TB Hygiene promotion priority actions

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Priority actions

Immediate distribution of basic hygiene items

Box: Recommended hygiene items for distribution

Basic hygiene items

  • Water containers - 10l per person
  • Hand soap - 250g/person/month (Note this should be doubled during outbreaks)
  • Laundry soap (or powder if appropriate) - 200g/person/month
  • Acceptable material for menstrual hygiene, e.g. washable cotton - 2m per person

Additional optional hygiene items

  • Toothpaste - 75ml/100g
  • Toothbrush - 1 per person
  • Shampoo - 250ml per HH
  • Bathing towel – 1 per HH
  • Disposable razor - 1 per HH
  • Underwear for women and girls of menstrual age - 2 per person
  • Laundry basin – 1 x 40l per HH
  • Washing line – 40m per HH
  • Washing pegs – 80pc per HH
  • Hairbrush / comb - 1 per HH
  • Nail clippers - 1 per HH
  • Hair scissors – 1 per HH
  • Nappies (diapers) and potties (dependent on household need)
  • Nappy rash lotion - 250ml per HH
  • Small yard brush – 1 per HH
  • Small dustbin – 1 x 40l per HH

Quantities for approximate guidance only. Alternative items may be considered in consultation with the population.

Soap and Jerry Cans (UNHCR, 2014)
NFI Distribution (UNHCR, 2009)

UNHCR and WASH actors must ensure that the refugee population is provided with basic hygiene materials including soap, water containers and women’s menstrual materials (see box on right hand side) on immediate arrival at the refugee setting and consistently throughout the emergency. It is essential that this distribution is organised as rapidly as possible as the refugee population may arrive without possessions.

How the basic hygiene kit is distributed should be carefully coordinated, especially if the hygiene items are included as part of a general distribution with other items such as blankets, or cooking equipment. Whichever way the distribution takes place, the WASH team must take direct responsibility for ensuring the type, quality, and timeliness of the hygiene items including any post-distribution monitoring. If hygiene items are distributed by the WASH team, then UNHCR and WASH actors should follow UNHCR best practice for commodity distributions which includes ensuring that the population is well informed of the time, place and type of distribution, and that the distribution is carried out in a secure, orderly, efficient, and transparent manner. More guidance can be found in the UNHCR publication “Commodity Distribution: A Practical Guide for Field Staff” UNHCR (1997).

Additional items to facilitate laundering of clothes and bedding, bathing, management of children’s faeces, water treatment, and compound cleanliness may be considered if appropriate, locally available, and the basic hygiene needs have been met (see Box 9.2). If these products are readily available on the local market, the use of a cash based approach (i.e. vouchers) is highly recommended in order to prevent undermining of local suppliers and stimulate the local market economy.

At the earliest possible opportunity, UNHCR and WASH actors should ensure that careful discussion takes place with representatives of the refugee population, in particular women and girls, to ensure that the hygiene items are needed and are appropriate to the culture and context. This is particularly important for hygiene items related to menstrual hygiene, bathing, handwashing and management of excreta.

Additional items to facilitate laundering of clothes and bedding, bathing, management of children’s faeces, water treatment, and compound cleanliness may be considered if appropriate, locally available, and the basic hygiene needs have been met (see box below). If these products are readily available on the local market, the use of a cash based approach (i.e. vouchers) is highly recommended in order to prevent undermining of local suppliers and stimulate the local market economy.

As soon as is possible, the hygiene team should plan to undertake focus group discussions (see Chapter 9) to ensure that the hygiene items being distributed are relevant and appropriate to the culture and context - in particular those related to menstrual hygiene, bathing, hand washing and management of children’s excreta.

Additional Care should be taken to avoid distributing products that may be unfamiliar. UNHCR and WASH actors should ensure that beneficiaries receive a visual practical demonstration in the safe use of hygiene items that are unfamiliar to them. This is particularly important if any household water treatment (for example PUR, aquatabs, or household water filters) or disease vector control products (for example bed nets) are being distributed.

Post distribution monitoring is an essential activity after every major distribution to not only ensure that the distribution was carried out correctly and the hygiene items were received by the population, but also to ensure that the distributed items are being used, the population is satisfied with the quality and usefulness of the products, and the population has the opportunity to provide feed-back on the hygiene items and the distribution activity. The post-distribution monitoring activity should take no longer than one day and may include a rapid randomized household survey and several focus group discussions (see Chapter 9).

Immediate mobilisation of the community to take action

The refugee population should clearly understand that they are not just passive recipients of humanitarian aid but they have the rights, capacity and means to manage and dictate the direction of their daily affairs, including their sanitary environment. The degree to which the refugee population can be mobilised depends upon the context and the capacity of the refugees. However in all settings, UNHCR and WASH actors should aim to support individuals or organisations to mobilise the larger refugee community to take action concerning WASH related problems in the refugee setting e.g. the safe disposal of excreta, clean up and safe management of wastes, contamination of water resources, or management of disease vector breeding sites.

Immediate dissemination of key hygiene promotion messages

Public Health Promotion (OXFAM GB, 2012)
Hygiene Promotion Poster (OXFAM GB, 2010)

UNHCR and WASH actors must ensure that the refugee population is provided with clear hygiene messages on immediate arrival at the refugee settings and consistently throughout the refugee emergency. The messages must be in their own native language, and must target the most critical hygiene risk practices for the current displaced context that are responsible for disease transmission, in addition to the key interventions to prevent them. Targeting too many messages can be confusing and can dilute the most important messages. All messages provided to the refugee population should aim to be positive (rather than scare mongering) with a focus on providing key facts.

Examples of generic key hygiene messages for hygiene practices can be found in the box on the following page. However, it is essential to review these messages and carefully tailor them to the local culture, customs, and context. At all times the emphasis should be on taking as much of an interactive approach as possible and mobilising people to take action themselves. Additional messages may be needed depending upon the context and any critical hygiene risks that are present.

In the early stages of a refugee emergency, UNHCR and WASH actors should use a mixture of mass media messaging to ensure that as many people as possible receive important information about reducing health risks. A mixture of approaches is especially important to reinforce messages through different communication channels and to also ensure that all sections of the refugee community are reached, including men, women, children, teenagers, different ethnic groups, different religious groups, and sections of the refugee population that are non-literate or have communication difficulties (deaf, blind, elderly, ill or infirm).

Efforts should be made to use any existing mass media communication infrastructure that exists. For example, in urban refugee contexts, there may be an existing network of media outlets, radio stations, television stations, and newspaper networks. In many settings the use of popular media (drama, songs, street theatre, dance, etc.) has been shown to be effective - however the provision of basic messages (for example broadcasting messages with loudspeakers or over a public address system) is better than delayed provision spent developing more popular media.

Box: Key hygiene messages for refugee settings

Handwashing with soap

  • To prevent diarrhoea, always wash hands with water and soap or ash, after defecation, after contact with faeces, before touching or preparing food, before eating and before feeding children.
  • Young children frequently put their hands in their mouths so it is important to keep the household clean and for children to wash their hands regularly, especially after defecating and before eating.

Toilet use

  • To prevent diarrhoea, use a toilet and ensure that all faeces, including those of infants and young children, is disposed of in a toilet or buried. Afterwards, hands should always be washed with water and soap or ash.

Safe water

  • To prevent diarrhoea, always drink water from a safe water source.
  • To prevent re-contamination, store water in a clean, closed water container with a narrow opening.

Food hygiene

  • Prepare and thoroughly cook food just before eating. Food left standing can collect germs that can cause diarrhoea. After two hours, cooked foods are not safe unless they are kept very hot or very cold.
  • Wash fruits or vegetables that are eaten raw thoroughly with safe water.

Diarrhea

  • Diarrhoea kills children by draining liquid from the body, which dehydrates the child. As soon as diarrhoea starts, it is essential to give the child extra fluids along with regular foods and fluids.
  • If the child passes several watery stools in one hour and vomits, there is cause for alarm – these are possible signs of cholera. Cholera can kill children in a matter of hours. Medical help should be sought immediately and the child should continue to receive ORS solution and zinc.
  • Cholera can spread throughout the community quickly through contaminated water or food. Make sure your water and food are safe and follow good hygiene practices.

Vector control

  • Flies that settle on faeces and then on food transmit the germs that cause Diarrhea. To prevent the spread of germs from flies: (1) cover food and drinking water, (2) dispose of faeces in a properly designed latrine or toilet, (3) keep the latrine or toilet clean, (4) reduce fly breeding sites by burying, burning or safely disposing of food refuse at the waste collection point.
  • Malaria, which is transmitted through mosquito bites, can be fatal. Wherever malaria is present, people should sleep under insecticide-treated bed nets; any child with a fever should be examined by a health worker.

Source: Facts for Life (4th Edition, 2010) – WHO, UNICEF, UNDP, WFP

Immediate assessment of hygiene related risks

A rapid assessment of hygiene behavioural risks should be carried out within the first few days of any refugee emergency. This is best achieved in collaboration with members of the Health programme and using a combination of observation walks, key informant interviews, and focus group discussions (see Chapter 9). Following the rapid assessment a prioritised hygiene promotion action plan should be developed that includes short, medium and long term strategies to reduce hygiene behavioural related risks. The risk assessment should be analysed taking into account current prevalence of WASH related diseases in addition to those that have the potential to cause rapid epidemics (see Chapter 2). Seasonal diseases should also be taken into account, particularly those linked to seasonal rain, temperature, and harvest seasons and hygiene promotion messages and activities.

Ensuring women’s menstrual hygiene management needs are met

Box: UNHCR sanitary protection standards for women and girls
  • Indicator: Percentage of needs met for sanitary materials
  • Standard: 100%
  • Rationale: To meet the basic and protection needs of refugee women and girls to uphold their dignity and self esteem.
  • Notes: This group includes girls and women 13-49 years old. The sanitary material kit includes either disposable napkins (12 per person per month) or reusable, absorbent cotton material (two metres long per person per six months), six underpants per person per year, and a 250g bar of soap per person per month (in addition to soap provided to the whole population).

Source: Practical Guide to the Systematic Use of Standards and Indicators (UNHCR, 2006)

Sanitary Pads Kyoke Refugee Camp (UNHCR, 2012)

During a refugee emergency it is possible that the populations may have fled with very few possessions. Therefore, UNHCR and WASH actors must ensure that all women on reproductive age (10-45) have immediate access to sufficient quantities of culturally appropriate Menstrual Hygiene Management (MHM) materials (sanitary cloth, reusable pads, disposable pads, soap, spare underwear) and WASH services (water supplies, bathing, laundering and drying facilities) to practice good menstrual hygiene management. Good MHM reduces risk of infection to girls and women and also gives them the empowerment to engage in daily activities and survival in an emergency refugee context. WASH facilities must allow all women and girls to change, soak, wash and dry MHM cloths with complete security and dignity.

UNHCR and WASH actors must ensure that the types and quantities of MHM materials that are distributed are decided in close consultation with women from the refugee population through the use of Focus Group Discussions and Key Informant Interviews. It is essential to understand what materials were commonly used in the refugee population's place of origins, in addition to any taboos, or specific cultural or religious considerations.

Universal access to hygiene promotion messages and activities

Hygiene promotion messages, activities, and supplies should be accessible to all sections of the populations including older persons, pregnant women, people with disabilities and children. Efforts should be undertaken to ensure that deaf (or hard of hearing), or blind (or partially sighted) persons are able to access hygiene information and participate in activities. Hygiene materials should match the levels of literacy of the displaced population. Particular care should be taken when designing hygiene promotion posters, or materials, for populations that are visually illiterate (cannot recognize pictures or symbols – commonly used in hygiene promotion images).


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Emergency hygiene promotion key references

  • Lambert, R., and Davis, J. (2002), 'Engineering in emergencies 2nd Ed.', Register of Engineers for Disaster Relief (RedR), London.



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» Ben Harvey - UNHCR Consultant