An interconnected approach to improving handwashing behaviors

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WASH and Neglected Tropical Diseases

More than 1 billion people worldwide suffer from one or more painful, debilitating tropical diseases that disproportionately impact poor and rural populations, cause severe sickness and disability, compromise mental and physical development, contribute to childhood malnutrition, reduce school enrollment, and hinder economic productivity. Five of these neglected tropical diseases (NTDs) can be controlled and/or eliminated with four to six years of mass drug administration (MDA). Although MDAs are key to reducing the spread of disease quickly and cost effectively, consistent reinfection occurs if behaviors and the environment remain unchanged. Schistosomiasis, soil transmitted helminths, and trachoma are all clearly linked to inadequate sanitation, contaminated food and water, and poor hygiene, which provide an opportunity for WASH-related approaches to help change behaviors and the environment.

The global NTD community has begun working together to address galvanize support for improved water, sanitation and hygiene (WASH) efforts to reach the control/elimination goals for NTDs in the coming 5-10 years. Two meetings were scheduled consecutively in September 2014 to discuss WASH and NTDs. The first was a roundtable in London organized by the SHARE consortium to review progress and advance activities in monitoring and evaluation and research. The second meeting was the annual meeting of the NTD-NGDO Network (NNN). The NNN meeting consists of several thematic meetings on the different diseases and working groups that culminates in two days of plenaries to report on the results of the thematic meetings.

WASHplus staff participated in the European Roundtable on WASH and NTDs and in the NNN meeting to discuss how to contribute to documents and materials being developed on WASH and NTDs. WASHplus has also started implementation of
its first WASH and Neglected Tropical Disease (NTD) activity in Burkina Faso, adding a facet of WASH integration to its
portfolio.

WASHplus Project in Kenya Shares Experiences in Transitioning Workshop

By George Nyairo Obanyi, FHI 360

george_obanyi1About the Author: George Nyairo Obanyi is the Information Officer for FHI 360/Kenya based in Nairobi. George provides communications support to the country office and field programs.

The USAID-funded WASHplus project ended its four years in Kenya with an experience-sharing workshop for key stakeholders held in Nairobi on September 25th 2014.

Representatives from USAID, government, other partners and community members converged for the one-day event during which the project showcased its achievements through plenary presentations, video shows and a photo gallery.

Kenya is one of seven countries where the WASHplus project works with partners to create supportive environments for healthy households and communities by creating and delivering interventions that lead to improvements in water supply, sanitation, and hygiene (WASH) and household air pollution.

In Kenya, the project partnered with the Ministry of Health to strengthen the capacity in public and private sectors as well as communities to implement sustainable WASH interventions.

WASHplus introduced and successfully promoted the small doable action (SDAs) concept, which has been accepted by government and other WASH actors to encourage hand washing, use of latrines, menstrual hygiene management and water treatment and safe storage.

Another key WASHplus achievement was its pioneering role in promoting inclusive sanitation approaches under an innovative, value-added community-led total sanitation (CLTSplus) approach to promote open defecation free (ODF) communties, which was successfully piloted in two rural counties and one urban site.

In its role as a national mechanism, the project helped to develop policies and training guides including a training curriculum for WASH-HIV integration and a module for training community volunteers.

Other notable achievements include:

  • Over 650 trainers from government and 8,000 CHWs trained on WASH-HIV integration and inclusive sanitation through Community Strategy
  • Improving access to sanitary pads for girls and women in communities
  • Community volunteers and leaders trained to help make supportive devices for individuals with disabilities

Interventions initiated and supported by WASHplus have now been transitioned to the government and other USAID-supported health projects.

Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem

Speaking at the experience-sharing workshop, the Deputy Director for Public Health at Kenya’s Ministry of Health, Dr. John Kariuki, said the WASHplus program had made strategic contributions to improving WASH interventions in the country.

“County legislators should now invest money to continue the process,” he said. “As we have worked with WASHplus, we will as a Ministry continue to give policy direction and guidelines to the counties.”

Said Dr. Kariuki: “The biggest lesson is about equity and sanitation. We cannot talk about a county being ODF if the people who are disabled or the old people are not using latrines. They are Kenyans and have a right to sanitation.”

The official urged stakeholders to lobby county governments to allocate funds for WASH activities:  “It does not happen automatically. You must be proactive, not wait for thing to happen.”

Representatives of organizations that partnered with WASHplus also praised the project for helping to shape the WASH interventions. Charles Ngira of the NGO Plan International said: “We should be talking of inclusive CLTS, not just CLTS. This model will totally solve our sanitation problem.”

Dr. Kariuki called for integrated CLTS programs that promote practices such as hand washing, menstrual hygiene management, the work of traditional birth attendants and air pollution, among other aspects.

“Let’s use CLTS as a vehicle to ensure we improve the health of our people,” he said.

“Sanitation has improved but we need to address equity and inclusion,” said Dr. Mores Loopapit, deputy project director of the USAID-funded APHIAplus Imarisha. “There is need to consider health outcomes in studies on access to hygiene and sanitation.”

Simon Makori, associate director of APHIAplus Nuru ya Bonde, urged stakeholders to support community health volunteers because they play a critical role on promoting WASH practices.

“Community health workers should be engaged in income-generating activities for sustainability,” he said.

For more information about the project, visit the WASHplus Kenya page: http://www.washplus.org/countries/kenya

Pic6_Charles Odira

Pic-4_Makena presents

Pic6_Charles Odira

Update from UNGA and TEDMED: Handwashing, Partnerships, Integration and Innovation

by Layla McCay

Cropped_headshot_reasonably_smallAbout the author: Dr. Layla McCay is the Director of the Public Private Partnership for Handwashing (PPPHW) Secretariat, housed at FHI 360. The USAID-funded WASHPlus Project supports the PPPHW in its efforts to promote handwashing and hygiene improvement. Follow Layla on Twitter: @LaylaMcCay

Partnerships and integration were the buzz words surrounding the UN General Assembly in New York in September. The Public Private Partnership for Handwashing secretariat delved into the deluge of international development players, with the purpose of seeking opportunities for handwashing, and learning about current issues in partnerships for international development.

A key message being reiterated in the development community over the course of UN General Assembly week is that as a community, we are becoming ‘post-public-private-divide’. There is increasing appreciation of the synergies and complementary roles of the different sectors, and an appetite to bring all players together to maximize impact. While that can be easier said than done, tendencies to either sanctify or vilify different sectors or particular players were deemed outdated; instead, the focus this September was on the benefits of working together to inspire and drive better practices all around. In terms of business, there was recognition that social good is starting to move out of the CSR/philanthropy departments to become business as usual, a business investment in efficiency and sustainability – which means we should expect more public-private partnering. Indeed, looking towards the successors to the Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs) are expected to be key drivers of the multi-sector partnerships that will be needed to deliver them.

Another persistent message during ‘UNGA’ was the importance of integration, as opposed to programming in silos. In the context of handwashing, this means exploring opportunities to integrate handwashing programs ‘horizontally’ into a range of sectors, such as sanitation, nutrition, maternal and child health, healthcare, HIV/AIDS, education, gender empowerment, economic development… but also considering how to integrate ‘vertically’, across the enabling environment, including investment in infrastructure and the social determinants of health. This approach is about harnessing the power of cross-sectoral partnerships to address a range of development challenges being experienced by a population, rather than focusing on single issues. It was striking how many of our development colleagues believed the barrier to meaningful, strategic integration was not just the practicalities of integrating on the ground, but the ‘single issue’ nature of funding for international development. For example, investing in school uniforms may help girls attend school – but to keep them in school, investing in menstrual hygiene materials and facilities may be needed too, but these two interventions may have entirely different funders and programs. The “celebrity couple” of nutrition and hygiene came up repeatedly, with the implication that this “couple” should think about taking their relationship to the next level, with greater integration of nutrition and hygiene work.

Integration across sectors for health promotion was also a theme at the TEDMED conference, which I got the opportunity to attend in September. You can read my general write-up of the whole event here. In terms of food for thought regarding handwashing, there was a compelling discussion about refreshing and diversifying messaging for health promotion. Using the example of breastfeeding promotion, one speaker noted that messages about breastfeeding for babies’ health are important but as these messages become increasingly familiar to people, they (a) risk losing their impact, and (b) only engage a subset of people. However by diversifying the messages to also make breastfeeding a women’s health issue, and a heart health issue (focusing on how breastfeeding reduces the mother’s risk of obesity and heart disease), new lines of engagement are opened, with the opportunity for new champions, new messages, new incentives, greater reach, more targeted appeal, and hopefully more uptake of the behavior. There may be useful lessons for diversifying hygiene messages to expand impact.

My first experience of seeing a ‘celebrity handwashing champion’ in action came in the form of Kajol, at Unilever’s Help a Child Reach 5 hygiene event with USAID. Her messages were simple, but her presence created a clear buzz. In addition to the keen interest of press in the room, some of whom told me they were there specifically to see her, it was interesting to see Kajol’s legions of fan clubs and fans around the world picking up and retweeting her handwashing messages (a tweet I sent about her reached over 100,000 people). This was an interesting insight into the potential reach of handwashing promotion messages from strategically selected and deployed celebrity champions.

Finally, the use of technology to improve hygiene is always an interesting question, and it tends to come up on these forward-looking platforms. It was inspiring, for example, to see examples from Unilever and MAMA of how mobile phones can be used to deliver hygiene education directly to pregnant women. At TEDMED, there was also some interesting discussion about crowdfunding health – using the web to set up facilities like Kickstarter to enable the public to directly fund specific health interventions in specific places. With the Millennials embracing this sort of targeted giving, there could be some interesting opportunities for crowdfunding hygiene in future. Throughout the events, there was significant talk about harnessing the voice, experiences, ideas, and energy of youth to drive progress.

TEDMED: 50 ideas that might just change the face of health around the world

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About the author: Layla McCay is a medical doctor and global health specialist, with a special interest in global health technology and innovation. She has worked across health policy sectors, from the World Health Organization and the World Bank to International NGOs and the British Government. She teaches international health at Georgetown University. You can find her on Twitter @LaylaMcCay

This post first appeared on the National Geographic blog here.

The most common overheard comment during TEDMED was “that could be a game-changer.”

The question of what exactly makes a “game-changer” is open to interpretation. Which of the nearly fifty ideas presented on the TEDMED stage this year will turn out to change the face of health and healthcare depends on where they spread, who receives them, and what is done with them. Since the game in question is health, our lives could depend on the outcome.

Opening the mind is an essential theme for a conference like TEDMED. Physicians were challenged as being ‘species snobs’ for failing to harness the knowledge of veterinarians to better understand and treat diseases in humans – and were entreated to use the animal kingdom, and diverse industries, to inspire innovations – like re-appropriating porcupine quills to seal wounds, or air bags for elderly people whose falls put them at risk of breaking a hip.

TEDMED’s speakers called for better detective skills to track down the true causes of ill health, from epidemics to drug abuse. Few threats to our health are new, so the typical question: ‘Why has this invader come amongst us?’ could perhaps become ‘Why is this pre-existing threat causing problems specifically here, now, to these people?’ That’s why an outbreak of dengue fever in Florida could be superficially attributed to the influx of dengue-carrying mosquitos from elsewhere – or attributed to a side effect of the recession (stagnant water in swimming pools expanding dengue mosquito breeding grounds, for example).

Jeffrey Karp, TEDMED. Photo courtesy Layla McCay
Jeffrey Karp, TEDMED. Photo courtesy Layla McCay

Opening our minds is not the only route our brains can take to better health. There are unexploited opportunities to harness how our brains work to make us healthier, whether you want to call it trickery or sophisticated brain stimulation. It turns out that if we take a pill that contains nothing but sugar, known as a placebo, it can still help cure our diseases – even if we know it’s a placebo. This effect could be harnessed to help heal our bodies from a range of illnesses. We can also try more sleep – there’s a theory that this might just help to reduce the risk of Alzheimer’s Disease, thanks to triggering the brain’s nightly bout of spring cleaning. And it seems we can heal better and feel better, just by adjusting our background light and the sounds we hear, especially in hospitals.

We can also use our brains to turn information into real life choices that promote health. For example, it is common knowledge that breastfeeding is healthy for babies, but less is made of the fact that breastfeeding is also healthier for mothers, reducing their risk of high cholesterol, diabetes, obesity and heart disease. On the other side of health promotion, rather than waiting for a resolution to the gun control debate, tech solutions could be adopted right now to reduce gun crime, like automatically stamping registered gun owner details onto bullets as they are fired. Technology can also help reduce ill health caused by healthcare – like a non-reusable syringe that helps prevent the many infections such as HIV caused by health workers all over the world reusing needles with different people, without sterilization in between patients. TEDMED Chairman, Jay Walker, explained that while the T in TEDMED stands for technology, “technology is not an answer – it’s a tool.”

But tools are needed in a health care delivery system that is driven by humanity. Doctors are not perfect machines: they have their own views and ethical values and skills and flaws, and are, by definition, fallible. Expecting homogeneity or perfection can be dangerous – recognizing the inevitability of error should be leading not to blame and shame, but to designing better safeguards.

But then again, the population is not perfect either. The requirement for legal organ donation to be entirely altruistic makes it a niche choice – and contributes to the huge organ shortage in places like the US. There are pros and cons, but perhaps there are lessons to be learned from Iran, where live organ donors are apparently honored, cared for and compensated, ensuring an influx of donors, meaning nobody who needs a new kidney has to die without one.

And as for patients, perhaps allowing themselves to be defined by an illness for too long may be a natural response to trauma, but it may also inhibit their recovery. And instead of trying to emulate ‘normal’, another, positive option is to boldly embrace differences, from the alternative thinking styles autism can bring, to festooning a prosthetic limb in chrome, glitter, or art.

Sophie de Oliveira-Barata, TEDMED. Photo courtesy Layla McCay
Sophie de Oliveira-Barata, TEDMED. Photo courtesy Layla McCay

Finally, TEDMED reminds its delegates that knowledge is fleeting, not eternal – what is once believed to be true may be later disproved. So we should avoid rigidity in our beliefs and keep asking questions. It is, perhaps, this thought that drives all innovation – and making us all understand this may be the real game-changer at TEDMED.

WASHplus Kenya End of Project Experience Sharing Workshop and Report

From January 2010 to September 2014 WASHplus worked with the Kenyan government to generate demand for sanitation; improve water, sanitation, and hygiene (WASH) practices among all households; and introduce simple supportive technologies to vulnerable households. The project supported the Ministry of Health (MOH) and its partners to integrate improved WASH practices into HIV policies, programs, and training. To do so WASHplus worked within existing structures under the MOH, such as the departments of Environmental Health, Sanitation and Community Health Services and the National AIDS and STI Control Program, as well as with other U.S. government bilateral partners—the APHIAplus projects and Centers for Disease Control and Prevention partners.

The two WASHplus program components—integrating WASH into HIV and advancing improved sanitation uptake—worked together to improve WASH practices across Kenya. The program objectives were to:

  • Assist government and NGO programs in Kenya to integrate improved WASH practices into HIV policies and programs, with special emphasis on inclusive approaches
  • Support uptake of improved sanitation practices using a community-led total sanitation (CLTS)-plus approach
  • Help to build a vibrant private sector to address demand for sanitation especially focused on quality latrines that meet minimum standards

What started as an activity to integrate sanitation and hygiene practices into HIV/AIDS care and support programs has grown over the years into a holistic approach to prevent diarrhea among households at risk. USAID’s WASHplus project helped communities and households in Kenya make the connection between improved sanitation, healthy hygiene habits, and positive outcomes for people living with HIV and AIDS (PLHIV), their families, children, the elderly, and other vulnerable households. Along the way WASHplus technical support, participatory training, partner engagement, and behavior change efforts yielded valuable lessons for other countries battling to improve sanitation and health outcomes in the context of uncertain funding. Innovation, flexibility, and commitment to working hand-in-hand with the government proved to be keys to the project’s success. With the government’s endorsement and adoption of WASHplus’s signature approach, small doable actions are likely to continue to resonate with many audiences long after the WASHplus transition.

On September 24th the WASHplus Kenya project held an end-of-project experience-sharing workshop in Nairobi. Photos from the workshop are presented below. The WASHplus Kenya end-of-project report “Integrating WASH into HIV Interventions and Advancing Improved Sanitation Uptake” can be downloaded from the WASHplus website.

Pic2 -Dr John Kariuki
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Kenya’s deputy Chief Public Health Officer Dr John Kimani addresses the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: Elisha Ratem
Caroline Vata, a government public health officer, presents a case study during the WASHplus Kenya end-of-project experience-sharing workshop  of in Nairobi September 25th 2014. Photo: George Obanyi
Caroline Vata, a government public health officer, presents a case study during the WASHplus Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: George Obanyi
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Evelyn Makena, WASHplus manager in Kenya, makes a presentation during the end-of-project experience-sharing workshop held in Nairobi on September 25th 2014. Photo: George Obanyi
Pic6_Charles Odira
Charles Odira of Plan International makes a point during the plenary session of an experience-sharing workshop held in Nairobi on September 25th, 2014 to enable other partners scale up its approaches. Photo: Elisha Ratemo
Pic5_CHW Kamau
A community health volunteer admires his own photo displayed in  gallery showcasing achievements of WASHplus program in Kenya. This was during the Kenya end-of-project experience-sharing workshop held in Nairobi on September 25th 2014 to enable other partners scale up its approaches. Photo: Elisha Ratemo
Pic7_Yatich with Dr Mores
Public Health Officer James Yatich explains about a commode he improvised for chronically ill patients. The innovation was displayed in a gallery showing the works of WASHplus program in Kenya over the past four years. Photo: Elisha Ratemo