Running head: HEALTH COMMUNICATION PROJECT

Health Communication Project

Michael Ferraro, Christopher Smith, Jennifer C. Zayd
The University of Saint Mary

Health Communication Project

Introduction
The National Cancer Institute (NCI) and the Centers for Disease Control and Prevention
(CDC) define health communication as the study and use of communication strategies to inform
and influence individual and community decisions that enhance health (U.S. Department of
Health and Human Services: Public Health Services, National Institutes of Health, National
Cancer Institute, n.d., p. 2). From this definition we can infer that a health communication
project is a project put in place to disseminate information to individuals or communities in order
to improve the health of a target population. This paper will analyze and discuss the USAID
Hygiene Improvement Project (HIP). This paper will establish the goals and objectives of the

project, how the target population was identified, how material was developed to support the
goals and objectives, how test marketing was completed and data gathered, and how successful
the program was in terms of obtaining their goals and objectives.
USAID Hygiene Improvement Project overview
The USAID Hygiene Improvement Project was a five year project running from 20052009 with the purpose of promoting sustainable at-scale improvements of three key hygiene
practices in at least two countries and through selected, and strategic activities ("HIP: On HIP,
rationale, team, etc," n.d., para. 1). The three hygiene practices that the HIP program focused on
were: safe fecal matter disposal, proper handwashing techniques, and safe storage and treatment
of water. The program focused on these key hygiene practices because worldwide, 20% of
childrens deaths are caused by diarrhea from unsafe water, poor hygiene practices, and
inadequate sanitation.

WASH
The Health Improvement Program rolled out a program called WASH to both schools and
those individuals positive with HIV/AIDS. The WASH Program stands for Water, Sanitation, and
Hygiene and was introduced in schools by parents, teachers, and student leaders (WASH, 2010).
These individuals were given resources and trained by members of the HIP program in order to
turn schools into WASH friendly schools. It is important to note that members of the HIP team
understood that different countries have different capabilities and values and it is for this reason
that while the premise of the WASH program stayed the same, it was adapted for each area that it
was introduced to.

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In order to increase support for establishing WASH friendly schools, HIP would recruit
supporters from such places as:
A champion organization such as UNICEF leading and convening
A coalition of public and nongovernmental groups to coordinate and implement the
program
Agreed-upon criteria for WASH-friendly schools (this guide can be used as a model)
A formal or informal agreement among key line ministries including the Ministry of
Education, Health, Sports, Youth, Water, etc.
Buy-in and participation of faith-based organizations this is key as they provide
education to a large proportion of youth
(WASH, 2010, p. 8)
When establishing a WASH friendly school, it was important for HIP members to discuss
adoption of an official policy endorsing the establishment of a WASH friendly school. Once that
was in place a plan for training teachers, parents and student leaders regarding the WASH
protocol was introduced. Training of evaluators who could evaluate how well the school was
complying with WASH friendly schools policy was necessary in order to make sure that the
schools kept up with the changes that were made in order to continue to be a WASH friendly
school. Development of a meaningful award to recognize the schools achievement as well as
establishing a WASH friendly school brand for the school to use was done in order to give the
school a sense of pride as well as let the general population know about their achievement.
Finally, there had to be resources available in order to support the building or reconstruction of
child friendly latrines with hand washing stations in the school (WASH, 2010, p. 8). Once all of
these criteria are in place, the work of training began.

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The training guide for the WASH program is a step-by-step guide with specific
instructions that fits into a two day, nine module workshop. The initial module discusses the
importance of clean water, proper sanitation, and hand hygiene. It requires the facilitators and
trainees do a walk of shame around the school grounds in order to assess for places that might
contribute to contamination. The guide is very specific suggesting that the facilitator point out
we end up eating each others shit (WASH, 2010, p. 17). Initially, this kind of language may be
considered crude and inappropriate to many Western people, but if we put it in a cultural context,
it has been specifically stated in order to bring a greater awareness to the seriousness of the
situation. After completing the walk of shame trainees are then given the task of calculating how
much feces are deposited near the school in a given day, week, or year in order to gain a better
understanding regarding the scope of the issue.
The third section of the workshop is an informative session where the statistical data
regarding the WASH program and its success are laid out as well as information on what changes
should take place in order to comply with being a WASH friendly school.
The fourth section of the workshop discusses routes of transmission and includes a short
story in order to humanize the information being given and the fifth goes into detail regarding
proper handwashing techniques and the importance of frequent handwashing especially before
eating and after using the latrine.
In the sixth section, the trainees are introduced to the concepts of clean water and given tips on
different methods that may be used to clean the drinking water at the school with an emphasis on
the water safety chain and not breaking the chain of cleanliness. This section also discusses the
pros and cons to each method of cleaning the water so that the school can pick the method most
likely to work with their population.

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The seventh section of the training guide goes in depth about the importance of using
latrines as opposed to open defecation and discusses practical needs and training techniques in
order to get the student population to adopt the use of latrine.
The eighth and ninth portions of the training workshop allow time for the parents,
teachers, and student leaders to work on their action plans so that they may turn their school into
a WASH friendly school and pledge to make the changes discussed. There is a tenth section open
to teachers that shows the teachers ways to increase excitement for both the teaching staff as well
as the students in regards to undertaking the WASH friendly school journey.
The WASH program has been very successful in decreasing instances of childhood
diarrhea with an estimated 40-50% decrease of instances of diarrhea noted at WASH friendly
schools.
While decreasing the instances of child diarrhea was high on the priority list of the HIP
program, it was also noted that WASH practices would be highly beneficial for those struggling
with HIV/AIDS and for this reason, the WASH program was adapted for this population as well
with the World Health Organization (WHO) working on the program in a joint project and
developing a toolkit in order to further the WASH HIV/AIDS integration program.
Focus on Sanitation
Proper sanitation in the countries reached by the Health Improvement Project was
found to be lacking. It was the assessment of the HIP team and sanitation specialists that the
governments of these countries (Ethiopia, Madagascar, Uganda, and Peru) lacked the funds to
improve the sanitation infrastructure adequately (EOP report, 2011). The findings suggested that
in order to improve sanitation, individual households would need to adopt improved sanitation
procedures. To do this behavior change messages that relied much more on socio-cultural

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normative approaches (e.g., peer pressure) than on health and hygiene improvement messages
were utilized with moderate success (EOP report, 2011, p. 19). In Ethiopia there was greater
success with decreasing open defecation as opposed to improved hand washing as barriers to
good hand washing such as an inadequate water supply, access to soap, and superstition related
to the use of ash existed. In Madagascar 88 villages became open defecation free while in
Uganda HIP was able to partner with local trade schools and encourage teaching and certification
of its students in sanitation hardware in order to increase the amount of individuals available to
improve sanitation infrastructure. The adoption of improved sanitation procedures in Peru has
been less successful than its counterparts. While the government of Peru lacks the funds to
improve sanitation infrastructure, the people of Peru feel it is the governments job to improve
sanitation and therefore adequate gains have yet to be realized.
While the focus on sanitation was not successful in all countries, a better understanding
of the needs and values of the countries was obtained so that moving forward there is already a
guide in place regarding what works for one country as opposed to what works for another.
HIP in Ethiopia
Ethiopia is acknowledged as being one of the poorest nations in the world. In 2013
Ethiopia had an estimated annual per capita income of $470 in 2013. Over a third of the
population lives below the poverty line of $1.25 per day. The nation is long known for having
deficiencies in education, health, and nourishment. The USAID determined that approximately
2.9 million Ethiopian citizens were in need of emergency food assistance. In recent years the
USAID has deployed over 35,000 workers to Ethiopia to address the health care needs of citizens
especially those living in rural areas.

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With the help of the USAID, Ethiopias GDP grew 10.3 percent in 2014. Another issue
faced by USAID involved and alarmingly high child mortality rate in Ethiopia. USAID helped
to reduce the child mortality by more than 6 percent each year since the year 2000.
In Ethiopia, HIP is working with the World Banks Water and Sanitation Program (WSP)
to help implement a hygiene and sanitation strategy. HIP is helping to improve hygiene and
sanitation in the Amhara Regional Health Bureau (ARHB) to support and encourage the national
commitment to achieve universal sanitation. HIP has also developed and is now working to
popularize a set of key hygiene practices that are feasible and cost-effective, but can be
implemented on a large scale through the programs of participating partners. For hand washing,
these include hand washing at critical times, using correct technique and soap or an effective
alternative such as ash or sand, and the use of hand-washing stations and innovation of
appropriate water-saving technologies. To guide the process, HIP worked with WSP and the
ARHB to develop a step-by-step process guide, a resource book, capacity building materials, and
state-of-the art job aids. HIP has developed a network of health extension workers, community
volunteers, development agents, farmers, and other outreach workers to promote change through
social mobilization and through house-to-house to discuss and explain hygiene improvement.
Plans have been made to build a WASH resource center in the Amhara Regional Health Bureau
to help with the cause.
HIP in Madagascar
After a coup dtat in early 2009, the nation of Madagascar found itself in the midst of a
political crisis that lasted five years and undid much of the recent progress in the country.
Madagascar was no longer allowed to participate in African Union and Southern African
Development Community (SADC). With assistance and intervention from the Mozambique

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government, Madagascar was able to develop a plan to end the crisis and elect a new leader.
Henry Rajaonarimampianina was elected President in January 2014. In May 2014, the US
government lifted all bans placed on cooperating with the Government of Madagascar.
Madagascar also regained its ability to participate in African Union and Southern African
Development Community (SADC) activities. Madagascar became eligible for the African
Growth Opportunity Act (AGOA) effective from June 26, 2014.
Many of the citizens of Madagascar do not have access to public restrooms, using a
flushing toilets, and soap for daily cleansing and regular hand washing. As a result common
diarrhea and acute respiratory infections have killed millions of children in the country. USAIDs
WASH Plus project planned to combat these two killers. The WASH Plus project, operated by
FHI 360, CARE, and Winrock International, is a follow-on program that builds on the efforts of
HIP. WASH stands for water, sanitation and hygiene. The plus represents the projects mission
to combat pneumonia and other respiratory illnesses caused by indoor air pollution from
inefficient cooking stoves.
HIP which ended in 2010, was established to improve water quality and hygiene in
homes, schools, health centers, markets, and religious centers. The WASH Plus project is a close
mirror of HIP, however its goal is to build on HIPs successes while eluding its pitfalls. It focuses
on the use of creative financing, innovation, and public-private partnerships to tap into domestic
partners in Madagascar, Kenya, and Zambia.
HIP in Nepal
Despite its close proximity to the prominent nations of India and China Nepal is one of
the poorest countries in the world. Nepal is presently coping with the effects of a decade-long
insurgency that ended in 2006. The country is located along the Himalayan mountain range and

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is greatly impacted by global climate change which involves water scarcity in some areas, but
increased flooding in others. The US has encouraged Nepal to develop a more prosperous,
democratic governmental structure.
USAID programs in Nepal have sought to reinforce recent gains in peace and security,
stabilize the transitional government, strengthen the delivery of essential social services, expand
proven health interventions, and address the global challenges of food insecurity and climate
change. The USAID helped implement the Nepal HIP, which promotes better hygiene practices,
including the safe treatment and storage of drinking water, and handwashing with soap. The
project was supported by the USAID from 2006-2008 in collaboration with UNICEF and the
Nepal Department of Water Supply and Sewerage.
Over the last two decades Nepal has seen a huge overhaul in its access to water supply,
yet the quality of drinking water has remained unacceptably low. In collaboration with Nepals
Department of Water Supply and Sewerage, the USAID HIP began working with UNICEF to
improve water quality in four pilot districts in the country with the hopes of taking the approach
nationwide. The overall goal is to improve family health, especially among children under age
five, by promoting better hygienic practices. The project adopted a three pillar approachaccess
to necessary supplies and equipment; an enabling environment that includes supportive policy
and institutional capacity; and promotion, including social mobilization, marketing, and
education. The Government of Nepal through the Department of Water Supply and Sewerage and
UNICEF served as the implementing bodies of this public-private sector effort, while
USAID/HIP provided focused technical assistance.
HIP and Peru

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The main focus for improving hygiene in the South American country of Peru was to
improve the quality and awareness of water by setting up certain protocols to keep families safe.
Through the USAID funded project managed by Management Sciences for Health (MSH), seven
Amazonian communities were targeted in an effort to bring preventative health measures to
families in these regions.
Until this point there were no resources or systems in place that could sufficiently treat
water to make it safe for human consumption. Through behavioral and quality research the
MSH/HIP team, in conjunction with the Centers for Disease Control team were able to identify
what behaviors needed to be changed or modified to improve conditions.
Awareness of the importance of water quality was achieved by incorporating fun
activities into the learning process. Flash cards, brochures and interactive games were used by
trained staff to educate the families. Focus of the activities centered on point-of-use techniques
including how to treat, store and handle water correctly. The activities covered the
contamination/diarrhea cycle; use of chlorination, SODIS, or boiling to treat drinking and
cooking water; steps to prevent contamination of wells; and proper hand washing and feces
disposal (). Residents were also taught how to use wall flip charts to keep up with certain
protocols.
A program was implemented to generate behavior change at the household level leading
to point-of-use water treatment through chlorination, solar disinfection, or boiling in an
environment where a commercial water treatment product (such as WaterGuard, Aquatabs, or
Pur) is not available and where almost no cultural norm exists for treating water (). These
protocols helped families stay on track to ensure safe consumption.

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There were some major accomplishments achieved with the implementation of this
program. In less than one year, 87 workshops were established to bring awareness and safety
protocols to all seven of the regions. Behaviors at the household were dramatically increased as a
result of the project. Local governments were so appreciative of the efforts that they asked for
additional training for their own staff members, so efforts could continue once the team was
finished. The goal of more children drinking healthy water was achieved in the first semester as
numbers rose from 49.9% to 60%.
The main lesson learned was that even in poor communities in Peru where there is a
major lack of education and products to ensure quality water consumption, lives can be improved
by simply increasing awareness and implementing protocol for families to follow. It is important
to tailor training programs and protocol to the specific needs of the communities involved.
Hip and India
The major initiative for India was to develop handwashing techniques and strategies to
best communicate these to the people. The project was only modestly funded by USAid in an
effort to form an All-India Handwashing Alliance for childhood diarrheal disease prevention.
The projects team was especially interested in learning from other international
organizations in the area of handwashing. HIP was able to hire 2 local consultants to assist with
the groups efforts. HIP consultants provided support and input to build an alliance. They
organized meetings with UNICEF, WSP, Save the Children, and Sulabh International to
introduce the proposed alliance and to seek partnerships (). These meetings provided valuable
information for the team to use in its efforts to form the all-India Alliance. It was determined that
the best way to tackle this issue would be to focus the alliance on a state level as opposed to a

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national level. In March 2010 MBPH launched the Saathi Bachpan Ke Alliance with a focus on
promoting best practices for reducing childhood diarrhea, including hand washing ().
The project had some successes that included a two day workshop in Delhi to educated
USAID and other staff members in the proper handwashing techniques. A presentation that
educates on the importance of these techniques was created with a list of potential alliance
partners were generated to allow for potential future growth of the program.
The lesson learned through this program was that forming alliance is a difficult
undertaking. The success of the program is contingent on having the right connections and
people in place to make the vision a reality. Much more work is needed to ensure the future
success of the project. Lack of handwashing is a major issue in India and ongoing education is
badly needed.

References
The hygiene improvement project. (n.d.). Retrieved from http://hip.fhi360.org/page/121.html
Training guide for parents, teachers, and student leaders: Wash friendly schools. (2010).
Retrieved from http://hip.fhi360.org/: http://hip.fhi360.org/file/27105/WASH%20Friendly%20Schools%20Training%20Guide.pdf

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U.S. Department of Health and Human Services: Public Health Services, National Institutes of
Health, National Cancer Institute. (n.d.). Making health communication programs work.
Retrieved from http://www.cancer.gov/publications/health-communication/pink-book.pdf
USAID hygiene improvement: End of Project Report. (2011). Retrieved from hip.fhi360.org/,
http://hip.fhi360.org/file/29823/Hygiene%20Improvement%20Project%20-%20%20End
%20of%20Project%20Report.pd