Hygiene promotion and cholera response

1Promoting hygiene

Building infrastructure is not enough: people must use it and adopt safe practices. Hygiene promotion is based on understanding behaviours: what people know, but also what motivates them (disgust, pride, caring for children, social norms) and what prevents them from acting (no soap, no water, no time).

• Key practices: handwashing with soap at critical times (after using the toilet, after cleaning a child, before preparing food, eating or feeding a child), latrine use, treated and safely stored water, food hygiene.
• Participatory methods: household visits by community hygiene promoters, demonstrations, focus group discussions, schools, radio.
• Monitoring through observation and simple surveys, not just the number of sessions.

2Hygiene items

• Hygiene kits adapted to and discussed with the community: soap (benchmark of around 250 g of soap per person per month for personal hygiene, more for laundry), water containers, menstrual hygiene products, items for babies and for people with incontinence.
• Distribution in kind or through cash transfers and vouchers if markets are functioning.
• Post-distribution monitoring: are the items being used? Is anything missing?

3The cholera response

Cholera causes acute watery diarrhoea and dehydration that can kill within hours without treatment; with prompt case management (oral rehydration salts, intravenous fluids for severe cases), the case fatality rate should remain below 1%.

• Health-WASH coordination: cholera treatment centres and units (CTCs, CTUs), oral rehydration points in communities.
• Reinforced chlorinated water supply (higher residual chlorine), household water treatment.
• Case-area targeted interventions (CATI): teams that visit households around a confirmed case to distribute water treatment products and soap, and to disinfect.
• Hygiene in treatment centres, disinfection, safe and dignified burials.
• Risk communication and community engagement; oral cholera vaccination in line with the decisions of the health authorities.

4Designing behaviour-centred hygiene promotion: the complete method

Hygiene promotion that is limited to "raising awareness" produces reports full of sessions and participants, but rarely changes in practice. Studies on handwashing show that knowledge is almost always high ("you have to wash your hands with soap") while observed practice remains low. The professional approach therefore starts from behaviours, their determinants and the material barriers, and then designs interventions that act on those determinants.

Step 1: choose a small number of priority behaviours

Two or three behaviours are selected according to their health impact in the context (epidemiological data), their feasibility and the gap between current and desired practice. Where diarrhoea and cholera are present, the priorities are generally handwashing with soap at critical times, safe storage and handling of drinking water, and latrine use, including for the faeces of young children. Each behaviour is formulated in an observable way: "caregivers of children under 5 wash their hands with soap after cleaning a child who has defecated".

Step 2: formative research

Several proven methods exist; the choice depends on the time available.

The expected output of formative research is not a report, but a short list of priority determinants and material barriers, for example: "soap is used for laundry and runs short for handwashing", "mothers say they do not have time to go back to the handwashing station", "water from the handwashing station is often taken for drinking".

Step 3: designing the intervention

• Remove material barriers first: handwashing stations placed where the behaviour occurs (latrine exits, cooking areas), sufficient soap, containers with lids and taps.
• Act on the motivations identified: disgust, nurture of children, social status, pride, rather than fear of disease alone.
• Use reminders and cues in the environment (footpath markings leading to the handwashing station, soap tied in place, mirrors).
• Mobilise complementary channels: household visits by community-based promoters, religious and community leaders, schools and learning spaces, local radio, women's groups.
• Team: a commonly used benchmark is around one hygiene promoter per 500 to 1,000 people depending on density and phase, with one supervisor per 10 to 15 promoters. Promoters are recruited from the community, with a balance of women and men, and paid according to the cluster's harmonised scales to avoid competitive bidding between organisations.

Step 4: test, measure, adjust

Materials and activities are tested with a small group, practices are observed after a few weeks, and the approach is adjusted. Hygiene promotion is part of the accountability mechanism: promoters collect feedback on water, latrines and distributions, and this feedback must lead to visible changes.

The question to ask of every hygiene promotion activity is: "which determinant of which behaviour does this activity change, and how will we know that it has changed it?" An activity that cannot answer this question is probably information dissemination, useful but insufficient.

5Measuring hygiene practices and managing hygiene items

Why self-reports are not enough

When asked about handwashing, people greatly overestimate their practice: out of politeness, a wish to do the right thing, or because the question prompts the right answer. Studies comparing self-reports with observation regularly find large gaps. A credible monitoring system therefore combines several sources.

For routine monitoring, cluster sampling or lot quality assurance sampling (LQAS) makes it possible to classify intervention areas as "achieved" or "not achieved" with modest sample sizes (19 households per area in the most common version), which helps to focus promoters on lagging areas.

Composition of hygiene items

The Sphere Handbook provides a reference list that is adapted with households; the most widely used benchmarks are as follows.

In-kind distribution or cash transfers

If markets are functioning (availability, stable prices, physical and safe access), cash transfers or vouchers leave the choice to households and support the local economy. A market assessment for hygiene items is needed, along with quality control of the products sold (water treatment products in particular). Products that are critical for public health during an outbreak (chlorine, treatment tablets) are often still distributed in kind to guarantee quality and speed.

Post-distribution monitoring

• Two to six weeks after the distribution, on a representative sample.
• Key questions: items received and complete, items used, sold or exchanged and why, missing items, satisfaction, problems during the distribution (waiting, safety, exclusion).
• Observation: presence of containers and soap, residual chlorine in stored water.
• Use of findings: adjust the composition of the next kit and the frequency of soap replenishment.

6The WASH cholera response: organisation, facilities and protocols

What WASH staff need to know about epidemiology

• Cholera is caused by Vibrio cholerae, transmitted through water and food contaminated with faeces. The incubation period ranges from a few hours to about five days.
• Most infected people have no symptoms or only mild symptoms, but they shed the bacteria for several days: this is why the outbreak spreads beyond the visible cases.
• Severe cases can die of dehydration within a few hours. With prompt access to rehydration, the case fatality rate should remain below 1%. A higher case fatality rate signals a problem of access to care (distance, cost, fear, late arrival) that WASH and risk communication can address together with health.
• Spread is often concentrated in "hotspots": neighbourhoods without safe water, markets, gathering places, transport routes, riverbanks.

Coordination

The response is led by the Ministry of Health, usually through a crisis unit or an emergency operations centre, supported by WHO and UNICEF. The WASH and Health clusters set up joint coordination. The global framework is that of the Global Task Force on Cholera Control (GTFCC) and its global roadmap to 2030. The key point for WASH is daily access to case data by neighbourhood, ideally by address or GPS point, so that interventions can be directed to where new cases appear.

Treatment facilities and the role of WASH

Chlorine solutions in treatment facilities

Solutions are prepared daily in labelled containers of different colours, by a trained person. Footbaths and the systematic spraying of people or vehicles are no longer recommended in recent guidance: their effectiveness is low and they give a false sense of security.

Case-area targeted interventions (CATI)

Households living close to a case have a markedly higher risk of being infected in the following days. CATI aim to intervene rapidly around each case or cluster of cases.

1. Trigger: daily receipt from the health sector of the list of new cases with their addresses.
2. Timeframe: intervention within 24 to 48 hours of the case's admission, as the effect declines rapidly over time.
3. Perimeter: the case's household and neighbouring households within a radius often set at between 100 and 250 metres depending on density, which represents anything from a few households to several dozen.
4. Team: generally made up of a WASH officer, a hygiene promoter and, ideally, a community health worker; joint health and WASH teams are recommended.
5. Package of activities: household water treatment products with demonstration, soap, storage container if needed, oral rehydration salts and explanation of danger signs, targeted disinfection of contaminated surfaces and objects in the case's household, testing and chlorination of nearby water sources, active case finding and referral, and chemoprophylaxis only if the health authorities decide on it for household contacts.
6. Recording: each intervention is geolocated and recorded with the time elapsed since admission, in order to analyse coverage.

Other components

• Water: residual chlorine raised to at least 0.5 mg/l at distribution points in affected areas, bucket chlorination at untreated water points (an attendant doses each container), support to the utility (chemicals, testing, repairs).
• Oral vaccination: decided by the health authorities with the support of the International Coordinating Group (ICG), which manages the global stockpile; the standard regimen is two doses, but single-dose campaigns have been conducted since 2022 because of the vaccine shortage. WASH supports the campaign through communication and does not replace it.
• Safe and dignified burials: with the health sector and religious authorities, respecting rites as far as possible.
• Risk communication and community engagement: short messages that are consistent across organisations, rumour management (rumour log, rapid responses), involvement of leaders and traditional healers.

7Worked example: four weeks of response in the town of Mabéla

Fictional context: Mabéla, a town of 300,000 inhabitants. The Ministry of Health confirms a cholera outbreak: 120 suspected cases and 6 deaths in one week (case fatality rate of 5%), concentrated in two neighbourhoods without a water network, Kassa (45,000 inhabitants) and Bomélé (38,000 inhabitants). The fictional NGO "Eau Solidaire" is assigned Kassa by the WASH cluster; another organisation covers Bomélé. The team has 20 staff and an emergency budget of 50,000 US dollars for four weeks.

Step 1: analysis in the first 48 hours

• Mapping of the 74 cases in Kassa from the CTC registers: three clusters of cases, around the developed river intake, the fish market and a fishermen's quarter.
• Residual chlorine readings at the neighbourhood's 18 water points: only 4 are treated, and only 1 is compliant (0.5 mg/l). Water vendors fill their jerrycans at the river.
• Interviews at the CTC: most deaths occurred among people who arrived late, coming from the fishermen's quarter, 6 km from the CTC. Rumours say that "the CTC kills people".

Step 2: strategic choices

1. CATI for all new cases in Kassa, with absolute priority for cases located in a new sector of the neighbourhood.
2. Bucket chlorination at the 14 untreated water points and at the vendors' filling point, with chlorine readings three times a day.
3. WASH support to four oral rehydration points opened by the health partner, including one in the fishermen's quarter.
4. Targeted communication: fishermen's leaders, imams and pastors, community radio, an organised visit to the CTC by leaders to respond to rumours.

Step 3: sizing the CATI

Assumption: 2 interventions per team per day (the case's household and about 20 neighbouring households), 4 teams of 3 people (a WASH officer, a promoter, a community health worker seconded by the district). Capacity: 8 interventions per day.

Cost of a package per household: 20 l container with lid and tap, treatment tablets for one month, two bars of soap, four sachets of oral rehydration salts, i.e. about 11 dollars. The budget set aside for packages (26,400 dollars) covers 2,400 households, i.e. 2,400 ÷ 21 = about 114 interventions over four weeks, or 4 per day. Team capacity is therefore greater than the package budget: the team decides to reduce the package for neighbouring households that already have a suitable container (tablets, soap and salts only, about 4 dollars), which raises coverage to about 160 interventions. Because cases are clustered, one intervention often covers two or three neighbouring cases; cases already covered by an intervention less than seven days old trigger only a short visit to the household concerned.

Step 4: the budget

Step 5: weekly monitoring

Interpretation: the rise in cases in week 2 is not a failure; it partly reflects better care-seeking after the work with leaders (cases arrive earlier, and the case fatality rate falls sharply). The fall in the case fatality rate depends primarily on health care, but the oral rehydration points supported by WASH and the work against rumours contributed to it. The rate of detectable chlorine in CATI households, at 74%, shows that one household in four does not use, or no longer uses, the tablets: qualitative follow-up cites the taste and forgetting. The response adopted is a reinforced demonstration at the follow-up visit and an exchange of open containers for containers with taps.

A good cholera response is reflected in indicators of speed and targeting (CATI timeliness, coverage of new foci, chlorine at water points in affected areas), not only in the number of kits distributed. The epidemic curve depends on many factors; the quality of the response is demonstrated through the process.

8Reusable tools and templates

CATI intervention form

WASH checklist for a cholera treatment centre

• Water: at least 60 l per patient per day available, at least 24 hours of storage, residual chlorine tested daily.
• Zoning: triage, observation, hospitalisation, recovery, neutral zone, morgue, waste zone; one-way circulation; fencing.
• Handwashing points with 0.05% solution or soap at every zone exit and at every bed.
• Daily preparation of chlorine solutions (0.05%, 0.2%, 2%) by a designated person, with a log and verification.
• Cholera beds and buckets for stools, buckets for vomit, emptied into dedicated latrines or pits after adding 2% solution.
• Separate latrines for patients and staff; showers.
• Waste management: segregation, waste pits and sharps pits, incinerator if possible.
• Laundry: washing, disinfection and drying of linen.
• Management of bodies: preparation with 2% solution, body bags, coordination with the family and the authorities for a safe and dignified burial.
• Training and equipment for hygiene staff (boots, gloves, aprons), team rotation.

Daily WASH situation report during an outbreak

Rumour log

Date, location, channel (market, radio, social media, household visit), exact content of the rumour, frequency (heard once or often), risk to the response (low, medium, high), response provided and by whom, follow-up. The log is shared every week with the risk communication committee.

9Common mistakes, donor expectations and adapting to contexts

Common mistakes

1. Measuring activity instead of behaviour. The number of sessions and of people "sensitised" says nothing about practices. Donors and evaluators now expect at least one observed indicator (handwashing facility with water and soap, chlorine in stored water).
2. Multiplying messages. Ten different messages, often contradicting each other from one organisation to the next, get lost. Three messages harmonised at the level of the cluster or the communication committee are more effective.
3. Distributing kits without demonstration or follow-up. Unused water treatment tablets, soap resold to buy food and containers used for other purposes are common without accompanying support.
4. Intervening too late around cases. A CATI carried out one week after admission has little effect. The bottleneck is often the transmission of data from health to WASH: it must be resolved on day one with a data-sharing protocol that respects confidentiality.
5. Spraying instead of treating. Spraying houses, people or vehicles is visible and reassuring, but not very effective; it consumes resources that are lacking for safe water and handwashing.
6. Stigmatising. Publicly identifying case households, or groups (fishermen, displaced people, foreigners), drives sick people into hiding and delays care.
7. Forgetting menstrual hygiene and specific needs. Standardised kits designed without consulting women, older people and persons with disabilities miss their target.

What donors and evaluators look at

• A behaviour change strategy based on formative research, even if rapid, and explicitly stated priority behaviours.
• Practice and quality indicators, and evidence that monitoring results have changed the intervention.
• During outbreaks: CATI timeliness, coverage of new foci, residual chlorine compliance in affected areas, documented coordination with health, alignment with GTFCC and WASH cluster guidance.
• Accountability: complaints mechanism, consultation on kit composition, post-distribution monitoring and adjustments.
• For cash transfers: market assessment, product quality control, expenditure monitoring.

Variations by context

10Interview questions and key references

1. "Surveys show that 95% of people know they should wash their hands with soap. Has your programme achieved its objective?"

A good answer distinguishes knowledge from practice, cites self-report bias, proposes observed indicators (handwashing facility with water and soap, structured observation) and lines of analysis of barriers (soap, water, location of stations, motivations).

2. "You are WASH coordinator and a cholera outbreak has been declared in your area. What are your priorities in the first week?"

The candidate cites coordination with health and daily access to case data, mapping of foci, securing water in affected areas (residual chlorine of at least 0.5 mg/l), WASH in treatment facilities, starting CATI within 48 hours, risk communication with harmonised messages, and stock management.

3. "How do you design a hygiene kit for a newly displaced population?"

The candidate starts from the Sphere benchmarks, consults women, adolescent girls, older people and persons with disabilities, checks practices (menstrual materials, anal cleansing, laundry), considers the cash transfer option, and plans for soap replenishment and post-distribution monitoring.

4. "What do you do about a rumour that water treatment tablets cause infertility?"

The candidate proposes logging and analysing the rumour, understanding its origin, responding through trusted voices (religious leaders, health workers, community members who use the tablets), with demonstrations and simple explanations, and coordinating the response with the risk communication committee rather than acting alone.

5. "How do you demonstrate the effect of your WASH response on a cholera outbreak?"

The candidate explains that attributing the decline in cases is impossible, and that quality is demonstrated through process indicators (CATI timeliness and coverage, chlorine at water points, chlorine in households) set against the epidemic curve by area, while acknowledging other factors (vaccination, season, case management).

6. "What is the difference between a 0.05% solution and a 2% solution, and how do you prepare them?"

The candidate states the uses (hands and skin; excreta, vomit and bodies), explains the calculation based on the concentration of the product (for example, for a 0.05% solution made from 70% HTH: about 0.7 g of product per litre), and stresses labelling, daily preparation and verification.

Key references

• The Sphere Handbook (2018 edition), standards on hygiene promotion, hygiene items, menstrual hygiene and incontinence, and WASH in disease outbreaks: Sphere Association.
• Ending Cholera: A Global Roadmap to 2030 and technical guidance on response, including case-area targeted interventions and WASH in treatment centres: Global Task Force on Cholera Control (GTFCC).
• Management of a Cholera Epidemic: Médecins Sans Frontières.
• Cholera Toolkit: UNICEF.
• Guidance on risk communication and community engagement in outbreaks: WHO, UNICEF and the International Federation of Red Cross and Red Crescent Societies.
• Wash'Em tools for handwashing promotion in crises: London School of Hygiene and Tropical Medicine and Action Against Hunger.
• Barrier analysis guide (Designing for Behavior Change): CORE Group and Food Security and Nutrition Network.
• RANAS approach to behaviour change: Eawag.
• Hygiene indicators and service ladders: WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP).
• Menstrual Hygiene Management in Emergencies toolkit: Columbia University and International Rescue Committee.