walking through places with open defecation, touching with people who have just defecated, playing with animals, etc. When we eat with our hands, we ingest the bacteria. Washing hand with clean water and ash/soap is the only way to remove faeces from hands. The key times for handwashing with ash/soap include: 1. before eating 2. before handling food/cooking 3. after defecation 4. after cleaning childrens bottoms (because excreta of children contain more bacteria/viruses than the ones of adults) Wetting, rinsing, or dipping hands into the water is not enough to remove particles present on hands. Hands must be scratched or rubbed together to effectively remove faeces. Water itself is not efficient to remove faecal particles. We need handwashing materials such as ash, soap, salt, clean sand, etc. Motivators for handwashing is very important because telling people that hand washing prevents diarrhoea does not work, and people do not change their behaviour for that specific reason. Examples of motivators: Disgust e.g. oil , dust, blood, etc Fear of contaminating object or event e.g. handling someone with skin disease

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remove smell and dirty things on the hand Hands look clean Habit eg. (Following practices taught by mothers, teachers ) Spiritual cleanliness eg. Washing before praying Self-Esteem eg. (feel good, confident) Social status e.g being proud of myself and physical image Peer pressure to wash hands when other children are looking.

Barriers Hygiene behaviour does not change by knowing hygiene education or messages, so it is important to identify barriers and find appropriate to overcome the barriers. Examples of barriers for handwashing and safe sanitation: No soap and water facilities available near latrines OR no alternative solution. (Hygiene Kit) Water looks dirty (no one will touch it) The soap is made dirty by previous users No social motivator to put pressure on children to Handwash properly, and others not setting a good example to follow (parents, teachers, friends, etc.) Most people accept open defecation practices in the community Belief that childrens faeces are harmless No resources to build their own latrine at brick kiln No water available nearby to maintain latrines Hygiene & sanitation awareness Hygiene & sanitation awareness is a planned approach of encouraging people to adopt safe hygiene behaviour to prevent water and sanitation-related (diarrhoeal) diseases at the household level. It focuses on peoples knowledge, but most importantly, what they actually do (behaviour) and want (motivators). Hyagiene & sanitation awareness combines learning opportunities with community participation in order to change high-risk practices and to improve use/maintenance of facilities. Challenges of Hyagiene & sanitation awareness Water and Sanitation hardware by itself cannot improve health very much; what matters is the way in which it is used, and the ways in which it may promote changes in hygiene-related behaviour. It is easy to encourage people to increase the amount of water they use for washing if it is available at the jhyaulis. But it takes a lot of time and effort to change dangerous practices which are considered safe, or are simply not thought about (due to cultural/social habit). Example: handwashing after defecation with water only.

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In many cases, the faeces of young children are considered safe. In fact children are the main victims of faecal-oral diseases, and they are more likely to contain the disease-causing bacteria or viruses. The faeces of children are more infectious than those of adults! The practice of washing hands with soap after defecation is another example of a behaviour that does not follow if more water and sanitation facilities are provided. However this has a major health impact! Health or hygiene education is a more directive approach which aims at transferring knowledge to other about aspects of hygiene/health. However increasing peoples knowledge on hygiene is NOT sufficient enough to change their risky hygiene practices. It is our job to figure out the real reasons people are motivated to change their behaviours, as well as the barriers they face which stop them from doing so. Why has Hygiene Education failed by itself? Hygiene education can have poor results because of the following problems:

1. New knowledge can be an overload. Hygiene education does not start with what people
already know, and new ideas can conflict with their beliefs, leading to rejection.

2. It assumes medically trained personnel are automatically believed and listened to. In fact 3. 4. 5.
there are other secondary target groups which have huge influence on peoples behaviour, such as local authorities, elders, mullahs, etc. Germ theory education is not effective and takes a long time to learn. Avoid negative messages based on threat of disease and scientific-based germ theory, since it is difficult for people to relate to. Health education alone cannot reach large populations. It is not possible to reach all childcarers or women in this region. IT is necessary to use other communication channels and activities to increase access to target groups. New ideas about disease/medical models will not replace medical anthropology beliefs. It is useless to fight against old beliefs, and we have to accept people will continue to have them. We just have to work with the positive beliefs.

6. Knowing does not mean doing. We cannot assume increased knowledge about
germs and diarrhoea will directly lead to behaviour change. Even with perfect knowledge, there are barriers to behaviour change, and we need to overcome these. The Hygiene Improvement Framework (HIF) is a model to help our field programmes achieve objectives. All three components- access to hardware, hyagiene & sanitation awareness/software, and an enabling environment- are necessary to reach any significant hygiene improvements in target areas.

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Access to Hardware Water supply Sanitation facilities HH container/filter/hygiene kits

Hyagiene & sanitation awareness/ Software Behaviour change methods Community Participation/Problem Solving

Hygiene Behaviour Change

Enabling Environment Improved Policy Community organization Cost recovery Partnerships/Aid

Component Beliefs, attitudes (individual) Subjective Norms (community)

Enabling Factors

Influences Culture, values, traditions, mass media, education, experiences Family, community, social network, culture, social change, power structure, peer pressure Income/poverty, sanitation services, womens status, inequalities,

Actions needed HH Sessions Hh sessions

Increased time/earning

Brick Kiln What are risk practices?

Motivators Plan Target practices Which can are most widespread? Which ones can be altered? Target Audience Entrepreneurs Message positioning (habits/motives/barriers) What are perceived advantages of safe practices? Media mix

Who is causing risk? Who is influencing them? What drives practices?

Methods Checklist observation, community mapping, Baseline Survey Structured observation, FGDs, FGDs, interviews,

How do they communicate?

Interview representative

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sample of target audience, FGDs Community Participation/Mobilisation Community participation means involving beneficiaries in programme activity needs assessment, planning, implementation and monitoring. In hyagiene & sanitation awareness it is crucial that we use participatory approaches instead of focusing on traditional methods of education such as lecturing, and imposing our ideas and solutions on the community. Advantages of beneficiary involvement include:

1. Appropriateness: Communities know more about WASH/hygiene issues based on their

collective experience and knowledge. Using their knowledge our activities will be adapted to their context and will encourage behaviour change. Communities can inform us on how to deal best with problems they face. Ownership: When people understand a problem, they will be more willing to solve it and take responsibility for management and maintenance. Sustainability: Solutions, modifications, and interventions will be more sustainable in the long term if they are relevant to their needs.

2. 3.

Levels of community participation can range from: 1. Supplying information ( identifying hygiene risks) 2. Consultation (input of users in design of water points and latrines) 3. Providing labour (for construction of latrines) 4. Empowerment (operation & Maintenance)

Gender Issues It is important not to forget the vulnerability of women in the community and social context, as well as considering their role and status in water, sanitation and hygiene provision and management. It is our duty to respect their roles, opinions, interests, and needs at different stages of the programme activities. Social context: Difficult to have physical access to women Women have less access to information; difficult for them to share knowledge. Females have less access to education due to domestic role Role in Sanitation & Hygiene: Involved in unsafe hygiene practices such as disposal of childrens faeces Responsible for water fetching, cooking, washing, household water management and treatment. Huge role in childcare, education, and teaching children hygiene habits such as handwashing with soap/ash, etc. Excluded from decision making at kiln and cannot make decisions for womens needs.

What we can do is to ensure their involvement systematically in programme designing, planning and implementation.

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Examples of application in programme activities: 1. Trying to get direct access to women in household visits or holding separate focus group discussions (FGDs), to find solutions to barriers. 2. Directly supporting women in maintenance/cleaning of family latrines since they are usually the ones responsible. 3. Promoting safe stool disposal for children in latrines and handwashing with soap/ash, etc after cleaning their childrens bottoms. Household Focus Most hygiene behaviour is centred at the household level. Although TDH is increasing access to water and sanitation facilities at the brick kiln with group modality, it is important that we stress change at the household level for sustainability. Changes to public facilities are unlikely to improve health unless we reduce contamination at the household level. People are more exposed to contamination in places where they spend the most time. Start from the home! Similarly when you look at your primary target population that has risky hygiene practices, you must also start from children and mothers who not only get infected, but are most likely to spread the disease.

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