In this summary report, we reflect on how programmes can be adapted for protracted outbreak responses This includes building in mechanisms for sustainability and advocating for longer term programmatic, policy and systems changes. This summary report presents key principles that can be drawn upon to influence contextualised approaches to sustainability, advocacy and policy change. For further information on sustainable programming, please see our resources on programmatic adaption and advocacy for policy change.
Note that whilst this resource was originally written with COVID-19 in mind, principles and activities can be applied to other disease responses.
What do we know about the sustainability of hygiene programmes?
There are multiple dimensions to consider if hygiene programmes are to be sustainable: the sustainability of behaviour, infrastructure, services and systems. Each of these components reinforce each other.
Source: Hygiene Hub
1. Sustaining behaviour change: To increase and sustain hygiene behaviours, such as handwashing or mask-wearing, we need to consider whether people are likely to continue to practice the behaviours after active promotion comes to an end. Two systematic reviews of hygiene-related behaviour change address sustainability, and both conclude that evidence about the sustainability of behaviour change programmes is limited (Study 1, Study 2). One of the reviews explored factors that influence sustained WASH behaviours, but it was unable to draw conclusive findings. However, the factors outlined below are likely to be important for the adoption of handwashing behaviours during the programme period and sustaining them after the programme ends:
Knowledge alone doesn’t enable sustainable behaviour change – Interventions employing one-way communication with the intention of increasing knowledge or skills surrounding hygiene were not found to have any effect on sanitation outcomes, nor did they lead to any sustained change in handwashing behaviour.
Design programmes based on theory and address determinants of behaviour – Interventions based on theory are more likely to increase handwashing behaviour change. Behaviour change interventions which combine psychosocial theory with an enabling environment are more likely to increase handwashing behaviour change and facilitate handwashing station maintenance. Addressing a range of determinants of handwashing, rather than just a few factors, will also likely lead to sustained changes.
Promote community ownership, leadership and support– Psychological and community-level resources (e.g. social support from the family and community) can help enable behaviours. Community engagement in running the program, from planning to design, implementation and oversight, will likely increase ownership. Some examples of community-based approaches for WASH interventions include Community Led Total Sanitation (CLTS) and Participatory Rural Appraisal (PRA) approaches, which have a sanitation component. To make it possible for behaviour change to be sustained, a sufficient ‘dose’ of the intervention needs to be achieved. Achieving sufficient ‘dose’ requires programmes to reach and engage their target populations enough times to achieve an effect, therefore requiring community engagement over time. It also requires programmes to consider the best ways of reaching all members of a society. Utilising multiple delivery channels can also help in achieving a sufficient ‘dose’ and enabling programmes to be effective at changing behaviour in the short and longer-term. See our resource on deciding which delivery channels to use and community engagement, for further information.
Work towards longer-term habit formation – For a behaviour to become a habit, it needs to move from something that we consciously think about, to something that is semi or fully automatic and done in response to familiar cues. Creating an enabling physical and social environment can therefore contribute to habit formation. Including signs or nudges about when to practice the behaviour and mandatory handwashing or mask-wearing in institutional settings, for example, can facilitate behaviour change. A habit-enabling environment normally requires: a) a stable, unchanging setting where the behaviour takes place, b) continued access to the necessary products required to perform the behaviour, c) an existing routine or series of actions into which the new, desired behaviour can fit into, and d) adjusted perceptions of social norms related to these behaviours. Visual cues can remind people to practice hygiene behaviours. Legal and regulatory interventions may promote lasting behaviour change in the interest of public health. Laws limiting the sales of tobacco products to minors, restricting smoking in public places, and mandating the wearing of a seatbelt while driving are some examples of how regulations can influence public health outcomes and lead to long-term changes of behaviour.
Address motivators for behaviour – Motivators, such as enjoyment and satisfaction from handwashing, self-determination, and identity, can contribute to sustained behaviours. People may experience sensory rewards from practicing hygiene behaviours, such as having pleasant smelling hands after washing them with soap. The SuperAmma campaign to promote handwashing behaviour in Southern India is an example of how motivators can be leveraged to change behaviour, such as a mother’s motivation to nurture her child and ensure their future success. Another study conducted in Nepal, Pakistan and the Philippines, explored other emotional motivations for handwashing behaviour, including shame and respect.
Leverage local norms – It can take time to change social norms. However, it can be relatively easy to change normative perceptions (i.e. people’s perceptions of what people do or how others should behave) and this in turn can contribute to behavioural change. Norm-based messaging can draw attention to the behaviour of others and make people more aware that others pay attention to their behaviour. There is evidence that individuals are more likely to practice handwashing behaviours when they are being observed or are in the presence of others. However, handwashing may often take place in settings that are private or hard for others to observe behaviour (e.g. bathrooms). To overcome this, other mechanisms within programmes can draw attention to normative behaviours, such as showing people washing their hands and adopting prevention behaviours on social media or television. One study conducted in Ethiopia, found that people with strong injunctive norms (behaviours that are approved or disapproved by others) and descriptive norms (behaviours that are practiced by others) were more likely to practice handwashing behaviour, and suggested that an intervention requiring a public-commitment to wash hands would help promote both types of norms and likely lead to increased handwashing.
The table below is based on a systematic review of handwashing and sanitation behaviour change interventions and gives an overview of how uptake, adherence and sustainability are likely to vary between interventions. Community based approaches and interventions based on theory are more likely to result in uptake and adherence, but still do not have enough evidence to support sustainability. For further information, see our resource on what works to change handwashing and hygiene behaviours.
Source : Adapted from De Buck et al (2017)
2. Sustainable enabling technology: Sustainability may not be possible if the behaviour is not convenient and easy to practice. Having infrastructure in place is key for ensuring the behaviour can be convenient, and therefore, having an ongoing supply of products to maintain the infrastructure is essential (Study 1, Study 2). If programmes involve the provision of infrastructure or encourage communities to invest in infrastructure that enables behaviours (such as handwashing stations in homes, health facilities and public places), then it is important to consider how to put in place a system for maintaining this technology. This resource explains how the design of handwashing facilities can have an impact on handwashing behaviour. Desirable facilities are more likely to be utilised and maintained. During the COVID-19 crisis, there was a dramatic scale-up in the number of organisations investing in handwashing facilities in public places. In light of this, WaterAid and the Sanitation Learning Hub developed guidance on public handwashing facilities, with both covering important steps for enabling the ongoing operation and maintenance of these facilities. The sustainability of handwashing facilities needs to be considered from the outset. This should include involving the target population in the design of the facilities, to ensure that they are acceptable, desirable and accessible for everyone to use. Sustainability can also be improved by constructing the facilities from materials that are durable, or which can be replaced easily and locally. They also recommend establishing an operation and maintenance plan with local institutions or communities and setting out roles and responsibilities in relation to who should fund, purchase and refill the soap and water, who should clean the facility (and how it should be cleaned), and who should fix the facility if it is broken. For further information on this topic, see our resource on changing hygiene behaviour through infrastructure.
3. Building sustainable services – COVID-19 case study: Some behaviours, like handwashing with soap, require infrastructure, products and access to services, such as a regular water supply. The COVID-19 pandemic has drawn attention to long-standing global inequities in water access and to the importance of promoting inclusive services, which provide water for all sub-groups of the populations (e.g. including those in rural locations, who are displaced and living within camps or people with disabilities). During the pandemic, governments and water service providers in many regions adapted their services and put in place mechanisms to enable populations to access more water or make it more affordable. For example, some governments in Africa drilled additional boreholes or organised short-term, water trucking services to water scarce communities. Other countries waived water bills or provided water subsidies during the pandemic. As COVID-19 response funding reduces or response initiatives wind down in some regions, it is important that we don’t see a return to the status quo. A coordinated systems approach will create lasting change. This may require actors to develop a better understanding of water vulnerabilities, by mapping access and the regularity of water supply. Such information can be a vital tool for advocacy and the prioritisation of longer-term investment in water infrastructure. Secondly, it will require governments, community organisations, donors, NGOs and consumers to develop strategies and plans which actively work towards more sustainable water services. UNICEF’s Framework for Programming for Sustainability in Water Services outlines a pathway for actors to achieve this.
4. Building sustainable systems: During outbreaks, coordination between non-government organisations (NGOs) response actors and governments is often suboptimal. However, past outbreaks have demonstrated that as the response progresses into a more protracted phase, these coordination systems also mature. Transitioning from the acute phase of the disease response requires coordination of mechanisms, strategies and policies and even individual programmes to be reviewed and adapted with sustainability and system-level changes in mind. The recent COVID-19 crisis created a ‘shock’ to international health systems and at the same time, has introduced an opportunity to build more resilient health systems in the long term. Resilient health systems would be able to identify, prevent or mitigate the spread of future outbreaks and reduce the impact of chronic health challenges, like diarrhoeal disease. This article explains that responding to such a health system ‘shock’ requires improvements to health information systems, funding/financing mechanisms and the health workforce. Realising these changes requires advocacy to highlight gaps in the health system and develop policies and strategies to address them. Taking the example of COVID-19 again, many COVID-19 programmes have also been ‘vertical’, meaning that they only prevent or treat COVID-19. However, as the pandemic moves into a more protracted phase, it is key that programming shifts to be more ‘horizontal’, meaning that COVID-19 prevention activities are integrated within other ongoing aspects of health programming. This is more likely to lead to health-system strengthening and allows for the continued provision of health and hygiene services without interruption or any decrease in quality.
How can organisations build sustainability mechanisms into disease programmes? - example of COVID-19
When implementing hygiene behaviour change programmes, it is important to understand that it is a process rather than a one-time event. Short-term projects are unlikely to lead to sustainability, so instead, it is worth creating and investing in long-term strategies. Here are some recommendations to help sustain programme management of COVID-19 programmes. Note that whilst this example is specific to COVID-19, lessons can also be applied to other disease responses.
Integrate current work with other sectors: Increased inter-sectoral collaboration can lead to an increased impact on a shared target population. COVID-19 is affecting people in numerous ways beyond their physical health, whether it be their mental health, education, nutrition or livelihood. Designing, or adapting your program to address multiple challenges and integrating your response with other sectors, can provide a more comprehensive system to support the population and make health and hygiene components more feasible and acceptable. A systematic review that looked at which factors facilitated programme sustainability, identified having partnerships with various stakeholders as being important in ensuring the sustainability of a health programme.
Design programmes to complement and in turn, shape government strategies: Government-led initiatives are more likely to be sustained if they have the support of outside organisations. When organisations work alongside the government in implementing programmes, it is also more likely that the government will see the value in continuing the programme and their commitment to it. An example of a successful government-NGO collaboration, is tuberculosis control in Bangladesh, where greater coverage and access to necessary services was achieved. In southern Africa, programmes for orphans and vulnerable children were sustained in part, due to the collaboration between the government and NGOs.
Involve new actors: Building partnerships between the public and private sector, as well as other actors, such as the media or universities, can help maintain support and progress of your programme. They may also be able to provide more resources, drive innovation and take on responsibilities. Involving new partners can require steep learning curves, and it is helpful to share a common goal, but ensure you keep each actor’s roles and responsibilities clear.
Partner with civil society organisations: Civil society organisations are a part of the communities they serve and this allowed them to respond rapidly to the pandemic in ways that were innovative and context appropriate. Consequently, the COVID-19 pandemic has encouraged many international NGOs and government agencies to strengthen their partnerships with local actors, who are better placed to understand community needs and may be able to work more safely in communities than external actors. It is important that support to civil society organisations continues to be strengthened and that these organisations play a role in setting their own future agendas and contributing to resilience building. For further information on the importance of community led organisations, see this UNAID report.
Improve coordination mechanisms and develop shared strategies: Coordinating efforts and developing shared strategies between implementers helps avoid redundancies and makes it easier to achieve programmatic goals. Some responses to COVID-19, including the UN’s Global Humanitarian Response Plan, encourages coordination between international organisations, NGOs, and national governments. Coordination is most sustainable when it is government led and aligned to border national strategies. Over the course of the pandemic, new coordination mechanisms have developed, such as Risk Communication and Community Engagement (RCCE) working groups. It is important at this stage to review the mid and long term purpose of these coordination groups and identify ways that collaboration, learning and sharing can continue. This does not always necessitate that these new COVID-19 coordination measures need to be maintained. For purposes of sustainability, it may be much better for coordination structures to be embedded in existing and well-functioning government mechanisms. For more guidance on effective government led COVID-19 response and coordination initiatives, follow the tips in this article.
Continue monitoring and evaluation: Monitoring and evaluating your programme will make it easier to identify areas that need improvement, so that you can adapt to changing needs. Programme evaluation can also help provide information on progress and potentially programmatic impact. For further guidance on monitoring the progress of your programme, see the Hygiene Hub resources on monitoring and evaluation.
Be transparent about programming: Transparency of information is especially important during public health crises, in order to build and maintain trust, manage fear and effectively support the adoption of health and hygiene guidance by the population. Organisational transparency in terms of their ways of working and the costs associated with programming can help maintain accountability, reduce corruption, and increase efficiency. The sustainability of short term programmes can be supported by developing clear programme manuals and sharing programme materials, so that initiatives can be easily replicated or adapted by others. Honest sharing of programmatic monitoring and evaluation information can help other actors to build on programmatic strengths and learn from past mistakes, strengthening the quality of future programming.
Could the COVID-19 pandemic result in long-term hygiene policy change?
Advocacy efforts normally aim to realise policy, programmatic or sector-level changes. However, for advocacy to lead to meaningful change, a number of factors need to align at the right moment in time. Often this is described as the creation of a ‘policy window’. Political theorists argue that there are multiple streams that contribute to policy windows arising. Generally, policy change occurs in response to an agreed ‘problem’. Theorists like John Kingdon suggest that ‘policies’ and ‘problems’ exist as two separate ‘streams’, which are influenced by a range of historical and contextual factors and the systems within which they occur. Running alongside these two streams is third - ‘politics’. In this theoretical context, ‘politics’ encompasses advocacy actors who may be pressing governments or the sector to act. The diagram below summarizes some of the factors in each stream, illustrating how these combine in a particular moment to create an opportunity for change.
Health Sector Reform Following COVID-19 Outbreak: Using Kingdon’s Multiple Streams, 2020. Source: Shahabi and Lankarani (2020)
Some people have suggested that the COVID-19 pandemic could be viewed as a large catalyzing ‘problem’, since it has highlighted important health shortfalls and inequities. The pandemic has shone a spotlight on the fact that hand hygiene is critical for interrupting the transmission of COVID-19 as well as a range of diseases. It has also drawn attention to the historically inadequate levels of investment and planning related to hygiene programming, policies, and sustainability. Lastly, the pandemic has demonstrated that hygiene promotion and handwashing infrastructure can be rapidly scaled up with increased willingness and buy-in from all actors. The diagram below shows an adapted version of the ‘three streams’ diagram above, which highlights how hygiene related factors may need to align to create a policy window. It illustrates that realising change will require all COVID-19 response actors to actively undertake advocacy work in order to influence policy decision makers.
Source: adapted from Shahabi and Lankarani (2020)
There are other positive initiatives that are likely to contribute to lasting change. For example, in 2020, the WHO and UNICEF set up the Hand Hygiene for All initiative. The initiative is designed to champion hand hygiene at a global level and sets out plans to support countries as they respond to the COVID-19 pandemic, while also developing national hygiene roadmaps to rebuild and reimagine the state of hand hygiene for the future.
Editor's note:
Author: Elli Leontsini, Peter Winch and Anika Jain
Reviewers: Tracy Morse, Helen Hamilton, Dan Jones, Sian White, Jenala Chipungu
Last update: 01.03.2023