Implementation of findings

Many of the methods and tools described in this handbook lead naturally from collecting and analysing data (i.e., establishing what the problem is) to planning what needs to be done to address the issues raised. For example, a healthwalk may reveal that part of a community is using a water source particularly vulnerable to pollution for its drinking water. Indeed, we have seen in Chapter 5 the impact of information gathered during a healthwalk on project design and implementation. Similarly, information from focus group discussions and semi-structured interviews may reveal a higher incidence of diarrhoea among this group. Presentation of these findings to the community will almost inevitably lead to a discussion of what needs to be done to remedy the situation, moving the emphasis from data collection to implementation. Thus a hygiene evaluation study does not end with the presentation of findings. It should lead to follow-up action on the basis of the findings.

Whether or not participatory approaches are given importance in the evaluation, the end result of the study will be the identification of high risk hygiene practices which currently exist, embedded in a context of local physical conditions, beliefs, and ideas. You will almost inevitably advocate that follow up action should include hygiene promotion activities. The goal of any hygiene promotion project must be to influence people to abandon the high risk practices identified in favour of low risk, safe practices. But, what influences people's decisions to change their normal practice? Many studies have shown that the answer to this question is "not received knowledge alone." Commonly, four factors influencing behavioural change are identified:

· Facilitation. The new practice makes life easier for the person adopting it.
· Understanding. The new practice makes sense in the context of existing local knowledge/ideas.
· Approval. Important and respected people in the community approve of and have adopted the practice.
· Ability to make change. It is physically possible for the person concerned to make the necessary changes.

Below are some examples of how information gathered using this handbook may be fed into an implementation process that takes these four factors into account:

Facilitation. In order to get people to use safe water for drinking purposes, it may be necessary to ensure that there are sufficient protected water sources throughout the community to make it easier and more convenient to use as opposed to traditional, unprotected ones. In planning terms, this may mean continuing a mapping exercise that identified existing sources instead of using the map, with the community, to plan the location of new water points.

Understanding. Hygiene promotion messages and activities are not received by people in a vacuum. Rather they are assessed, accepted, modified, or rejected by people within the context of their existing health concerns and beliefs about illness. A number of similar evaluations have, for example, elicited the local concepts of hot and cold illnesses that need to be treated by controlling diet and reducing intake of some foods. In a number of cases, the promotion of ORS has run into difficulties because diarrhoea is classified as a hot illness requiring treatment with cooling substances, while sugar, a major constituent of ORS, is categorized as hot, therefore rendering ORS an unsuitable treatment. Project implementers have found various ways to overcome such problems including substituting honey (considered a cooling substance) for sugar in one case, and in another, encouraging people to use ORS in conjunction with herbal teas made from guava leaves - a traditional remedy considered cooling and seen to overcome the perceived heating effect of the sugar in ORS.

Approval. In order to enhance the desirability of change, it may be necessary to target hygiene promotion at certain groups of trend setters, such as traditional healers, local leaders, or young mothers who are likely to be copied by their peers. Often this would best be done through a continued use of the group discussion techniques used earlier in the evaluation.

Ability. If behavioural change requires resources, it may be beyond some people's abilities to make the change. Promotion of latrines, for example, may need careful planning with communities, using many of the techniques discussed earlier to enable targeted assistance/subsidies to be allocated to those who would otherwise be unable to make the change.

In projects where the promotion of low risk hygiene practices has been achieved, the follow-up action to evaluations may involve tackling other issues that are next in the list of priorities. Whatever the outcomes of your study are, we shall be interested to learn about your experiences of using this handbook (see Evaluation Sheet at the back of the book).