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National Hand Hygiene Behaviour Change Strategy - 2016-2020 Final Artwork-Ilovepdf-Compressed
National Hand Hygiene Behaviour Change Strategy - 2016-2020 Final Artwork-Ilovepdf-Compressed
2016-2020
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
CONTENTS
FOREWORD BY MINISTER 4
ACKNOWLEDGEMENTS 5
ABBREVIATIONS 6
EXECUTIVE SUMMARY 7
CHAPTER 1: INTRODUCTION
1. Background 8
1.1 Water, sanitation and Hygiene Context 8
1.1.1 National WASH Context 8
1.1.2 Health impacts WASH 10
1.1.3 The importance of washing hands with soap 11
1.1.4 National Handwashing hygiene programming bottleneck analysis 12
REFERENCES 45
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Dr Sanjana Bhardwaj
(UNICEF);
Dr Peter Harvey
(UNICEF regional WASH specialist);
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ABBREVIATIONS
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In addition to the sanitation challenges, South Africa is a water-scarce, middle income country
and is facing significant water shortages affecting 28% of towns, and high rates of non-revenue
water (39% of municipal water) and 36% water loss. Significant water pollution problems (including
acid mine drainage) and a deteriorating standard of waste-water treatment plants. According to
the General Household Survey (GHS) of 2012, the proportion of households with access to piped
or tap water in the dwelling, offsite and onsite in the country is 91.2%, however the report also
indicates that 15% of the population still require improvements to their water source to meet the
RDP standards.
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Diarrhoea is closely linked to socio-economic Many diseases and conditions (mostly affecting
status and has the most adverse effect in children) are transmitted through hands and
South Africa’s impoverished communities. simply because handwashing with soap at
South African children living in poverty critical times is not commonly practiced. [9]
are approximately ten times likely to die
from diarrhoea that their more privileged Amongst all the WASH interventions,
counterparts. Poor nutritional status, poor handwashing with soap alone shows greatest
environmental conditions, and illnesses such reduction in diarrhoea morbidity (over 40%) and
as HIV/AIDS make children more susceptible to prevents 30-47% of childhood diarrhoea and
diarrhoea and dehydration. Unsafe or lack of 23% of respiratory infections as elucidated by
water supply, sanitation services and hygiene (Rabie T, and Curtis V) [10,11]. Handwashing
is ranked 11th on the list of risk factors causing with soap has also been shown to prevent
deaths in South Africa, most of diseases diarrhoeal incidence amongst persons living
and subsequent deaths are preventable by with HIV and AIDS (Huang D, 2007:56).
improved hygiene and specifically good hand Because handwashing with soap can prevent
hygiene practices (Stassa: 2012) [7]. the transmission of a variety of pathogens, it
may be more effective than any single vaccine
1.1.3 THE IMPORTANCE OF (GPPPHW) [9].
HANDWASHING HYGIENE
Handwashing with soap however is not
Hygiene promotion is instrumental in commonly practiced as studies show that
encouraging good practices that can prevent hands are washed with soap at only about
the onset and spread of diseases associated 5-15% at critical times. A recent review of
with WASH. Washing hands with soap is one literature shows that globally, only 19% of the
of the most important steps anybody can take world population wash their hands after being
to avoid spreading germs and getting sick. in contact with excreta.
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• Environmental cues as reminders can trigger handwashing behaviour, such as posters in the
latrines and signs leading to handwash stations.
• Using visual reminders to accelerate links between cue and action to show that if, for
example hands are not properly cleaned, hands remain unclean;
• Intervention through doing to help form procedural memory not just by explaining how to
wash hands, but by actively having people do so, for example group handwashing at school.
• Conscious storytelling: People believing there is a deep and meaningful purpose behind their
habits strengthens their habits, for example mothers believing they are keeping their children
healthy may prevent relapse and encourage behaviour [9].
SECTION 3
BEHAVIOUR CHANGE IMPLEMENTATION FRAMEWORK
To achieve the desired health outcomes and strategy vision, and to ensure that resources are focused
where there is greater need, handwashing hygiene interventions should take into consideration and
focus attention on:
• The geographic spread of diarrhoea and respiratory diseases in children under-5, and other
hygiene related diseases;
• Hard to reach places, such as rural areas; and informal settlements, where a large number of
people still live without the basic water and sanitation services; and
• Areas where community social norms and behaviours are potential factors to increase the risk
of WASH related disease;
The mission of hand hygiene promotion is not to achieve a single handwashing event, but to
instill a routine and sustained habit that happens automatically at critical times. Identifying a target
audience is of importance to ensure that focus is on those groups of society that will enable
promotion programmes to have the largest impact, based on their roles in society.
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The Strategy identifies a primary and secondary • Actively engage in the practice of washing
target audience; hands with soap at critical times.
Children and caregivers are identified as a Men are often main decision-makers that
primary target audience. influence resource allocation in the household,
therefore their involvement and support to the
a) Children primary target audience in attaining positive
behaviour change is critical.
Habits are often developed in childhood and
children are more susceptible to behaviour • Tools that target men should be developed
change and the uptake of new habits. Schools to include them in hygiene promotion,
and Early Childhood Development Centers especially fathers of children under-5.
are key settings for learning new habits.
Additionally, children can be enthusiastic and 2) Secondary target audience
effective handwashing advocates.
To develop good hand hygiene habits, children • Government departments, agencies
should be; and policy makers
• Educated to learn and understand the The Strategic Development Goals (SDGs)
importance of washing hands with soap requires governments to set new water,
properly at critical times to prevent illness; sanitation and hygiene targets for ensuring the
and attainment of health and well being, including
• Encouraged to disseminate the the reduction in child and infant mortality rates.
handwashing message with the aim of For the interest of public health, hygiene should
improving hygiene behaviours within be an integral part of sector development
households and in the wider communities. planning, particularly for the health, education,
water supply and sanitation, and housing
b) Caregivers sectors.
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• Ensure that children are educated on a) Provide guidance and training on washing
the importance of keeping handwashing hands with soap at critical times and
facilities in good order and that hygiene with proper technique across all HIV
products are available and responsibly programmes (e.g. home, community,
used; school and facility-based programmes);
• Provide opportunity prior to meals for and place hand-washing stations with
washing hands with soap at all times; needed supplies (soap or ash, and water)
• Consider assignments that allows in programme sites.
the learners to demonstrate proper
handwashing comprehension; and b) Include WASH in national HIV/AIDS policy
• Motivate learners to always wash their and guidelines; and ensure that policies
hands after the toilet and before meals. and guidelines suggest environmental
health collaboration at all levels, as part of
3.3 INTEGRATION OF the multisectoral focus; and
HANDWASHING HYGIENE c) Identify washing hands with soap as a
INTO PRIORITY HEALTH critical behaviour for people living with HIV
PROGRAMMES and AIDS and TB [25].
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The Water and Sanitation sector should Hygiene promotion refers to a more systematic
promote and advocate for sustainable hygiene and planned approach to encourage the
promotion delivery in all water services widespread adoption of safe hygiene practices
programmes and build capacity of Sanitation for prevention of diseases. It begins with, and
Coordinators in behaviour change approaches. is built on what local people know, do and
want [20].
3.6 BEHAVIOUR CHANGE
APPROACHES AND STRATEGIES To realise the objectives of this strategy,
handwashing and hygiene programmes in the
3.6.1 Hygiene Promotion vs Health country should;
Education
• Adopt approaches that build on and
Hygiene promotion entails the use of strategies connect effectively to existing beliefs and
that encourage or facilitate a process whereby practices of communities; and
people assess, make considered choices, • Build upon the knowledge of people,
demand, effect, and sustain hygienic and their attitudes and wants, and focus on
healthy behaviours. identifying the motivators and key drivers
of behaviour change.
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Table 3: below outlines the broader motivations and key drivers of behaviour change.
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As communities gain awareness of their hygiene The 21-day challenge is an approach that can
situation through participatory activities, they be introduced as an exciting activity in schools
will be empowered to develop and carry out and other sectors as a way to get children to
their own plans to improve the situation. wash their hands everyday at certain moments,
with the aim to instill that particular habit.
This is based on using participatory tools, from
problem identification and analysis to planning 3) Adoption of a country “slogan” and
and selection of appropriate solutions. These use of ambassodors and/or champions
solutions may include both construction and
management of new physical facilities as well Best practice indicates that adopting a slogan
as adoption of safer individual and collective may advance the marketing and advertising
behaviour change [24]. efforts of any campaign. The creation of a
South African hand hygiene slogan should
3.6.4 Unconventional behaviour be adopted and agreed upon by various
change approaches stakeholders, through an established multi-
stakeholder Coordinating Committee.
1) Leap Frogging
This strategy also advocate for partnership with
Using new and innovative technology or pattern local public figure/s and community champions
of behaviour to accelerate the desired change to advance the handwashing agenda, as
in hygiene practices of society is critical. people can identify with and emulate public
figures for various reasons and can identify
These should include innovative ways and with people within own communities.
approaches that can ensure;
3.7 BEHAVIOUR CHANGE ADVOCACY
• People are able to keep their hands clean AND COMMUNICATION
at critical times where water and soap are
not immediately available; and a) The strategy aims to achieve the following
• Encouraging the use of hand sanitizers broad communication objectives;
or wet wipes where water is not readily
available; • To increase health and hygiene literacy
• Using new media and technology, such amongst South Africans, by communicating
as mobile phones and Apps for targeting messages extensively and increase mass
adolescents and young adults. awareness on an ongoing basis;
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times, which should be based on the risks Wet hands with clean
water and use soap;
Rub both hands together,
rub back of the hands;
of faecal-oral transmission of gastro-enteric
pathogens being high if handwashing with
soap is not practiced at each of the following
key four (4) contaminating events. 3 4
Rub in-between the fingers
Clean your wrists;
and clean the thumbs;
• After visiting the toilet; after changing baby
nappies; before handling food or eating;
and before feeding a child or others.
5 6
• Understanding the benefits of using a toilet Save water and do not leave the tap running
and keeping toilets clean;
• Understanding the importance of using “Make washing hands with soap a habit, it saves lives”
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The success of promotion initiatives will be reliant on amongst other factors, the understanding
of existing barriers and vulnerability factors in the targeted communities and/or audience. These
factors may either hinder or facilitate the desired behaviour.
The table below outlines vulnerability factors, their impacts and possible responses and approaches
towards hand hygiene promotion interventions.
Building local skills in constructing simple, economical handwashing stations from locally available
materials, such as the internationally promoted Tippy Tapp, can create hygienic enablers for
handwashing with running water, especially in areas where there is no running water and required
facilities.
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Source: UNICEF
SECTION 4
ORGANISATION AND COORDINATION
4.1 Institutional Arrangements
To ensure effective implementation and to realise strategy objectives, the strategy identifies focal
departments and relevant stakeholders, and outlines their responsibilities in ensuring sustained
hygiene behaviour change promotion in the country. The Departments of Health (DOH) , Water
and Sanitation (DWS) and Basic Education (DBE) are identified as key champions for handwashing
hygiene promotion.
The DOH, Environmental Health will assume the role of the coordinator to manage the implementation
of the programme and engage stakeholders.
Key champion departments and identified stakeholders will formulate a National Coordinating
Committee. The committee will lead on specific strategy components. The specific duties of the
Coordinating Committee will be outlined in Terms of Reference (TOR).
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Below are institutional arrangements and roles and responsibilities for the management and scaling
up of handwashing and hygiene at national, provincial and district levels.
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This strategy advocates for the country’s hygiene programmes to take the form of a Public-
Private Partnership (PPP). Public-Private Partnerships are useful to improve the impact of hygiene
promotion programmes in the country, through collaborative and integrated planning.
The private sector invested a significant portion of its energies to understanding the consumer in
order to make and promote appropriate products and achieve their accompanying behaviours.
Industry has already brought soap for bathing and laundering into over 90 percent of households
worldwide, showing how successful it can be at making soap and its accompanying behaviours
almost ubiquitous, including changing domestic hygiene practices [9].
Government hygiene programmes can greatly benefit from the successes of the private sector on
influencing behaviours, and the private sector also stands to gain from partnership through market
expansion and in meeting cooperate social responsibility.
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• Handwash messages included in antenatal The methodology also has to grapple with
care classes; the evidence that people behave differently
• Handwash messages included in birth kids in the presence of an observer [28].
for new mothers;
• % of community workers/home-based
carers with the knowledge of handwashing CHAPTER 6
critical times and technique. IMPLEMENTATION PLAN
• Health messages included in Community
• Health Worker education packs for The implementation plan summarizes the
community outreach. issues identified in the strategy and translates
them into achievable time bound actions.
5.3 Methods for collection; The action plan is also guided by the need
to address priority bottlenecks of the HWH-
Data should be collected at district, provincial WASH-BAT in improving hygiene promotion
and national level. Collection of data systems programming and increase impact.
should build on existing monitoring and
evaluation processes an systems. Training The action plan outlines specific objectives,
on data collection should be provided to relevant actors, operational indicators and
community based health workers to increase timelines for 2016-2020;
its reliability e.g. household practices, incidents
of diarrhoea in the household, especially in
children under-5. There are a variety of data
collection methods and tools that are used
to monitor and evaluate hygiene promotion
programmes. Examples include household
questionnaires, community mapping,
focus group discussions, health walks, in-
depth discussions with key informants, and
observation.
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OBJECTIVE 1:
TO INSTILL AND SUSTAIN THE HABIT OF WASHING HANDS WITH SOAP AT CRITICAL TIMES AMONGST SOUTH AFRICANS, THROUGH
IMPROVED KNOWLEDGE ON THE LINK BETWEEN HYGIENE AND DISEASE;
SUB-OBJECTIVES ACTIVITIES/ACTIONS RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
1.1 Implement hand • Plan for hand hygiene Province 2017 - 2018 • Hand hygiene • # of provinces and with
hygiene promotion promotion implementation at Districts and promotion forms part hand hygiene in the
targeting the primary provincial and local levels. metropolitan of provincial, district Annual service delivery
audience. • Advocate for adequate Municipalities and local annual service plans;
and dedicated budgets delivery plans; • # of provinces and
for hygiene promotion • WASH provision and municipalities with
programmes. hygiene promotion dedicated budgets for
forms part of hygiene activities
emergency planning; • # of municipalities with
• Dedicated budgets WASH and hygiene
provided for hygiene promotion integrated
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promotion activities. into emergency and
disaster plans;
• Mainstream hand hygiene DBE 2016-2020 • Hand hygiene • % schools with hygiene
in and schools and early DSD promotion integrated programmes in place;
learning development; DOH into school curricula • # school teachers and
and early learning SGBs trained;
development.
• Mainstream hand hygiene DOH, DWC, DSS, 2016-2020 • Hand hygiene taught to • % of new mothers,
into programmes: Private health care pregnant women and HIV/AIDS, TB
- maternal and neonatal care; sector new mothers attending patients, young girls
- menstrual management; Stakeholders antenatal and prenatal and caregivers with
- HIV/AIDs and TB; health care, HIV/AIDs knowledge of the
- Child nutrition; and TB patients, EPI, importance of washing
- Expanded Programme on menstruating girls. hands with soap,
Immunisation (EPI) and the link between
hygiene and disease;
• Implement awareness raising DOH 2016-2020 • Community awareness • National Handwashing
drives as part of long term DBE drives conducted celebrity ambassador/s;
hand hygiene programmes. DWS and awareness days • Highly publicized drives
Stakeholders commemorated; and field visits with
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• Identify and forge celebrities.
partnerships with pubic • Global Handwashing
figures/celebrities day; World Toilet Day,
as ambassadors to Water Week;
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
promote handwashing.
1.2 Ensure that hand • Develop and implement a NDOH 2016-2020 • National communication • Audio messages, TV
hygiene promotion hand hygiene promotion PDOH plan developed, costed messages, newspaper
messages reaches communication Plan; Municipalities and implemented; advertisements,
all communities in • Increase levels of knowledge Partners • Developed targeted, billboards;
South Africa. and awareness on the appropriate, and • Mobile and social media
importance of washing standardized messages campaigns;
hands with soap; and promotion material • Message distributed at
and tools; shopping malls and taxi
ranks, churches;
OBJECTIVE 1:
TO INSTILL AND SUSTAIN THE HABIT OF WASHING HANDS WITH SOAP AT CRITICAL TIMES AMONGST SOUTH AFRICANS, THROUGH
IMPROVED KNOWLEDGE ON THE LINK BETWEEN HYGIENE AND DISEASE;
SUB-OBJECTIVES ACTIVITIES/ACTIONS RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
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chain for promotion of handwashing with
of handwashing with soap;
soap at café’s and • # cafe and restaurant’s
restaurants; with handwashing
messages and
handwashing facilities
and soap available for
customers;
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OBJECTIVE 1:
TO INSTILL AND SUSTAIN THE HABIT OF WASHING HANDS WITH SOAP AT CRITICAL TIMES AMONGST SOUTH AFRICANS, THROUGH
IMPROVED KNOWLEDGE ON THE LINK BETWEEN HYGIENE AND DISEASE;
SUB-OBJECTIVES ACTIVITIES/ACTIONS RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
1.3 Strengthen • Train and reorient Community DOH 2017-18 • Community Health • Number of CHW,
capacity on hygiene Health Workers on hygiene Stakeholders workers and WBPHCTs WBPHCTs trained;
promotion and promotion and behaviour DBE trained on hygiene • Stakeholders
behaviour change. change approaches and DSD promotion approaches; consulted; (health
tools. • Consultations professionals, NGOs,
• Consultation and workshops held with all CBOs, politicians,
capacity building with stakeholders on their parliamentarians and
key stakeholders on the role in implementing the policy makers, media);
implementation of the strategy; • # of teachers
strategy; • School teaching capacitated;
• Capacitate teachers on material on hygiene • # of SGBs capacitated;
handwashing promotion and promotion available; • # of increased schools
the use of teaching materials; with soap and water on
or near handwashing
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facilities.
• Training of SGBs to
support implementation of
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
2.1 Ensure the availability • Advocate for the provision DBE 2016-2020 • Adequate and usable • % of ECDs, primary and
of adequate WASH of and availability of DWS handwashing facilities, secondary schools with
facilities for school, handwashing facilities, DOH water and soap a handwashing facility
health facilities and adequate water and DSD dispensers provided with soap and water
at home to enable soap in schools, health Stakeholders in most schools, in or near sanitation
sustainable hand facilities, homes, public health facilities, public facilities;
hygiene behavior gathering places to facilitate gathering places and at • % of ECDs, primary and
change. handwashing.; home; secondary school with
• Empower communities with • Adequate menstrual handwashing facilities
the skills to construct simple hygiene management with soap and water
low-cost technology for facilities (for cleaning near food handling
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handwashing, and disposal) available premises and food
in most schools; serving areas;
• Communities and • % of schools with
schools provided with adequate washing and
skills to construct low- disposal facilities for
cost WASH facilities for menstrual management;
washing hands. • % of schools with
handwashing facilities
and soap in or near
menstrual facilities;
• % health facilities with
handwashing facilities
and soap available in or
near toilets facilities for
use by clients;
• % of Public gathering
places distributing
hygiene messages in or
near toilet facilities;
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OBJECTIVE 2:
TO PROMOTE THE CREATION OF AN ENABLING ENVIRONMENT FOR WASHING HANDS WITH SOAP, WHERE HANDWASHING FACILITIES,
WATER AND SOAP ARE MADE READILY AVAILABLE;
SUB-OBJECTIVES ACTIVITIES RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
• % of households with
a handwashing facility
on or near a sanitation
facility;
• % of households and
schools with Tippy
Tapps next to sanitation
facilities.
OBJECTIVE 3:
TO IMPROVE AND STRENGTHEN HYGIENE AND HANDWASHING COORDINATION IN THE COUNTRY
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OBJECTIVES ACTIVITIES RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
3.1 Ensure effective • Strengthen inter-ministerial DOH 2016-2020 • National WASH TASK • # meetings held;
coordination coordination for hygiene and DWS Team and Technical • # Intergovernmental
of hygiene and handwashing promotion to DBE Team established with forums with WASH
handwashing meet national SGD targets; DSD endorsed Terms of aspects integrated;
activities and • Integrate handwashing Stakeholders Reference; • MOUs in place
interventions in the aspects into existing inter- • Intergovernmental between government
country. governmental forums action forums (ISHP, NSTT) departments;
for the promotion of long with handwashing • # of policies with
term programmes; aspects; handwashing and
• Advocate for the inclusion of • Strengthened hygiene hygiene aspects
handwashing and hygiene aspects into the integrated.
aspects in government National Sanitation Task
policies to ensure health in all Team.
policies.
OBJECTIVE 3:
TO IMPROVE AND STRENGTHEN HYGIENE AND HANDWASHING COORDINATION IN THE COUNTRY
OBJECTIVES ACTIVITIES RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
3.2 Forge partnerships • Establish a South African DOH, DBE, DWS 2016-2020 • SAPPPHW established • # of meetings held;
with the private Public-Private Partnership for Private sector and operational; • # of joint awareness
sector for short and handwashing (SAPPPHW) Stakeholders • Prototypes of suitable drives;
long term promotion to address WASH issues CDC, UNICEF, WHO, handwashing stations; • # of handwashing
programmes. for schools, health World Bank • Joint handwashing prototypes developed
establishments, households, campaigns held; and tested.
emergencies, women and
girls needs;
• Promote the development
of handwashing innovations
and designs that will meet
and are driven by local
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demands and preferences;
• Promote space for
private sector to support
government campaigns to
motivate and mobilize people
on washing hands with soap.
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
OBJECTIVE 4:
TO PROMOTE EVIDENCE BASE INTERVENTIONS AND APPROACHES
SUB- OBJECTIVES ACTIVITIES RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
4.1 Ensure the use • Collaborate with research DOH 2016-2020 • Research gaps and • # formative research
of hand hygiene institutions to conduct Research institutions needs identified; conducted;
approaches and local formative research on Institutions of higher • Formative research • # survey articles
interventions based hand hygiene behaviour, learning conducted to inform published;
on evidence. knowledge and practices; Stakeholders interventions. • SA handwashing
• Formulate handwashing local CDC, WHO, UNICEF. • Handwashing and baseline data;
baseline information; hygiene Baseline; • New and innovative
• Establish a WASH research • Research studies on handwashing
think tank to coordinate various appropriate technologies.
research and determine local handwashing
research needs; technologies and
innovations;
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• Conduct research into • Research symposium
appropriate handwashing held and resolutions
technologies; documented.
• Conduct a research
NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
symposium.
OBJECTIVE 5:
TO IMPLEMENT MONITORING SYSTEMS TO MONITOR EVALUATE HYGIENE
SUB- OBJECTIVES ACTIVITIES RESPONSIBILITY TIME FRAME OUTPUTS INDICATORS
5.1 Strengthen Hygiene • Develop national sanitation DOH 2016-2020 • National hygiene and • National Hygiene norms
and Handwashing and hygiene norms and DBE handwashing norms and standards;
monitoring systems standards in the country to DWS and standards in place; • Defined hygiene
meet SDG targets; Stakeholders indicators and
• Set specific national agreed Research Institutions monitored;
upon hygiene indicators and Private Sector,
national targets; NGOs
• Conduct an assessment Support of Statistics • National hygiene and • Defined hygiene national
of human resources SA and NGOs handwashing agreed targets and reported ;
requirements to reach upon targets available • # of national monitoring
Hygiene targets; and shared; systems with hygiene
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• Develop a human resource • Hygiene indicators indicators integrated.
strategy to reach hygiene integrated into existing
behavior change targets. national monitoring
• Integrate hygiene monitoring systems, e.g. STATSSA
indicators into existing water, general health survey;
sanitation, hygiene, health
and education monitoring
systems;
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NATIONAL HAND HYGIENE BEHAVIOUR CHANGE STRATEGY | 2016-2020
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