Implementing the SAFE Strategy for Trachoma...

Implementing the SAFE Strategy for Trachoma Control

A Toolbox of Interventions for Promoting Facial Cleanliness and Environmental Improvement

Paul Emerson and Laura Frost, with Robin Bailey and David Mabey

A Toolbox of Interventions for Promoting Facial Cleanlinessand Environmental Improvement

Paul Emerson and Laura Frost,with Robin Bailey and David Mabey

Implementing the SAFE Strategy for Trachoma Control

The authors are grateful to the following individuals for their helpful advice, discussion,and for hosting visits to their programs:

Sheila West, Harran Mkocha, and program stafffrom the Kongwa Trachoma Project, Tanzania;Momodou Bah, Ansumannah Sillah, Jerreh Sanyang,and Hannah Faal from the NECP and Sight SaversInternational, The Gambia; Jim Zingeser, AliAmadou, and Mohamed Salissou Kané from TheCarter Center, Niger; Dan Salter and Mrs. Phi fromIDE, Vietnam; Mike Meegan and program stafffrom ICROSS, Kenya; Lisa Tapert, ChadMacArthur, Manisha Tharaney, and Helen KellerInternational program staff from Burkina Faso, Mali,Morocco, Nepal, Niger, and Tanzania; Joe De-graftRiverson, Sam Jackson, and World Vision programstaff from Tanzania, Ethiopia, and Vietnam;Solomon Gudina from the BBC World Service trustin Ethiopia; and Silvio Mariotti from the WorldHealth Organization.

Most of the photographs were taken by PaulEmerson. We are grateful to other individuals andorganizations who have allowed use of their photo-graphs: Jim Zingeser (Zinder latrine project,Sudanese boy washing face), Sophie Masson andAmy Ratcliffe (school-based trachoma program inBurkina Faso), Vanessa Vick (trichiasis surgery inEthiopia), and Annemarie Poyo (Ghana water pump).

Support for the formatting and printing of thisguide was provided by the Conrad N. HiltonFoundation and The Carter Center.

Acknowledgments

Users of this guide are permitted to make photocopies for distribution. An electronic copy is available at The Carter CenterWeb site: http://www.cartercenter.org. Additional print copies available through The Carter Center Trachoma ControlProgram at (404) 420-3830.

Printed in January 2006

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1What Is Trachoma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Identifying Trachoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1How Trachoma Leads to Blindness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1The Challenge of Sustainable Trachoma Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2The Scale of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2The SAFE Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Ultimate Intervention Goals for the Elimination of Blinding Trachoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

2 Identifying Context-Specific Risks for Trachoma Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . .5Flies, Faces, and Feces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Eye Rubbing and Fingers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Shawls, Towels, Bed Sheets, and Pillows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Sharing a Towel or Washcloth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6A Framework for Understanding Hygiene Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

3 Generating Momentum for Changing Health-Related Behavior . . . . . . . . . . . . . . . . . . . . . . . . .8General Behavior Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Steps to Behavior Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Targeting Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Key Players in a Trachoma Control Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Generating and Maintaining Momentum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

4 F and E Interventions in Trachoma Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Hygiene Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Promotion of Individual Towel and Washcloth Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15School-Based Trachoma Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Promotion of Water Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Rainwater Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Pit Latrines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Provision of Village Cleaning Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Other Interventions That Have Been Tried . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

5 Communicating Health Through Social Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Step 1: Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Step 2: Message Development and Pretesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Step 3: Materials Development and Pretesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Step 4: Campaign Delivery and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

6 Monitoring and Evaluating Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Importance of the Baseline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Steps for Monitoring and Evaluating Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Step 1: Develop a Purpose and Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Step 2: Gather Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Step 3: Analyze Data, Interpret Findings, Draw Conclusions, and Make Recommendations . . . . . . . . . . . . .42Step 4: Present Findings and Act on Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

iv

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There is no excuse for the unnecessary suffer-ing caused by blinding trachoma. While wecannot eradicate this devastating disease, we

have the tools to eliminate the more serious compli-cations of trachoma, such as blindness.

The disappearance of trachoma in the UnitedStates, Europe, and some developing countries hasoccurred in conjunction with economic developmentand access to health infrastructure. Historically, thekey features for stopping trachoma transmission havebeen improvements in hygiene and sanitation andaccess to water. These are incorporated into theWHO-endorsed SAFE strategy for trachoma controlas the F and E components: Facial cleanliness andEnvironmental improvement.

There is a perception that hygiene promotion andenvironmental improvement are abstract, expensive,and immeasurable, but this is not true. This guidedemonstrates that F and E can form a vital part of atruly integrated strategy for trachoma control that willalso provide many additional health benefits, such asreducing intestinal worms and diarrheal diseases.

Rosalynn and I have seen the life-changing bene-fits of trachoma control programs on our many visitsto Africa. In particular, during our 2005 visit toEthiopia, we witnessed a latrine revolution takingplace. I was struck by the fact that the program didnot just include the men of the village, but was driv-en by the women who wanted the best for their fami-lies in terms of their current health and a brighterfuture for their children. The behavior of childrenhad been changed. Now instead of relieving them-selves in the fields, they were proudly using their ownsmall potties. The situation in Ethiopia is simply oneexample of how trachoma programs can improvepeople’s lives if we just apply ourselves and act.

This trachoma toolbox has been created to pro-vide program managers and implementers an arrayof possible solutions, as illustrated in case examples,

for the F and E aspects of their trachoma controlprograms. It fills a gap in current documentation ofimplementation of the SAFE strategy by giving prac-tical guidelines and highlighting where interventionsmay or may not work.

Now that we have the tools necessary for trachomacontrol, the onus of responsibility falls on all partiesto deliver the full SAFE strategy to everyone at risk.Together, we should act on our commitment toempower those men, women, and children sufferingdaily from this entirely preventable disease.

Foreword

Former U.S. President Jimmy Carter discusses trachoma with a man from Mosebo village, Ethiopia.

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1 Introduction

The purpose of this manual is to provide pro-gram managers and planners with guidancefor designing interventions for facial cleanli-

ness (F) and environmental improvement (E) in tra-choma control programs. This manual

■ Shows how to learn about risk practices, identify appropriate F and E interventions, and identify target groups for interventions.

■ Offers a toolbox of F and E interventions withspecific examples and case studies.

■ Explains how to communicate about a trachoma control program through the media.

■ Provides steps for evaluating a trachoma control program.

■ Gives resources for further information.

What Is Trachoma?Trachoma is an infectious eye disease that is the lead-ing cause of preventable blindness worldwide. It iscaused by ocular infection with bacteria calledChlamydia trachomatis, and blindness is the result ofrepeated infections over many years. Each activeinfection can be treated with antibiotics, and stepscan be taken to avoid infection or prevent transmis-sion to reduce the risk of blindness in the future.

Identifying TrachomaThere are five distinct stages of trachoma, whichhave been categorized in a grading scale by theWorld Health Organization (see Figure 1.1). Onlythe last stages, trachomatous trichiasis (TT) andcorneal opacity (CO), are clearly visible withoutexamining the lining of the eye (conjunctiva) byeverting the upper eyelid.

The other stages, trachomatous inflammation follicular (TF), trachomatous inflammation intense(TI), and trachomatous scarring (TS), can be identi-fied only by everting the upper lid and examiningthe conjunctiva. It is not possible to identify thesestages of trachoma by simply looking at the eye.

How Trachoma Leads to BlindnessWhen a person’s eyes get infected with Chlamydiatrachomatis, the bacteria develop in the cells of theconjunctiva. This infection usually results in thedevelopment of inflammation and a few folliclesunder the upper eyelid (stage TF). Many cases of TF

are mild and get better in a few weeks or months.Sometimes the infection causes more severe inflam-mation (stage TI) and the eyes may become painful,a white or watery discharge may be present, and theindividual may find it uncomfortable to be in brightsunlight. These signs of active disease (stages TF andTI) are most commonly seen in children.

The cycle of active infection and resolutionrepeated over many years leads to the developmentof scars on the conjunctiva (stage TS). Scarring isnot a sign of active infection, but rather it indicatesthat an individual has had repeated trachoma infec-

Corneal opacity (CO)Easily visible corneal opacity over the pupil

Figure 1.1. Simplified trachoma grading classification system from the WorldHealth Organization.

Trachomatous inflammation follicular (TF)The presence of five or more follicles in theupper tarsal conjunctiva of at least 0.5 mm

Trachomatous inflammation intense (TI)Pronounced inflammatory thickening ofthe tarsal conjunctiva that obscures morethan half of the normal deep tarsal vessels

Trachomatous scarring (TS)Presence of scarring in the tarsal conjunctiva

Trachomatous trichiasis (TT)At least one eyelash rubs on the eyeball or there is evidence of recent removal of in-turned eyelashes.

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tions in the past. Scarring is more common in adultsand is seen first in teenage children in trachoma-endemic areas. As active infections lead to more scar-ring, the scars slowly develop into a network. Overtime, this network of scars contracts, shortening theinner lining of the eye. This shortening distorts thelid margin, pulling the eyelashes closer to the eye.Eventually the lashes are pulled around so far thatthey touch the eye. This is called trichiasis (stageTT) and is seen typically in individuals over age 35,although cases do occur in individuals in their 20s oryounger. At first trichiasis is uncomfortable for theindividual, but it soon becomes painful as more lash-es rub against the eyes. Smoke, dust, and sunlightmake it more painful, and the individual will preferto stay indoors. The rubbing of the lashes scratchesthe transparent part of the eye (the cornea) andother infections develop. The combination ofscratching and infection finally turns the corneaopaque, and the individual loses vision (stage CO).Vision can be restored only by corneal transplant,but patients report improved vision after trichiasissurgery, which reverses the in-turning of eyelashes.

The Challenge of SustainableTrachoma ControlAlthough some children with active trachoma maycomplain of sore or dry eyes, many feel like there issand in the eye or experience some ocular discharge;most do not even know they are infected. Active tra-choma usually goes ignored and untreated. In sharpcontrast, trichiasis is a terrible condition that isimpossible to ignore. It is widely recognized, andthere is usually a specific word for it in the local lan-guages of endemic regions. There are many tradi-tional beliefs as to why some individuals get trichia-sis, but people in the endemic regions do not linkthe mild eye problem seen in children to the horrorof trichiasis and blindness in adults.

Surgery can reverse the in-turning of the lashesseen in trichiasis. Active trachoma can be treatedwith antibiotics. Transmission can be reduced bygood hygiene and environmental improvement. Butthe challenge for sustainable control is for peoplewho are at risk of blindness from trachoma to under-stand the link between good hygiene, good sanita-tion, and improved living conditions for their chil-dren and being spared the misery of trichiasis asadults. Improving the sanitation, hygiene, and accessto clean water within a community will lower itsprevalence of active trachoma in a sustainable man-

ner, meaning that future generations will be sparedthe blindness of trichiasis.

The Scale of the ProblemTrachoma is endemic in 55 countries, mostly inAfrica and the Middle East, although a few coun-tries in the Americas and Asia are also affected (seeFigure 1.2).

According to the most current estimates, some 84million people are affected by active disease, morethan 10 million additional people have trichiasis —and are, therefore, at immediate risk of blindness —and another 7.6 million people have been blinded.In addition to the misery and pain of trichiasis andthe disability caused by blindness, trachoma causesdependency and is a barrier to development. Thecost of disability and potential loss in productivityalone has been estimated to be in excess of $2 billionUSD per year.

The SAFE StrategyTo combat trachoma, the World HealthOrganization has endorsed an integrated strategyknown as SAFE (see Box 1.1 for more detailedinformation):

Surgery for people at immediate risk of blindness

A ntibiotic therapy to treat individual active casesand reduce the community reservoir of infection

F acial cleanliness and improved hygiene to reduce transmission

Environmental improvements to make livingconditions better so that the environment no longer facilitates the maintenance and transmission of trachoma

These four components form the foundation ofthe effort to eliminate blinding trachoma. All fourcomponents must be present for a trachoma controlprogram to be successful. That is, equal attentionmust be given to providing surgery, antibiotics,hygiene promotion, and environmental improve-ments. If only surgery and antibiotic therapy areprovided, with little effort to make sustainablechanges in hygiene and sanitation, only the symp-toms of the disease, not the causes, will beaddressed. For sustainable control of trachoma, the Fand E components of the SAFE strategy must bepresent in a program in addition to the S and Acomponents.

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Ultimate Intervention Goals for theElimination of Blinding TrachomaThe World Health Organization has set ultimateintervention goals (UIGs) for trachoma that indicatethe final targets that must be achieved to eliminateblinding trachoma globally.

Trachomatous Trichiasis UIGFor blinding trachoma to eventually be eliminated asa public health problem, each country must reducethe number of people with trichiasis to fewer thanone per 1,000 people in a district. This can beachieved by making surgery available to people withtrichiasis to eliminate the backlog of cases.

Active Trachoma UIGFor blinding trachoma to eventually be eliminated asa public health problem, each country must reducethe number of cases of active trachoma (TF) in chil-

Figure 1.2. Shading indicates the countries where trachoma is endemic.

dren between the ages of 1 and 9 to less than 5 per-cent of the population of children in any district. IfTF prevalence is greater than 10 percent in childrenages 1–9, districts should conduct mass distributioncampaigns of tetracycline eye ointment orazithromycin oral antibiotic. In any district whereTF is between 5 percent and 10 percent in childrenages 1–9, targeted treatments may be used instead ofmass treatments.

Facial Cleanliness and EnvironmentalImprovement UIGHygiene promotion and environmental improve-ment should be conducted in a community so that,at any given time, 80 percent of the children in thecommunity will have clean faces.

No active trachoma

Data confirmed endemic active trachoma

No data identified, believedendemic active trachoma

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Box 1.1The SAFE Strategy for Trachoma Control

Environmental Improvement: Trachoma persists where peoplelive in poverty with crowded living conditions and where thereis insufficient basic infrastructure for water, sanitation, and

waste disposal. Unless such conditions change, trachoma will returnafter antibiotic treatment. The scope of this component is so broadthat it is daunting for program managers and planners. It is essential,however, for sustainable trachoma control and should be achievablewith the help of collaborators from other sectors such as education,water, and rural sanitation.

Surgery is used to reverse the in-turned eyelashes ofpatients with trichiasis. It is usually the first part of theSAFE strategy to be delivered because it addresses the

needs of those at immediate risk of blindness. Lid surgery is afairly simple procedure that can be offered in the communityor at health centers. Patients are often afraid of the operation,and offering community-wide surgery is the best way of gettinggood compliance. Lid surgery takes away the pain of lashes onthe eyes but does not remove the scarring or restore sight. It isimportant that the surgeons have had training and supervisionbecause there can be a high rate of recurrence if the surgery isnot performed carefully.

A ntibiotics are used to treat active trachoma and to reduce the reser-voir of infection in a community. Topical tetracycline eye ointmentapplied to the eyes every day for six weeks will treat active trachoma.

Alternatively, the drug azithromycin can be taken orally in tablets (or liquidfor infants), and one dose per year will treat active trachoma. The distributionstrategy depends on the prevalence of trachoma, availability of drug, and avail-ability of staff for screening or distribution. The World Health Organizationrecommends that all individuals in communities where the prevalence of activetrachoma exceeds 10 percent of children ages 1 to 9 be mass-treated withantibiotic therapy. In communities where the prevalence of active disease isbetween 5 percent and 10 percent, health officials may choose to either mass-treat or treat only people with active disease and their families.

F acial Cleanliness: Dirty faces are associated with active trachoma.Children with dirty faces are more likely to transmit trachomaif they have active infections or get trachoma if they are not

infected. Discharge from the eyes and nose attracts eye-seeking fliesthat can bring the infection or carry it to other people. Rubbing thesore and dirty eyes with cloths, bed sheets, or a mother’s shawl cancontribute to the transmission of trachoma. Trachoma control programsmust convey that it is desirable for children to have a clean face — andthat this should be the usual state.

A doctor performs trichiasis surgery in Ethiopia.

A woman takes the antibioticazithromycin in Amhara, Ethiopia.

A schoolgirl uses a leaky tin to wash her face andhands in Kongwa,Tanzania.

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How is trachoma transmitted from person toperson? As Figure 2.1 shows, young chil-dren are the source of infection with tra-

choma. Transmission takes place when the bacteriamove from the eyes of infected young children to theeyes of an uninfected person. Because there are sever-al routes of transmission—eye-seeking flies, hand-to-eye touching, mothers’ shawls, towels, bed sheets,and pillows—it is necessary to identify the context-specific risk practices in each country.

It is important to consider that the relative impor-tance of any transmission route may change with theseason, living conditions, or environment and thatsome routes of transmission may not operate at all insome environments. For example, because the eye-seeking fly identified as a vector of trachoma, Muscasorbens, is not found in Mexico or Brazil, it wouldnot be appropriate to promote fly control as a tra-choma reduction method in these countries.

Flies, Faces, and FecesNot all species of fly are able to transmit trachoma.For flies to be vectors, they must be present where

there is active trachoma, they must pick up theChlamydia bacteria from infected eyes, and they musttransfer it to uninfected eyes. The only species of flythat has been demonstrated to be a vector of tra-choma is the Bazaar fly, Musca sorbens, and its siblingspecies, the Australian Bush fly, Musca vestustissima.The common housefly, Musca domestica, is suspectedto be a trachoma vector. After the rains in Africa, thepopulation of the housefly explodes and hundreds offlies crawl over everything—including human eyes.The large green flies seen in Africa around toilets,fresh fruit, and meat do not come into contact witheyes and so cannot be trachoma vectors.

Musca sorbens breeds in feces, most prolifically inhuman feces lying in the shade on the soil surface,but also in cow dung and dog feces. Therefore, whereMusca sorbens is present, steps to minimize fly-to-eyecontact and reduce breeding opportunities for flies bydisposing of feces properly should be taken.

Eye Rubbing and FingersChildren touch their eyes much more frequentlythan adults. Children rub their eyes in an attempt to

2 Identifying Context-Specific Risksfor Trachoma Transmission

Figure 2.1. Ways trachoma is transmitted.

Child withC.Trachomatis New host

Flies

Fingers

Cloths, towels, sheets

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make them feel better; children usually rub them ifthey are painful or if they are irritated by somethinglike dust, sand, or flies. Children tend to have moreirritated eyes if their faces (particularly around theeyes and lashes) are dirty; if the environment is dry,sandy, or dusty; and if it is windy. If eyes are rubbedwith dirty hands, then more irritation can be intro-duced, and the urge to rub them becomes greater.

Good hygiene practices, including hand and facewashing, should be promoted by all trachoma con-trol programs, especially in dry and dusty environ-ments and where children have dirty faces.

Program managers may consider also taking stepsto reduce children’s exposure to wind-borne dust,such as planting shade trees near schools and publicmarkets or using live fencing around schools andplaying fields. Such practices generally receive com-munity support and also help reduce dust. Certainlythese practices will do no harm and may marginallylessen trachoma transmission.

Shawls, Towels, Bed Sheets,and PillowsAll over the world, mothers wipe their children’sfaces to remove mucus from the nose, food from themouth, tears from the eyes, or dirt on the face. Inmost countries, the mother uses her own clothes todo this —her shawl in Asia, her kanga in East Africa

or South America, or her wrapper in West Africa.Because the bacteria that cause trachoma are oftenpresent in the discharge from the eyes and mucusfrom the nose, this practice could spread the bacteriato another child.

Sharing a Towel or WashclothIn some cultures, people use cloths to wash theirfaces; in others, people use only their hands. In somecultures, people typically dry their faces with a towelafter washing; in others, people leave their faces todry on their own. When people share towels orcloths, the batcteria that causes trachoma can spread,contributing to high levels of infection in a family oreven in a school or other group, if people sharewashing facilities.

A Framework for UnderstandingHygiene ImprovementThe Hygiene Improvement Framework (see Figure2.2), developed by the Environmental Health Projectfor hygiene improvement programs, is a useful modelfor planning and implementing F and E interven-tions for reducing trachoma transmission. The modelhas three components: accessing hardware, promotinghygiene, and enabling environments.

Hygiene promotion involves encouraging existingpractices, such as face and hand washing; it involves

Enabling EnvironmentsPolicy improvement

Community organizationIncome-generating activitiesInstitutional strengthening

Access to HardwareWater systems

Sanitation facilitiesCommunity cleaning equipment

Hygiene PromotionHand- and face-washing promotion

Community cleaning promotionIndividual towel and cloth use promotion

School programs

Figure 2.2. Hygiene Improvement Framework.

HYGIENE IMPROVEMENT

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promoting new practices, such as individual toweluse; and it involves changing key behaviors such asdisposing of children’s feces in a latrine instead of ona rubbish heap. These practices must be supportedby community hardware such as water systems, sani-tation facilities, and community cleaning equipment.Finally, hygiene improvement cannot be implement-ed and sustained at the community level without theenabling of institutional and policy environment.

Flies land on a child’s face in The Gambia.

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All of the F and E trachoma control inter-ventions discussed in this guide require acommunity commitment. This section pro-

vides methods for approaching and working withcommunities appropriately to generate and maintainmomentum for the design and implementation of Fand E interventions.

General Behavior ChangeIn the past few decades, research has shown somegeneralizations about behavior change that can beapplied to F and E trachoma control interventions.

So while research shows that behaviors such ashand and face washing can prevent trachoma, simplyprescribing these behaviors is not likely to lead tolong-term behavior change if the situation, culture,and available resources are not also taken into con-sideration. Programs must to be initiated in a verysensitive way, showing a great deal of respect to acommunity’s beliefs and practices and having a clearunderstanding of the structural barriers to the adop-tion of new behaviors.

Motivators and Inhibitors of Behavior ChangeIndividuals react differently to adopting new behav-iors. Some are progressive and will adopt new ideasand practices quickly, while others are traditionalistsand more cautious about change. Traditionalists havegood reason for not readily accepting new behaviors.They cannot squander the few resources they haveon unproven practices. Traditionalists must under-stand how F and E interventions will ultimately ben-efit them, or they will not be interested.

In trying to change individuals’ behavior, programmanagers must consider how behavior is influencedat several levels.

Individual level. A person will take up a newpractice when he or she believes it has sufficient ben-efits—health or otherwise. An individual is influ-enced by his or her culture, values, and traditions, aswell as his or her education.

Community level. Key people in the person’scommunity will also influence his or her interest intrying the new practice. These people can includerelatives and members of the social network. Thereare always key people in the community, such aselected or traditional leaders, health workers, ormoneylenders, whose agreement is necessary for anew behavior or technology to be adopted. In mosttraditional societies, individuals need to maintain agood social network, which means they are not ableto contradict the community decision-makers. To dosomething of which the key community decision-makers do not approve may cause an individual tobe cut out of the social network.

Intersectoral level (enabling factors). To take up

3 Generating Momentum forChanging Health-Related Behavior

Community members make latrine slabs in The Gambia.

First, an individual’s behavior is informed by pre-existing concepts, attitudes, and values. That is,behavior is shaped by culture and tradition.Therefore, an understanding of an individual’s cul-ture and tradition is vital for planning effectivebehavior-change programs.

Next, an individual’s knowledge can be increased,but his or her behavior may not change as a result.

Finally, an individual’s actions are determined notjust by knowledge, but also by situation and struc-ture. For example, if a woman knows the benefit ofimproved hygiene and wants to wash her childrenmore frequently but her husband thinks it is a wasteof water, or that the water cannot be spared, she willnot be able do it. Facilitating behavior change meansaddressing situational and structural constraints.

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a new practice, an individual also needs skills, time,and means. It is not possible to wash children’s handsand faces without adequate water supplies and it isnot possible to build a good-quality latrine withoutmaterials. If water and building materials are notavailable, individuals cannot practice the new behav-iors no matter how great the desire to do it.

Political decision-makers. In theory, nationallaws affect the behavior of individuals. For example,the law can dictate that a head of household befined if there is no access to a latrine in his house-hold. But such laws seldom achieve the behaviorchange for which they aim. Instead, political or gov-ernment bodies can do a great deal to establish theenabling factors that facilitate behavior change.

When a person finds that a new practice hasimmediate benefits—convenience, a cleaner envi-ronment, less hardship, recognition from respectedothers—he or she is more likely to continue it.Note that improved health is seldom an immediatebenefit of a new practice. It is, therefore, often not amajor reason why a person adopts a new practice.When asked, however, people will often sayimproved health is the reason for a new practice, butonly because they know this is the expected answer.

Steps to Behavior ChangeFigure 3.1 shows the steps involved in behaviorchange. What is important to know about thebehavior change process is that people do not sud-denly begin to do something they have never donebefore. People learn. They think through the bene-

fits of doing it or not doing it. They observe theircommunity to see if anyone else is doing it—and ifthe community accepts those people. They learn thenecessary skills. They apply it to their own lives.They evaluate whether it is worthwhile to continuepracticing it. They may reject it. Or they mayencourage others to follow them in carrying out thenew behavior.

Targeting InterventionsFor maximum impact, program managers must tar-get F and E interventions to three specific audiences:

1. Primary target group: People carrying out the risk practices, such as schoolchildren andmothers.

2. Secondary target group: People who influ-ence the members of the primary group and arein their immediate society, such as fathers andmothers-in-law.

3. Third target group: People who lead andshape opinion, such as schoolteachers, religiousleaders, political leaders, traditional leaders, andelders. These people have major influence onthe credibility of a trachoma control program,and hence its success or failure.

Members of target groups may differ dependingon the type of F and E interventions that have beenidentified as important for the community. Forexample, Table 3.1 details the target groups for anintervention that seeks to promote increased facewashing among children.

PREKNOWLEDGE“There is no problem.”

KNOWLEDGE“I am aware ofhygiene promotiontechniques andunderstand them.”

APPROVAL“I approve ofhygiene promotiontechniques, but amnot sure I’m readyto try them.”

INTENTION“I intend topractice hygienepromotion tech-niques at sometime.”

PRACTICE“I am practicingsome hygienepromotiontechniques.”

ADVOCACY“I see the benefitsof these hygienepromotion tech-niques and amready to showthem to others.”

Figure 3.1. Process of behavior change.

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In this example, the program designers maydecide to target children and mothers to promoteface washing, to target heads of households to allo-cate water for hygiene purposes, and to target com-munity leaders to recognize and congratulate themothers of children with clean faces.

Once a program designer has identified the targetgroups for a specific intervention, he or she willneed to reach all of them, but each group may needto be addressed separately with different messagestailored to the audience’s interests and concerns. SeeSection 5 for more information on this process.

Program designers must look closely at the feltneeds of the community before planning interven-tions. If an intervention responds to a felt need inthe community, and the problem is merely a lack ofinfrastructure, then there is little need to includepromotion. For example, because most trachoma-endemic communities have a felt need for water andsanitation, an intervention that provides these willlikely be successful. But if an intervention does notrespond to a felt need in the community, promotionwill need to be an integral part of the intervention.For example, few trachoma-endemic communitieshave an existing felt need for adequate garbage dis-posal. Therefore, simply providing a mechanism forgarbage collection is unlikely to result in any behav-ior change unless the practice is promoted and thetarget group takes the steps to change behavior.

Key Players in a Trachoma Control ProgramHygiene and environmental improvement are of theutmost importance in health promotion and areessential for the long-term sustainability of trachomacontrol. And they are achievable—with support andcollaboration from other entities and individuals.

National LevelBecause hygiene promotion and environmentalimprovement are such broad concepts, the F and Easpects of SAFE share common objectives with arange of other groups and government departments,such as women’s unions and ministries of education.By combining efforts, these groups could see resultsthat exceed what each could achieve individually,and a coordinated approach should help each toachieve its own targets. All interested groups anddepartments should share their breadth of skills,knowledge, and experience on a committee thatcould be called the Trachoma Task Force, TrachomaCoordinating Committee, or Trachoma SteeringGroup. This committee should include experts inwater, sanitation, community development, andeducation, in addition to health.

The steering committee should set priorities,decide what can be achieved with available resourcesand expertise, and allocate responsibilities. Thesedecisions then should be translated into an actionplan with clearly defined roles for each member.

Finally, the committee should calculate the localand regional ultimate intervention goals for tra-

Primary Target GroupWho carries out face washing?

Secondary Target GroupWho in the immediate society influences the primary group?(e.g.,Who collects the water and who decides how it is used?)

Third Target GroupWho leads and shapes opinion in the community?

■ Children and mothers.■ Possibly also fathers, older siblings, and other

family members.

■ Mothers and other women in the householdusually collect the water.

■ Male household heads may decide how thewater is used.

■ Teachers may judge children with clean facesto be better or worse than the others.

■ Key women in the community may criticizemothers for allowing their children to be dirty.

Table 3.1Target Groups for an Intervention to Increase Face Washing in Children

Generating and MaintainingMomentumFor F and E trachoma control interventions to besuccessful, they need ongoing momentum, national-ly and in communities.

National LevelAt the national level, the steering committee isresponsible for generating and maintaining momen-tum for trachoma control interventions. An integralpart of the steering committee’s action plan shouldbe to advocate for trachoma to be included on theagenda of all relevant sectors. For example, in thehealth sector, nurses, doctors, and health inspectorsshould be trained to be advocates for trachoma con-trol. In the education sector, teachers should betrained on trachoma, and school curricula shouldinclude trachoma education. In the environmentsector, governments should create plans for districtand regional water and sanitation provision.

Community LevelThe way in which momentum is generated and main-tained at the community level depends on the specificF and E intervention. Activities that result in newinfrastructure, such as a water point or householdlatrines, require a great deal of momentum to getthem started but are then self-sustaining. Conversely,activities that require behavior change such as keepingchildren’s faces or the village clean require long-term, sustained momentum. For all interventions, however,

program managers should consider the followingbasic principles:

■ Respond to the felt needs of the com-munity. If the target group does not wish

to participate in the intervention, thenthe program manager should eitherchange it to fit the perceived needs,go elsewhere, or do something else.

■ Identify community decision-makers (e.g., political, religious, orother leaders whom communitymembers follow) and involve themin sensitization and decision makingso that they will advocate for imple-

mentation.

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choma control developed by the World HealthOrganization (see Section 1). Such statistics will helpthe committee plan, raise funds, and allocateresources. In addition, knowing the goals for theprogram can keep committee members motivated asprogress is made and measured.

Community LevelHygiene promotion and environmental improve-ment activities can involve many different people inthe community. Target groups, individuals, andcommunities most affected by trachoma shoulddecide who within the community should beinvolved in the activities. Figure 3.2 shows some ofthe people who have important roles to play in sup-porting hygiene promotion. The rings indicate thethree different target groups. Who to involve willdepend on the specific activity and the unique con-text of each program. It is important that considera-tion be given to each player and his or her possiblecontribution valued. Program managers should con-sider that excluding some community groups couldalso result in negative consequences.

Source: Adapted from UNICEF,A Manual on Hygiene Promotion,1999

MothersChildren

Fathers

Religiousleaders

Communityleaders

Mothers-in-law

Neighbors

Teachers

Health workers

DonorsElders

Governmentagencies

Partnerorganizations

Figure 3.2. Key individuals for promoting hygiene.

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■ Time the interventions so that they do not con-flict with other important activities. Interest anduptake of new community-based projects will alwaysbe poor during the main planting and harvestingseasons or during religious festivals. Time projectsthat include building to coincide with the time ofyear that people usually build; plan income-generat-ing projects (like traditional soap making) to startwhen money is usually at its lowest.

■ Ensure that there is adequate time in the com-munity spent on discussion and sensitization beforeplans are implemented.

■ Ensure that potential pitfalls (e.g., access tocommunity water points, latrines, or other infra-structure) are considered and resolved before imple-mentation.

A boy in Malakal, Sudan, washes his face.

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This section provides a toolkit of interven-tions for the promotion of facial cleanliness(F) and environmental improvement (E) in

trachoma control (see Box 4.1). The range of possi-ble F and E interventions for a trachoma controlprogram is presented. The following are provided foreach tool:

■ Background■ Basic principles■ Situations and locations where it works

and does not work■ Advantages and disadvantages■ Case example (for selected tools)The section ends with a description of other

interventions that have been tried. These interven-tions are new, or are new innovations or activities inthe field of trachoma control, such as window anddoor screening. Program experience, research, andevaluation is still ongoing for these interventions;some show promising opportunities for trachomacontrol, but overall effectiveness has not yet beendetermined.

Hygiene PromotionThe SAFE strategy includes facial cleanliness or facewashing as one of its pillars. Programmatically, this can

be best interpreted as hygiene promotion in a broadersense because washing hands and faces usually gotogether. In a large study in Tanzania, a team from theKongwa Trachoma Project succeeded in increasing theproportion of children who had sustained, clean facesand found that these children had less active tra-choma. Hygiene promotion is also a core goal of manypotential partners such as Save the Children,UNICEF, Water Aid, and Action Aid and may beincluded in government WATSAN (Water andSanitation) task forces or groups. The messages of fre-quent face and hand washing are simple; there aremany potential partners with whom to share materials,resources, and experience; and it need not be expen-sive. Hygiene promotion really does work to reducelevels of trachoma infection and should certainly be acentral part of all trachoma control programs.

Basic PrinciplesThe aim of hygiene promotion for trachoma controlis to increase the proportion of children who havesustained clean faces. This requires that the accept-able standard of cleanliness and appearance in thecommunity as a whole be raised so that it is unac-ceptable for children to have mucus coming fromtheir noses, dirt on their faces, and food aroundtheir mouths. Adults should make sure children areclean, and children should understand being dirty isnot normal. However, there are considerable physi-cal, behavioral, and cultural barriers to this. Wherewater is scarce, it is difficult for women to allocate itfor washing because it may be considered an unnec-essary waste —after all, the children will get dirtyagain quickly. Women and children are invariablygiven the task of water collection, but men oftendecide how to use it. Even if mothers and childrenare convinced of the need for good hygiene, fathersmay not allow it. In parts of West Africa, washingthe faces of young children (under about 3 years) isnot encouraged because it is considered to make thechildren undisciplined and difficult to control.Women influenced by this aspect of culture wouldnot wish to appear to be bringing up children whoare unlikely to be good community members and,therefore, do not wash them.

4 F and E Interventionsin Trachoma Control

Box 4.1Intervention Toolkit

■ Hygiene promotion■ Promotion of individual towels and washcloths■ School-based trachoma programs■ Promotion of water availability■ Rainwater harvesting■ Pit latrines■ Provision of village cleaning equipment

Other interventions that have been tried:

■ Construction of public baths■ Fly control■ Radio listening clubs■ Leaky tins■ Window and door screens

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Good hygiene can be maintained with relativelysmall quantities of water (less than a liter of waterper child per day would be sufficient to wash thehands and face at least twice) and the water then canbe used for another purpose such as watering plants.The challenge facing trachoma programs is gettingpeople to link good hygiene with good health, andgood health with better prospects for the future; andto understand that just small quantities of water areneeded for good hygiene; and to know that waterused in this way is used well. Appearing clean shouldbe considered as the typical state, not a sign thatwater is being squandered. Cleanliness should bedesirable and taken as a sign that families care fortheir children and want the best for them.

Hygiene promotion can be conducted in manyways, but some of the strategies currently used bytrachoma programs include the following:

■ Village meetings conducted by health workers■ School-based education■ Use of a leaky tin or calabash to demonstrate

that just small quantities of water are needed

■ Counseling given to expectant mothers at prenatal clinics and to mothers at immuniza-tion clinics

■ Cultural drama, dance, and song groups■ Mass media campaigns such as radio, television,

and posters The strategy a program manager adopts should

consider, and be sensitive to, the physical, behav-ioral, and cultural barriers to the adoption of goodhygiene practices. It should fit the budget available,and its effect should be able to be evaluated against abaseline (see Section 5 for more information).Demonstrating that hands and faces can be washedwith just small quantities of water can help peopleadopt the practice. Community leaders and deci-sion-makers should lead by example, ensuring thatthey and their own children are clean and presenta-ble. Case Example 4.1 shows examples of hygienepromotion campaigns.

Where It Works■ Hygiene promotion is effective where there is

good availability of water.

To reach large populations, trachoma control programshave implemented hygiene promotion campaigns on avariety of scales. Drama performed by the Team AgainstTrachoma at a school in Nepal (picture 1) involves per-formers as trachoma educators and reaches schoolchild-ren and parents who come to see the show.The qualityof the message is ensured by the school health teacher.Village drama groups like this one from Dodoma,Tanzania (picture 2), perform for both schoolchildren andadults from the wider community.This type of dramagroup has the potential to reach many more people andfrequently performs for audiences of thousands. For thisdrama group from Tanzania, the World Vision trachomaprogram ensures the quality of the message and provides

training, uniforms, and musical instruments to the group.Even more people can be reached by a poster cam-

paign such as the one conducted in urban areas of Sudan(picture 3).The message presented in the poster is clearand aims to be unambiguous, but the message taken bythe audience may not be the one intended. Large num-bers of people can be reached with radio campaigns(picture 4). If the trachoma control program or taskforce writes scripts for the radio shows, the quality of themessage can be very high, although the question-and-answer format and interviews with people in the villageare usually more popular. In this case, the most peopleare reached in the most enjoyable way, but the quality ofthe message may be reduced.

Case Example 4.1Hygiene Promotion Campaigns

1 2 43

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■ It is effective in schools because teachers caninspect children’s hands and faces for cleanlinessevery morning and after breaks.

■ It is even more effective when it promotes the useof soap or ash with hand and face washing.

■ It is effective when the program or campaign isflexible. The messages and thrust of the programcan be changed as needed to best influence behav-iors.

■ Evaluation of the program’s effectiveness by usingsimple key indicators is useful because it allowsprogress to be monitored and effect to be evaluat-ed. A sample of children can be inspected for thefollowing:Ocular discharge . . . . . . . . . . . . . . . .(yes or no)Nasal discharge . . . . . . . . . . . . . . . . .(yes or no)Dust or dirt on the face . . . . . . . . .(yes or no)Food around the mouth . . . . . . . . .(yes or no)Dirt, dust, or food on hands . . . . .(yes or no)

■ Hygiene promotion is best integrated into allaspects of a trachoma program. Azithromycin distribution is a good time for cultural groups toentertain the community with songs and dancespromoting hygiene. Latrine promotion caninclude education on hand washing. Every contactwith the community should be used to reinforcethe basic message of “be clean — be healthy.”

Where It Does Not Work■ Hygiene promotion is compromised where water

is considered scarce or where it is actually scarce.In these circumstances, the program will need topromote the notion that only small quantities ofwater are needed for good hygiene.

■ Hygiene promotion does not work well when pro-grams focus only on mothers and do not includefamily decision-makers. Both the people who col-lect the water and the people who make decisionsabout water use must be targeted by the program.

■ Just focusing on the health issues of hygiene maynot encourage uptake. Associating cleanliness withbeauty, a way of showing one cares for his or herfamily, or enhancing the prospects of children atschool may help sell the idea.

■ Mass media campaigns without personal involve-ment cause the wrong message, or no message, tobe transmitted. Playing radio slots or pinning upposters without support from individuals isunlikely to have a major effect.

Advantages■ Evidence shows that hygiene promotion works to

reduce active trachoma.

■ The messages of washing hands and faces are simple and clear.

■ Some elements of hygiene promotion are possiblewith any budget.

■ Costly materials and resources are not needed,although the ability to spend money on massmedia helps.

■ Evidence shows that washing hands and faces willreduce children’s possibilities of getting sick withother conditions, including diarrhea.

Disadvantages■ It is easy to transmit messages and to get people to

remember campaigns and key information, butless easy to actually influence their behavior.

■ Hygiene promotion campaigns should includeregular monitoring and occasional evaluation sothat the effect on behaviors can be measured andrefined, if necessary.

Promotion of Individual Towel andWashcloth UseYoung children have the greatest rates of trachomainfection, and because they carry the most bacteria,they are the greatest source of infection. Parents andsiblings of children with active trachoma are at riskof being infected by their close contact with theinfected child. One of the main transmission routeswithin the family is probably the sharing of towelsand washcloths.

Basic PrinciplesIn communities where children use washcloths anddry themselves with towels, promoting the use ofindividual cloths and towels will reduce transmissionof trachoma within the family. This health messagecan be delivered through health workers, theschools, radio, posters, village meetings, and soforth, or promoted more directly by providing wash-cloths and towels to young children. The targetgroup should be children under the age of 10, withgreater emphasis on reaching those under 5. Towelsand cloths can be printed with the logo of theprovider or other health promotion images and canbe distributed to preschools and nurseries as part ofan integrated program or used as motivating giftsand prizes for children or adults. Case Example 4.2describes a campaign for promoting individual toweluse in Nepal.

Where It Works■ Promoting individual cloth and towel use works

in communities that regularly use washcloths,

16

such as in Asia and North Africa, rather than insub-Saharan Africa.

■ The program can be used as message reinforcementfor community- or school-based health promotion.

■ It works well in preschools and nurseries.■ It works well in primary schools, particularly

when children start school at the age of 4 or 5.

Where It Does Not Work■ Promoting individual cloth and towel use does

not work where washcloths are not routinely used.■ It does not work where there are few preschools,

nurseries, and primary schools.

Advantages■ Individual washcloth and towel use is a simple

and clear message to promote.■ Washcloth and towel promotion can be used in

school- or community-based education campaignsto reinforce hygiene promotion messages.

■ Washcloths are commercially available at lowcost.

■ The low cost of individual washcloths for eachchild makes them attainable for most mothers intrachoma-endemic regions who want to reducerisks of trachoma.

■ Printing a logo on the washcloths is a good way

to enhance recognition for the national campaign,promoter, or donor.

Disadvantages■ Low individual cost of printed washcloths can be

achieved only with high production runs. Theseruns can make the overall cost high.

■ Unless there is a clear strategy to distribute thewashcloths or towels, it may be difficult to takethis intervention to scale.

Case Example 4.2Promoting Individual Towel Use in Nepal

As in some other countries in Asia and NorthAfrica, people in Nepal often use a washclothto clean their faces. All the children in selectednursery schools in the Far West region ofNepal have been given their own washcloths.The cloths are labeled with a picture so thateach child can recognize his or her own, andlabeled with names to aid the teachers.Thechildren wash their faces when they arrive atnursery school in the morning and then againafter their games and activities outside.

Individual towels hang in a nursery school in Nepal.

These children attend a preschoolin Zagora, Morocco, that has a trachoma program.

17

■ There have been no scientific trials specificallyinvestigating whether individual towel use reducesrisk of trachoma. The evidence for this interven-tion is based on risk-factor analyses.

School-Based Trachoma ProgramsEvery trachoma-endemic country has an educationsystem. Depending on the country, children asyoung as 4 years attend centers of learning and aretaught by teachers. One of the United NationsMillennium Development Goals is for every child tohave access to a basic primary education by the year2015, and commitment to this goal by governmentsand nongovernmental organizations is likely toincrease the proportion of children in school.Schools provide an excellent forum for training chil-dren about trachoma, promoting behavior likely toreduce trachoma, and influencing healthy behavior.The philosophy behind school-based trachoma pro-grams is that they can reach large numbers of chil-dren in endemic areas and they will act as a conduitof knowledge and behavior, teaching those at homeand influencing behavior at the community level.

This can be achieved at relatively minimal cost anddelivered in a sustainable manner in schools, whichwill lead to sustained behavior change in the targetcommunities.

Basic PrinciplesSchool-based health promotion works on the “train-ing the trainers” concept. After curriculum andresources have been developed in partnership withthe relevant government education department, theteachers are trained. The teachers deliver the healthcurriculum to the students who then act in accor-dance with the training. A greater effect can beachieved by training the teacher-trainers in govern-ment teacher colleges, where they exist.

In school-based programs, materials are designedto help empower teachers to deliver the health mes-sages. Because primary school teachers are usuallyoverworked and poorly paid, they often are reluctantto allocate time to lesson preparation. Therefore,materials are best prepared class-ready to encourageteachers to use them. Suitable materials include les-son plans for teachers, age-appropriate resourcebooks for students, flip charts, posters, art supplies

Burkina Faso is one of several trachoma-endemic coun-tries that works with Helen Keller International on aschool-based component to its trachoma control pro-gram.The program runs in small rural community schoolscalled écoles satellite.

The program aims to train all the teachers in eachschool on the trachoma curriculum.Training is popularwith teachers and takes place during allocated time.Thetop-quality teaching materials that have been developedand distributed are class-ready, so there is no need forteachers to spend time on preparation. In addition to edu-cating students, the program works with other partners to

Case Example 4.3School-Based Program in Burkina Faso

Clockwise from far left:A boy in Fada N’Gourmauses trachoma materialsin class. Plastic bucketsand kettles form simplehygiene kits. Adequatelatrine facilities are pro-vided for both boys andgirls. Children learn abouttrachoma in class.

ensure that each school has accessto on-site water and adequatelatrine facilities for girls and boys.Water provision is a major challengein this part of the world, and whereit is not possible to dig a well, thechildren are asked to bring water to school each morning. Hand and face wash-ing is promoted through the use of plastic buckets and kettles. Long-term sus-tainability of the school-based component is achieved by incorporating the tra-choma curriculum into the national primary school curriculum.This will makelearning about trachoma an entitlement to all primary school children at risk forthe disease.

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for students to make their own materials, prizes tomotivate students, and uniforms or musical instru-ments for health and drama clubs. Drama groupsand interschool competitions can reach and involvelarge sectors of the community, not just thoseattending school. Sustainability (but not quality) canbe guaranteed by including trachoma and healthpromotion in the standard curriculum, ensuring thatall children are learning about trachoma. See CaseExample 4.3, which describes a school-based pro-gram in Burkina Faso.

Program Components Components of a school-based program can includethe following:■ Training for teachers (program staff will need to decide

how many teachers from each school are trained).■ Lessons on trachoma, using program resources

such as booklets and pamphlets. Such lessons maybe in designated health classes or classes in sci-ence, mathematics, civics, social science, reading,language, and comprehension. Nearly any classcould contain trachoma material and other healthpromotion messages from time to time.

■ School assemblies.■ School cleaning and provision of rubbish pits

and bins.■ Provision of water to schools (via wells, rainwater

harvesting, or the town supply).■ Provision of latrines to schools.■ Promotion of leaky tins and leaky calabashes for

hand and face washing, and promotion of soap orash to improve cleaning.

■ Tree planting to reduce dust and improve theschool environment.

■ Trachoma clubs, health clubs, anti-trachomateams, and other mass organizations that conducttrachoma awareness activities, make posters,inspect cleanliness of other students, and presentdrama and songs.

■ Drama and dance clubs that perform and presenttrachoma messages to the school and adults in thevillages. Drama groups, particularly where theyinclude adults in addition to students, can helpthe program reach the wider community. Thesehave been used effectively in Mali, Burkina Faso,Ethiopia, and Tanzania.

■ School trachoma quizzes and interschool quizzes.Interschool quizzes and trachoma competitions inwhich community leaders are judges and parentsare spectators have been extremely popular inNepal and Vietnam.

■ Poster and drawing competitions.■ Rallies and parades in towns and villages.■ School-based screening and case treatment by

health staff. Sometimes the health teacher adminis-ters case treatment with tetracycline eye ointment.

■ Home visits by trachoma club members or thehealth teacher to families of individuals with tra-choma.

Where They Work ■ School-based programs work where there is a

good basic education structure in place with suffi-cient staff and adequate infrastructure.

■ They work where there is pride in the educationservice, teachers are hardworking, students areattentive, and the community supports education.

■ They work where all children have access toschool.

■ They work where the teachers feel supported bythe school-based program, such as through in-service training or visits to schools by programfacilitators.

■ They work where rates of school enrollment forboys and girls are high.

■ They work where there is support from the pro-gram or local health staff, which can greatlyenhance the sustainability and effect of a school-based program.

■ They work where there are materials such asbooklets that can be taken home and shown toyounger family members and parents by the stu-dents. These increase the scale of the effect.

■ They work where lesson plans require students totalk to their parents or elders about trachoma,which extends the scope and scale of the program.

Girls practice hand washingin school in Vietnam.

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Where They Do Not Work■ School-based programs do not work where the

education structure is weak due to insufficientnumbers of schools, or unmotivated or frequentlytransferred teachers.

■ These programs do not work in areas where fewchildren go to school.

■ They do not work when teachers are taken out ofschool for a one- or two-day training session, butthen do not receive follow-up support with mate-rials and visits from program staff.

Advantages■ School-based health promotion can reach large

numbers of children as a captive audience.■ School-based health promotion can enhance deliv-

ery of health education in schools, which helpsteachers do their jobs better and supports the educa-tion system.

■ School-based health promotion can strengthenopportunities for sensitization on HIV/AIDS andmalaria, and treatment programs for schistosomia-sis or intestinal worms.

■ Schools provide a good forum for demonstratingnew technologies and appropriate use of existingtechnologies, raising the level of expectationamong the next generation of adults.

■ Sustainability can be guaranteed by including tra-choma in the curriculum.

■ Schools can be used as a conduit to reach children whodo not attend school and adults in the community.

■ Awareness of other trachoma control activitiessuch as drug distribution, provision of surgery,and media campaigns can be raised through theschools.

Disadvantages■ It is fairly expensive and time consuming to set up

a program because the ministry of education mustapprove teachers’ participation in the program andprogram materials.

■ Success largely depends on the quality of trainingand resources available.

■ The effect of the program will vary on a school-by-school basis depending on the motivation ofthe teachers and those assigned to support them.

■ The program can collapse if the trained teachers aretransferred without the knowledge of the program.

■ The program may not reach the poorest individu-als and, therefore, may miss those at greatest riskof trachoma.

■ School-based trachoma promotion may divert

attention of health teachers away from othermajor health risks such as malaria and HIV/AIDS.

Promotion of Water AvailabilityHygiene promotion in the absence of water is almostmeaningless. Those involved with hygiene promo-tion at the village level (e.g., health workers, schoolteachers) should be able to set an example of goodhygiene by having a clean appearance and by follow-ing the guidelines that they encourage others toadopt. This is almost impossible without water.However, there are many ways to achieve water pro-vision. Local expertise will be the best guide as towhat works in a particular context.

Long distances to water and poor water availabili-ty have been linked frequently to high levels of tra-choma. Certainly, life without easy access to water istough. Having a reliable and regular supply of waterwithin a 20-minute walk from home can transformthe lives of people in trachoma-endemic areas. Whenwater is provided, the prevalence of active trachomaand other health problems will likely lessen. Womencan save several hours each day by not having to trekfor water, and this time can be better spent on agri-culture, child care, or home care activities.

Where water is in short supply, people makeattaining it their first priority. Providing waterthrough a trachoma program can help address thisneed and greatly contribute to local development.

Basic PrinciplesIn most trachoma-endemic areas, there is no regularpiped water supply. Water generally comes from

A woman pumps water in Ghana.

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wells and boreholes that may be supplemented bysprings, rainwater harvesting, use of dams, and col-lection from seasonal streams and water sources.Local knowledge from the government water sup-plies department and nongovernmental organiza-tions providing water supplies are the best sourcesfor determining the most suitable type of water sup-ply for each area. These may be shallow wells fittedwith hand pumps, deep wells with hand pumps, orboreholes with motorized pumps, solar pumps, orwindmills. Water sources that use motorized pumps,solar pumps, and windmills are also best fitted withlarge holding tanks so that when the engine isswitched off, the sun is not shining, or there is nowind, water is still available.

Suitable locations for water points need to bedecided carefully. Where water can be found nearthe surface of the ground, it is easy to dig productivewells, which can be sited at the convenience of thecommunity. Where groundwater is scarce or deep,the location will have to fit the underlying aquifer.Geophysical surveys can locate water but do notindicate whether it is suitable for use by people.Village history and memory may be more usefulthan an expensive survey; people can usually explainwhere water was found in the past or what type ofvegetation is associated with good groundwater.Modern digging technology may allow those watersources to be tapped where traditional techniqueshave failed.

Community participation and collective responsi-bility is fundamental for success in water provision.Due to the high cost of installation and the possibil-ity of high maintenance costs, community waterprovision should not be initiated unless there is anestablished village water committee or developmentcommittee. This committee will have responsibilityfor revenue collection, maintenance of equipment,rights of access to the water, and ownership of thewater source. All of these issues must be clarifiedbefore the facility is installed. People expect to payfor water, and the committee can bank the revenueto ensure there is money to pay for repairs or main-tenance. Two models of revenue collection are com-mon: a house-to-house payment collected on amonthly, bimonthly, or six-month basis, or paymentat the source for each full container collected. Themonthly collection model works well where there isa strong system of village government and an estab-lished rule of law. (The threat of punishment stopspeople defaulting payment.) The payment at source

model works well when an individual has responsi-bility for collecting the money and organizingrepairs and is allowed to keep all income above acertain threshold every month. The water sourcebecomes that person’s livelihood and he or she usual-ly takes great care that it is treated well and kept ingood condition.

It is vital that proper consideration be given tosustainability of water sources because they should beexpected to last 20 years or more. It is not acceptablefor expensive water sources to lie idle because there isno money to repair them or people are locked outbecause of disputes over who owns the water.

Where It Works■ Water provision works where there is a shortage of

water. Enthusiastic support will be given to anyprogram that offers water.

■ Water provision works where the government cangive strong support. Frequently there is a waterprovision plan in existence, but shortage of moneystops it from being implemented. The programcan support the government provision strategy.

■ Water provision works where there is an individ-ual responsible for the water source that reports toa committee and collects revenue from the water,which usually ensures that the pump and sourceare kept in good condition.

Where It Does Not Work■ Water provision does not work when the commu-

nity has poor levels of cohesion and organization,which makes it unlikely to be able to coordinaterevenue collection. As soon as maintenance isrequired, the water source will be abandoned orthe program will be faced with additional costs.

Advantages ■ Lifetime benefits of water vastly outweigh high

installation costs. A covered well and pump cost-ing $3,000 USD could provide safe water for avillage of 1,000 people for 20 years. No otherintervention by a trachoma program can give somuch benefit for so little unit cost.

■ Water provision is likely to have immediate bene-fits for trachoma and other health issues.

■ Where water is in short supply, water provisionusually responds directly to a major developmentpriority.

■ Water provision demonstrates commitment to thecommunity and is likely to enhance uptake ofother aspects of the trachoma program because thecommunity will be supportive.

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Disadvantages■ A water program is potentially very expensive

(costing at least $20,000 USD for a 100 m bore-hole, pump, engine, 40,000 L holding tank anddistribution pipes).

■ Sustainability depends on the effectiveness of thelocal management committee. Threats to successcome from poor management, inadequate revenuecollection, and corruption from account holders.

■ Water provision requires close collaboration withtechnical experts and providers of pumps.

Rainwater HarvestingRainwater harvesting is the capture of rainwater. Inits simplest form, it can include putting buckets orbasins under the eaves of a house when it rains.Complex systems can be designed to capture morewater from large roofs fitted with gutters and drain-pipes leading to large holding tanks or from the con-struction of dams across seasonal streams. It is a use-ful system for providing water in the wet season, butbecause storage of large quantities of water is diffi-cult, the water collected may only last days or weeks.Unless substantial dams can be constructed, this isnot a solution for providing water to large groups ofpeople through a long dry season.

Basic PrinciplesThe quantity of water that can be harvested is calcu-lated as the area under a roof (not the area of theroof) multiplied by the amount of rain. For each 1 m2

of floor area under a roof, 10 L of water can be col-lected for each 10 mm of rain. For example, if a pri-mary school classroom block 40 m long and 12 mwide has an area of 480 m2, the quantity of waterthat can be harvested is 4,800 L if there is a modestrain of 10 mm (1 cm). Although this is a lot ofwater, it would probably serve a school of 350 stu-dents for only three to four days, and much less ifthe water is also used for watering plants.

Water tanks of 1,000 L capacity for home use canbe made with just sand and cement. When strength-ening wire, such as chicken wire, is added, tanks ofup to 2,500 L can be constructed. Larger tanksrequire specialist construction and reinforcing bars.Plastic and corrugated iron tanks of 500–5,000 Lcan be purchased, although the plastic tanks tend tocrack in the hot sun when empty and the corrugatediron ones rust. Large holding tanks suitable forschools and public buildings made from reinforcedcement can hold 20,000–45,000 L, and dams canhold very large quantities of water.

A model system on a public building, such as aschool or clinic, would have a subterranean tank of30–45,000 L at each end of the building fed bylarge gutters on both sides of the building. A longi-tudinal bar just above the gutter reduces the quanti-ty of leaves and other plant debris that is washedinto the tanks. A silt trap with an inspection coverwill catch a lot of the dust carried down the pipe.The water will be drawn from the tank by a handpump. A large overflow pipe will be fitted below thelevel of the silt trap. It will have a 90-degree angle init and a substantial galvanized steel grid over theoutlet to prevent animals from entering. It is impor-tant that the entrance and exit of the water holdingtank be covered with a fine screen, so that rodentsand small animals cannot get into the water.Mosquitoes, which can carry diseases like lymphaticfilariasis, breed in standing water, so it is importantto prevent them from entering the water holdingtank. Case Example 4.4 shows how water is harvest-ed at a health clinic.

Where It Works■ Rainwater harvesting works well for buildings

with large tile or tin roofs.■ It works in areas where it is not possible to dig

wells because of a low water table or rockyground.

■ It works in areas that experience modest rain atleast every few days during the wet season.

■ It is particularly useful for dry areas that have tworainy seasons per year.

■ It is useful for individual families.

Rainwater is harvested for use at this Tanzanian home.

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Where It Does Not Work■ Rainwater harvesting does not work well on hous-

es or buildings with thatch roofs.■ It does not work well in areas of low rainfall,

where most of the year’s rain usually falls duringjust a few days or there are long dry periodsbetween rains.

Advantages■ Rainwater harvesting is useful for areas with rocky

soil or a deep water table where it is difficult todig wells.

■ It is a good system to ensure a constant supply ofwater for a family during the wet season.

■ It is possible to fill the storage tanks with waterfrom other sources.

■ It has low running costs after initial expensive setup.

Disadvantages■ Rainwater harvesting has a high initial cost. The

materials for a model system with two 45,000 Ltanks would cost more than the construction ofup to 10 shallow wells.

■ It is only useful during the rainy season.■ Lizards, snakes, rats, and birds can find their way

into the storage tanks in the dry season and die.The bodies contaminate the water in the wet sea-son and can lead to spoilage of the entire tank. Forthis reason, it is important that the entrance and

exit holes of the tank be covered with a fine-gaugescreen so that animals cannot contaminate it, andinsects like mosquitoes cannot enter the water andbreed.

■ Because holding tanks need to be lower than theroof, water usually can only be drawn off at groundlevel.

■ Most of the largest tanks are usually undergroundso that they are stronger. This adds two areas ofconcern: Water should be drawn off with a pumpto avoid contamination, adding to cost, and thelikelihood of animals crawling into the tankthrough the overflow pipe and drowning inside isincreased.

■ Where water is harvested from a public building it is unclear who owns it. This issue must beaddressed before projects begin or damaging disputes are sure to occur.

■ Large dams will be used by animals and becomecontaminated with their feces. They may also contribute to increased levels of schistosomiasisand malaria.

Pit LatrinesIn their simplest form, pit latrines are holes in theground with some sort of structure to allow the userto squat over the hole without falling in. At theirmost developed, they have cement slabs reinforced

People use the public dam for bathing and to water their cattle.

This tank at the clinic holds 3,000 L.

Case Example 4.4 Rain Harvesting at Lorn’gosua Clinic in Kajiado District, Kenya

Lorn’gosua is in a semiarid region of Kenya where the water table is verydeep. It is not possible to dig wells, and the community does not havesufficient money to rehabilitate the old borehole.The community har-vests rainwater in two dams built across deep rain-washed gullies anduses the water for themselves and their cattle.The water in the dams isnot clean. Staff at the clinic have attached gutters to the roofs andinstalled commercially available 3,000 L water tanks to harvest clean rainwater for hand washing and forstaff and patients to drink. It wasagreed in a village meeting thatthe nurse-in-charge at the clinicwould control access to the water.He ensures that the water is usedonly in the clinic and that it isreserved for hand washing and forstaff and patients to drink. Duringthe dry season the storage tanksare sometimes filled with waterdelivered from a truck.

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with iron bars over the hole, pit ventilation pipes,and solid, attractive buildings. Unless modified to beconnected to a septic tank and soak-away, pit latrinesare temporary; when the pit is full, a new one mustbe dug. Simple pit latrines can be made more per-manent by lining them with concrete rings so that itis possible to pump them out. By pouring ash orother alkaline substances down traditional pits, thevolume of their contents is reduced, thereby pro-longing their life span. The life of a pit latrine canalso be extended by restricting what is disposed in it.

The specific design, depth, and method of manu-facture of pit latrines depends on what is most suit-able for the environment and culture of each coun-try. Best practices on a country-by-country basis areusually available from the government, sanitation,waste disposal, or rural development department.

Basic PrinciplesLatrine construction should be sympathetic to thesoil conditions. Extremely sandy soils may needcement rings or other support to prevent pits fromcollapsing. Lightly sandy soils may need a cementcollar or head to prevent rainwater penetration.

Latrines should be dug on well-drained and levelground away from places where water runs or poolsin the wet season. They should be at least 30 m awayfrom a well or water source and should not penetratethe water table.

Latrines should be accessible, not more than 6 maway from the house and not where vegetation or anuneven surface might stop people from going to it.(Remember that it should be possible to reach thelatrine safely at night.)

Latrines should have privacy. They should have ade-quate screening and should not be built next to paths,roads, or places where the users will be seen going inand out or heard when they are in the latrine.

Construction must be sympathetic to the beliefsof the local community. Health workers should talkto community members and find out what kinds oflatrines they would be most comfortable using. Incases where community members believe that thecharacteristic odor of the latrine is considered dan-gerous, health workers can promote ventilated pitlatrines, which have ventilation pipes covered withfine mesh screening that allow air to escape. Theopening of the latrine is covered, but air and odorscan escape without allowing insects into the latrine.

Religion may dictate that the drop hole is orien-tated from north to south and not east to west.

Different groups may require separate latrine

facilities. In some cultures, men and women may notuse the same latrine, or it may not be possible for awife or husband to share a latrine with his or her in-laws. Children may need a separate facility.

A sense of ownership is vital for sustainability.Nobody will want to use a dirty latrine or one withpoor privacy. For a latrine to be maintained correct-ly, someone must feel individual responsibility for it.Guidelines will change with context, but householdlatrines appear to work best. In the household allusers know each other, making it easier for someoneto have responsibility for keeping the latrine cleanand in good order. Communal latrines rarely workfor a long time unless someone takes responsibilityfor keeping them clean.

The depth of a latrine will depend on the soilconditions, height of the water table, and what willfill it. A pit of 1 m diameter and 4 m depth shouldbe suitable for an average family for a period of fiveto eight years. The speed that it fills will also dependon what people use to clean themselves. Water takesno space and encourages decomposition by provid-ing the solvent for microbial activity. Paper addsminimal volume and breaks down. The depthshould be increased when sticks, stones, or maizecobs will be used or where other waste such as bat-teries or glass will be disposed of in the latrine.

Where the soil is particularly rocky or the watertable is very high, compartment latrines can be con-structed. These latrines have a cement-block com-partment built onto the ground with a drop hole inthe top. The normal superstructure is built on, oraround, the compartment. One enters the latrine byclimbing a step or two to get onto the compartment.In two-compartment latrines, one compartment isused for six months and then left to compost whilethe other is used. After another six months, the firstcan be emptied and the contents used as fertilizer.

Household latrines offer huge advantages to theowner in terms of convenience, safety, and cleanli-ness, and they give the owner a feeling that he isdeveloping the family compound. These advantagesare likely to be far more important to the ownerthan the health considerations. Case Examples 4.5and 4.6 show pit latrines and compartment latrines,respectively.

Where They Work■ Pit latrines work well when there is a felt need for

sanitation in the population and it is not possibleto provide permanent sanitation facilities.

■ They work well where the ground is relatively easy

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to dig, has a water table 5 m or more below thesurface, and does not flood. (Compartmentlatrines can be used where the ground is hard todig or water table is high.)

Where They Do Not Work■ Pit latrines do not work well where there is a high

water table, such as lakeside sites, or where theground is liable to flood. Again, compartmentlatrines may work in these environments.

■ They do not work well where there is very rockyground and it is not possible to dig. Again, com-partment latrines may work in these environments.

Advantages■ An individual latrine can be inexpensive. The

materials required to build a basic pit latrine with areinforced cement slab and a cement head to the

pit are about two bags of cement, two wheelbar-rows of sand, 6 m of 6 mm diameter iron bar, and120 L of water. The cost of these materials, exclud-ing transport, is unlikely to exceed $25 USD.

■ Household ownership means that the head ofhousehold feels responsible for the maintenanceand upkeep of the latrine.

■ The life of a pit latrine may be longer than it takesto fill the pit. Although pit latrines are temporary,well-made slabs can be removed from a full pitand transferred to a new one.

■ Latrine construction lends itself to flexible cost-sharing schemes. Recipients can be asked to pay fortheir completed latrine, pay for the skilled labor,contribute labor and some materials (like sand andwater), contribute labor only, or be given responsi-bility for making the super-structure or house

(1) A man makes a mold for a slab with an ironform and local sand base. (2) The man casts the slabwith cement reinforced with iron bars. (3) The finishedlatrine has a lid. (4) This pit was dug to about 4 mand lined with mud blocks. (5) This pit was plasteredwith cement.

Case Example 4.5Household Latrine Project in Zinder, Niger

Latrine coverage is very poor in Zinder, Niger. Less than 20% ofhouseholds have a latrine.The latrine project has provided localmasons with the skills and equipment to build family latrines at rela-tively low cost.The climate is dry, the water table deep, and soilsandy. The poor latrine coverage is, in part, due to the poor durabili-ty of local latrines.They collapse during the wet season, eitherbecause water runs down the pit toppling the slab or the sides ofthe pit collapse when the soil is wet.

To avoid these problems, latrines are raised above the soil surface byabout 15 cm, and the pits are lined with mud blocks and plasteredwith cement. An attractive and reassuringly solid slab is made fromferro-reinforced cement and mounted on top of the pit.The wastefilters out the bottom of the pit, which is not lined with cement.When the latrine is finally full, the slab can be removed and usedagain on another pit.

1 2

4 5

3

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around the finished latrine. Varying the level ofrecipient contribution allows program managers todesign interventions at all levels of cost.

■ The running cost of a completed latrine is practi-cally nothing.

■ Because they are so inexpensive, demonstrationlatrines can be given to key community membersto encourage latrine uptake in the community.These people can then lead by example and advo-cate for latrine use.

■ Once a family becomes accustomed to the conven-ience of having a latrine, it may be difficult to dowithout one. Sanitation will then become a higherpriority when the family allocates its resources.

Disadvantages■ There may be hidden programmatic costs of a pit

latrine program. Organizing the construction ofhousehold latrines takes a long time and a lot ofattention from program staff. The hidden pro-

grammatic cost of the latrines in terms of timeand transport may, therefore, be high.

■ Pit latrines are temporary. Once full, they need to bereplaced, although well-made slabs can be reused.

■ When the program latrines are full, there will be aneed for new ones to be built. Unless some com-munity members have been trained in latrine con-struction, and probably given the necessary equip-ment, the community may not be able to satisfyits own demand. Very poor people may never havethe money to spend on cement for a new latrine.

Ventilated LatrinesIn an unventilated pit latrine, warm air and odorsfrom the pit rise and escape from the drop hole.Large green flies of the genus Chrysomya are attractedby the odor and breed in the latrine. Ventilatedlatrines have a vent pipe made of plastic or brickdirectly above the pit. As long as this pipe has a goodairflow and stands at least 50 cm above the height of

Case Example 4.6Two-Compartment Latrines in the Red River Delta Area of Vietnam

The Red River Delta in Vietnam is one of two areas in the countrywhere trachoma is still endemic.The high water table and risk offlooding make it impossible to dig pit latrines, so the trachoma pro-gram is promoting the use of two-compartment latrines.The baseof the latrines – which forms the compartments – is made ofcement blocks, but the building can be made from any material.Thebuildings are usually finished with cement blocks because of thehigh-quality look.When one compartment becomes full, it is closedand left to compost for about six months and the family uses theother compartment.The composted waste is dug out of the base ofthe latrine through a door, and the highly prized fertilizer can be soldor used by the family for its own vegetable gardens.The design ofthe latrine separates urine from the feces and the urine is used asliquid fertilizer. Local masons have copied the design to use for fami-lies who have seen the benefits of the two-compartment latrines.

Above left:The high water table means pit latrines are notpossible. Above: The doors to empty the compartmentsafter composting can be seen clearly to the left and right of the stairs.

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the roof (assuming that a roof has been built), thewarm air from the latrine will be drawn up the pipeand fresh air will flow down the latrine hole. Thiscirculation of air reduces odor and can control flies.To ensure good airflow, pipes should have a smoothinterior and be at least 11 cm in diameter.

Reducing flies around latrines is beneficial. Beingdisturbed by flies when using the latrine or seeing aseething mass of maggots in the pit is off-putting;most people would find it dirty and prefer to goelsewhere. Flies that live in the latrine can carrygerms from the latrine with them when they land ona person’s food, exposing him or her to all of thecontamination from the latrine. It is important totry to reduce the number of flies entering and exit-ing the latrine.

Flies still will be attracted by the odor from thevent pipe and drop hole of a ventilated pit, but thosebreeding in the latrine and trying to escape shouldbe killed in the pipe. Young flies emerging from thelatrine will fly toward the brightest light available.This light will come from either the drop hole or thevent pipe. When the latrine is covered or the drophole is in a darkened room, the flies will go up thepipe. The pipe should be covered with a layer of cor-rosion resistant fly screen, such as stainless steel oraluminum, which will stop them from escaping. Theflies will try to get out but will eventually die ofexhaustion and fall back into the pit.

Advantages■ A vent pipe reduces odors and can control flies.■ A vent pipe increases the perceived value of the

latrine because it looks more modern.

Disadvantages■ Including a PVC or brick vent pipe can double

the cost of the latrine.■ Making the drop hole in a darkened room requires

the building to be very well made and, therefore,expensive. If it is too dark, latrine users will haveto keep the door open when using the latrine.This is clearly impractical, and ventilated latrinesare usually made with a gap at the top of the door,on short legs, or with high-level windows. All ofthese designs allow flies and light to get into thelatrine. If the light from the drop hole is brighterthan that down the vent pipe (e.g., when thescreen on the vent is blocked), flies will not becontrolled.

■ The vents are often blocked or missing. Fly screenson top of the pipe should be made from a corro-

sion-resistant material such as stainless steel or alu-minum. These materials are frequently not availableand are substituted with plastic mosquito screening.The fine holes in the plastic mosquito screeningeasily get blocked with dust, rendering the vent use-less. Plastic screens slowly become brittle as a resultof exposure to sunlight and then break. This prob-lem allows them to function as vents, but they donot control flies.

■ Replacing the fly screen requires the assistance of askilled person — one who has the correct glue fora PVC pipe or a mason for a brick pipe. It is rarelydone, and vents are often blocked or unscreened.

Provision of Village CleaningEquipmentOne of the easiest ways to improve the village envi-ronment and to reduce the factors that encouragethe transmission of trachoma is to ensure the villageis relatively free from human and animal waste,household rubbish does not accumulate in thestreets, and communal areas are clean. Clearing longgrasses and uncontrolled vegetation reduces thenumber of places that can be used for open defeca-tion. Removing household waste reduces flies. Anabsence of rubbish around wells and meeting pointsimproves morale and encourages community partici-pation. Because the areas where trachoma exists areoften remote and inaccessible, they usually do notbenefit from government-funded rubbish or wastecollection. Therefore, community cleaning has to becoordinated locally.

Basic PrinciplesEnvironmental improvement can be enhanced bycleaning if the community identifies it as a need andis mobilized to do it. Community mobilization canbe encouraged or fostered by a combined program ofhygiene education, provision of cleaning equipment,and follow-up visits.

Most village leaders are open to the suggestionthat their villages will be improved by a clean andhealthy environment. Village health workers andmembers of village development committees shouldbe involved in the decision making about whether toadopt village cleaning.

Decisions about when village cleaning will takeplace, who will participate (and how nonparticipa-tors will be handled), who has responsibility for stor-ing and maintaining the equipment, and for whatelse (if anything) the equipment will be used need tobe made before the equipment is handed over.

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Scheduled group participation involving all the able-bodied adults in the community works very well. Forexample, village cleaning may take place weeklybefore a religious gathering or after the market day,monthly on a lunar cycle, seasonally when the workon the farms is reduced, or at the start and end ofrainy seasons.

Promoting village cleanliness is seriously compro-mised if equipment is not provided. The quantity oftools that can be provided will probably be insuffi-cient to enable large sections of the community towork together, but the donation is a display of com-mitment to the community from the provider andindicates that the goal of a clean and healthy villageis taken seriously. Whether to provide a token set oftools or sufficient tools to allow many people towork simultaneously will depend on the local situa-tion and resources available. A suitable set of toolswill include a rake, spade (or other digging tool),machete/cutlass/panga (or other cutting tools), and awheelbarrow. Other possible tools include a pickax,digging fork, and donkey cart.

Follow-up visits by field staff and visitors areimportant to maintain the momentum and reinforcehealth messages. See Case Example 4.7 to find out

how village cleaning was part of the trachoma con-trol program in The Gambia.

Where It Works■ Villages that already demonstrate social cohesion

and are actively involved in promoting their owndevelopment benefit from health education andprovision of cleaning equipment.

■ It also works in smaller villages where most peopleknow each other and there is collective responsibility.

Where It Does Not Work■ Provision of cleaning equipment does not work

well when given to poorly developed villages with-out a series of explanatory and planning meetings.

■ It does not work well where villages are large andpeople do not know each other, so there is littlecollective responsibility (unless multiple kits aregiven to several neighborhoods).

■ When a village has weak leadership, politicalschisms, or division of power, any interventionrequiring community support will be difficult.

Advantages■ Village cleaning can be used as an entry point to

the community.

Case Example 4.7 Village Cleanup Days in The Gambia

Village cleaning was included in the GambianNational Trachoma Control Program in anattempt to reduce the number of breeding sitesfor eye-seeking flies and to remove garbage andexcess vegetation from the villages. Excess vege-tation was considered to be a resting place formalarial mosquitoes and was thought to encour-age open defecation. After a series of villagemeetings, sets of tools (five spades, five rakes, fivecutlasses, one wheelbarrow) were handed overto a named person in the village for use withcleaning. Decisions about who would beinvolved in village cleanup days, who would haveaccess to the tools, and where the tools wouldbe securely stored were all made before thetools were provided. In most villages, cleaningtakes place on Fridays immediately after theafternoon prayers and all able-bodied adult menand women participate.Village cleanup has beenmost successful in small villages where there is agood sense of community.Villagers report thatthey enjoy living in a clean community because itreflects well on everyone and they believe that itimproves health.

A woman clears rubbish from her village.

Cleaning supplies are delivered by truck.

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■ In conjunction with other aspects of the SAFEstrategy, such as latrine projects and antibiotic dis-tribution, cleaning demonstrates a broad commit-ment to the community.

■ Provision of cleaning equipment works well whenaccompanied by health education and group deci-sion making about who has responsibility for thestorage of equipment and management of thecleaning.

■ It is relatively inexpensive. A set of Chinese- orIndian-manufactured tools (widely available inAfrica) with five rakes, five spades, five cutlasses,and a wheelbarrow can be purchased wholesale foraround $50 USD. Sets of higher quality toolscould cost between four and 10 times as much.

■ It is sustainable. Once established, village cleaningcan continue with participants using their ownagricultural tools and without further intervention.

Disadvantages■ There is currently no published scientific evidence

that the provision of tools for village cleaningreduces the prevalence of trachoma.

■ Hidden costs of staff time and transport may behigh. To be effective, the provision of tools shouldbe accompanied by village-level meetings and peri-odic follow-up visits by members of a field team.

■ It is not sustainable. Cheaply purchased tools havea very limited life of between one and two years,and the brittle metal does not lend itself to repairby local blacksmiths.

■ Acceptance of community cleaning programsvaries. Well-organized, strongly led villages withgood levels of community mobilization are likely towelcome the village cleaning initiative immediately.Other villages will never adopt it. And it is likelythat the poorly organized villages that lack socialcohesion and leadership are those with the highestlevels of trachoma that would benefit the most.

■ This is a local-scale intervention that is not likelyto have a uniform effect and, because of the needfor follow-up, may be difficult to implement on anational or even regional scale in large countries.

Household Garbage DisposalRegular collection of household garbage does notusually take place in trachoma-endemic countries,and garbage may accumulate in individual com-pounds and communal areas. The garbage may pro-mote the breeding of flies and provide hiding, rest-ing, or breeding sites for mosquitoes, cockroaches,rats, and other vermin. While there is no record of

any trachoma control program currently promotinghousehold garbage disposal, this practice couldenhance efforts at village cleaning and environmentalimprovement. Household garbage is best disposed ofusing the “burn, bash, and bury” practice. Garbagecan be transported to pits or burned in piles on site.The burned waste is then “bashed” with a stick orspade to reduce its volume and buried. At least 15 cmof earth should be used to cover household garbage.

Other Interventions That Have Been TriedThe following interventions are being used by thenational trachoma programs of some countries.There is currently little scientific evidence to showthat these interventions are likely to reduce trachomaand there may be few collateral health benefits. Theimpact of these interventions on trachoma and otherdiseases may be minimal, if there is any healthimpact at all, so they should not be the first priorityfor program planning or delivery.

Construction of Public Baths Community development to alleviate poverty andempower women is an important part of the HelenKeller International trachoma control strategy insouthern Morocco. The approach includes the con-struction of public baths, called hamman, in tra-choma-affected communities. Individuals pay a smallamount of money to use the baths and there are sep-arate designated days for men and women. It is cul-turally appropriate in Morocco for people to usepublic baths. In other countries, public baths maynot be welcomed by community members, but otheracceptable approaches can be adopted.

Fly ControlEye-seeking flies, in particular Musca sorbens, areknown to be vectors of trachoma. The most appro-priate long-term control measure to reduce the num-ber of Musca sorbens is to reduce the number ofavailable breeding sites by promoting latrines.However, there are additional ways to control the flypopulation.

Spraying. Chemical control with sprays is possibleand known to be effective for controlling flies.Spraying requires specialist equipment, training, andplanning to be effective. There are two strategies: fre-quent space spraying or periodic use of residualinsecticide.

Space spraying with a pyrethroid insecticide suchas permethrin or deltamethrin is best conducted in

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the early morning before winds and convection cur-rents can carry the droplets away from the targetarea. Control can be achieved on a village-wide basiswith an “attack” phase of spraying every two days fortwo weeks to kill the adult population and any newadults emerging, followed by a “maintenance” phaseof spraying twice a week to kill any flies that havemigrated to the area. This technique has been highlysuccessful in The Gambia where fly control reducedactive trachoma by about 50%.

Residual spraying with DDT or deltamethrin isused routinely to control malarial mosquitoes. Thesame spray teams can be used to control eye-seekingflies by spraying the outside of houses in addition tothe inside. This plan works because flies usually reston the outside walls of houses and other structures atnight, when it is hot, or during rain. If the wallshave been sprayed, the flies pick up a lethal dose ofinsecticide through their feet.

Any prolonged regular use of insecticide will leadto the evolution of insecticide resistance in flies aftertwo to five years, after which the insecticide willhave to be changed. The reliance on specialist equip-ment and high cost of consumables (the insecticide)means that chemical control of flies should probablyonly be attempted where there is an unusual andtemporary increase in transmission risk. Thisincreased risk may occur in displaced populations orrefugee camps. In these circumstances, the collateralbenefit of reducing flies and mosquitoes (e.g.,reduced diarrhea and malaria) may well make theuse of insecticides practically essential.

Scatter Bait. In Vietnam, World Vision uses scatter-bait fly killers to control flies. A good attractant(e.g., cooked rice) is treated with commercially avail-able insecticide, then used as bait. The treated bait is

scattered around the areas with the highest fly con-centrations. The flies come to feed on it and arekilled by the insecticide. This technique is common-ly used in Europe and North America to control fliesin closed environments, such as poultry houses andcattle barns, where there is a finite population offlies. It is not used in open areas. The insecticide-treated bait could be hazardous for children, free-range chickens, or even small stock.

Bottle Traps. Homemade fly traps using old plasticdrink bottles and feces have been developed by theInstitute of Child Health in London and theInternational Community for the Relief ofStarvation and Suffering (ICROSS) in Kenya. Thedevice uses two plastic bottles, mounted one abovethe other, to create a flytrap. The lower bottle is thebait bottle and is covered with mud so that it is darkon the inside. It is filled with a mixture of goat drop-pings and cow urine to attract the flies. After feed-ing, the flies fly up into the top bottle where they aretrapped and die.

Radio Listening ClubsIn Ghana, The Carter Center has worked with localwomen to set up radio listening clubs. The project

Sprays are used to control flies in The Gambia.

A Ghanaian woman hosts a radio program.

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was initiated to increase access to the national radiostation that, along with its normal programming,was being used to provide information about tra-choma. Wind-up or solar radios are purchased for acommunity that gathers to listen to the radio. Theradios do not need replacement batteries and haveproved to be robust; they have already lasted severalyears. The project also involves distributing tapes tolocal radio stations with programs or jingles abouthygiene and trachoma. In an assessment of programeffectiveness, the project has found that 72% of thewomen in the radio listening clubs could repeat thejingle distributed to radio stations. The CarterCenter and Helen Keller International have run sim-ilar programs in Niger and Mali.

In Niger, the typically factual and dry health mes-sages have been replaced by broadcasts of “Healthand Hip-Hop” by volunteer disc jockeys. The formatof the shows is up-to-date music punctuated withhealth-related questions from listeners. Due to theage of the majority of listeners, many questions con-cern HIV and sexual health, but the DJs also pro-vide messages about hygiene and trachoma.

Leaky TinsLeaky tins can show that small amounts of water areall that are needed for face and hand washing.Households find old containers (cleaned) or locallyavailable gourds and calabashes and make a smallhole at the base. When water is poured into theleaky tin or calabash, the trickle of water thatemerges from the hole is adequate for washing eyesand hands. The African Medical and ResearchFoundation (AMREF) has promoted leaky tins inMaasai communities in Kenya and Helen KellerInternational has done so in Kongwa, Tanzania.

Soap-Making ClubsSoap making is a simple technology that ties togeth-er hygiene promotion and income generation. In thebest soap-making programs, the participants (usuallywomen) learn about the importance of soap andhygiene. The soap they produce is sold in local mar-kets to raise money for their personal needs or for acause on which they agree collectively (e.g., buyingseeds to start a community garden, or buying bednets for their houses). Soap-making technology is thesame everywhere, but the best local ingredients mayvary by country. In the context of their trachoma

control programs, The Carter Center is supportingsoap-making clubs in Niger and Helen KellerInternational is supporting clubs in Morocco andTanzania. Other nongovernmental organizations willbe involved in soap-making activities and can pro-vide this local knowledge.

Window and Door Screens In Morocco, Helen Keller International runs aschool-based trachoma program that includes theactivity of placing screens on windows and doors inthe schools and kindergartens to protect childrenfrom eye-seeking flies. Though screening is a provenmethod to reduce harm from flies, screening activi-ties have not been used specifically for trachomacontrol. In addition to targeting schools, screeningcould be done for households in trachoma-endemiccommunities. Costs of a household program couldbe considerable however, and for this reason, screen-ing could be promoted instead of purchased.

Children use water from leaky calabashes to wash theirfaces in Tanzania.

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Windows and doors are screened on this school in Zagora, Morocco.

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Communicating health refers to working incommunities to develop tailored messagesand approaches through a variety of chan-

nels, such as radio or village meetings, to develop,promote, and sustain behavior change.

This section presents the “social marketing”approach to communicating health. Social market-ing campaigns use similar techniques that have beensuccessful in commercial marketing campaigns. Incommercial marketing, products are sold to con-sumers, whereas in social marketing, ideas, attitudes,and behaviors are “sold” to target groups. Socialmarketing campaigns use information about theknowledge, attitudes, and practices of people in tar-get groups to design messages that will motivatebehavior change. Instead of simply telling peopleabout the importance of a health issue, a social mar-keting campaign will link the issue to the needs,dreams, and desires of the target groups. The use oftarget groups requires research at the beginning ofthe campaign, followed by testing and evaluation ofall aspects of it.

The nonprofit development organizationInternational Development Enterprises (IDE) hasextensive experience applying the social marketingapproach to trachoma control, and its campaign inVietnam is featured in this section of the guide. Inaddition, this section presents step-by-step method-ology for developing and implementing a socialmarketing campaign.

A social marketing campaign can serve as atremendous support to all F and E trachoma controlinterventions. It can raise the profile of the entireSAFE program and should be integrated into allplanning, implementation, and evaluation activities.

An effective social marketing campaign has sever-al benefits for a trachoma control program, includ-ing the following:

■ Increase knowledge about trachoma andhygiene promotion in a language or visual mediumthat target groups can understand and to which theycan relate.

■ Promote behavior change, such as using ofindividual towels for face and hand washing.

■ Challenge fatalistic ideas that trichiasis and eyediseases cannot be avoided.

■ Reduce stigma and offer a solution for thosewith trichiasis.

■ Promote services for environmental improve-ments and trachoma control in general.

■ Lead policy-makers and opinion leaders towardmaking environmental improvements in the com-munities of target groups.

■ Improve skills and sense of self-efficacy in targetgroups by teaching or reinforcing new behaviors suchas facial and hand cleanliness and village cleaning.

■ Raise the profile of the program by generatingawareness and interest.

The four steps for developing a social marketingcampaign will be discussed in this section. Theyinclude (1) research, (2) message development andpretesting, (3) materials development and pretesting,and (4) delivery and evaluation.

Step 1: ResearchIn developing a social marketing campaign, the firststep is to ask a set of questions about the knowledge,behavior, dreams, and media habits of the targetgroups. Media habits are the behaviors that exposethe members of target groups to new ideas. Forexample, do they attend village meetings, where dothey see posters, when do they listen to the radio,what newspapers do they see and how often, do theywatch TV or go to video shows? Once programdesigners know how to reach people, they candesign a suitable strategy to inform the target groupsabout the program in a way that will interest them.

The following are the three main ways of collect-ing information about target groups:

1. Use personal knowledge along with existinginformation collected by others

2. Conduct a structured questionnaire with thetarget groups

3. Conduct key informant interviews or discussions with the target groups

It is best to use all three methods to collect infor-mation, but if time or resources are limited, then thegreatest amount of information can be obtained

5 Communicating HealthThrough Social Marketing

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from using existing, institutional knowledge, fol-lowed up with key informant discussions or focusgroups. Case Example 5.1 shows how research wasused as the foundation for message development inVietnam.

Before beginning this research, it is important toclarify the message that will be promoted in thecommunication strategy. Remember, a social mar-keting campaign should be designed to support thetrachoma interventions and must therefore be linkeddirectly to them. In addition, it is important toidentify the desired audience, in other words, thespecific target groups. Section 3 of this guide dis-cussed primary, secondary, and tertiary targetgroups, and a social marketing campaign mustdefine these groups.

Personal Knowledge and Existing InformationTo begin the research about target groups, the pro-gram designer should find out what knowledge

already exists. He or she can find out what otheragencies are already doing to reach the target groups,plus ask other program staff members for theirinput. A brainstorming session about how best toreach the mothers of preschool children may revealjust as much as a survey—and will be considerablycheaper. Table 5.1 lists of some of the key questionsto answer about each target group.

After gathering this initial research, the programdesigner should create a table that displays all theinformation collected about each target group.

Structured QuestionnaireNext, the program designer can create a structuredquestionnaire to find out more about the targetgroups. The questionnaire should build on theinformation that is already known. Examples ofquestions are provided in Table 5.2, but the programdesigner will want to add his or her own.

A questionnaire of this kind can provide quanti-tative data about the target groups that will be usedfor developing messages (Step 2) and choosing chan-nels of communication for the social marketingcampaign (Step 3). If designed purposely, this surveycan also provide baseline information about the tar-get groups that will help in the monitoring and eval-uation of the campaign (Step 4).

Case Example 5.1Social Marketing Research in Vietnam

As part of the multiorganizational trachoma controleffort in Vietnam, International DevelopmentEnterprises (IDE) designed a social marketing cam-paign to encourage adoption of certain hygienehabits. In the design phase of the campaign, IDErepresentatives conducted research to betterunderstand the target groups. First they conducteda quantitative habits and attitudes survey that pro-vided baseline information on socioeconomic situa-tion, media habits, and water usage habits.Theythen conducted qualitative in-depth discussionswith target groups to learn more detailed informa-tion. Research objectives included the following:understanding the key issues in people’s lives (i.e.,which situations cause the strongest feelings of hap-piness, sadness, anxiety, and anger), understandingchildren’s dreams and aspirations, and learning aboutlocal proverbs for possible inclusion in campaignmaterials.The people to which IDE researchersspoke were men with children under age 10, youngwomen with children under age 10, women ages55 and older, and children ages 13-16.They spoketo men and women with children under age 10 tolearn both about the lives of the adults and theiryoung children. Findings showed that people’s mainconcerns revolved around their family’s happiness.Their primary concerns were health, crops, money,and children’s progress at school. IDE decided touse these as emotional hooks in the social market-ing campaign.

The Group Itself

■ How many people are in the target group in our interventionarea?

■ Where are they? (Are they usuallyat home, do they travel frequently,do they get together regularly atmarkets or other gatherings?)

■ Are they able to read? If so,in what language?

■ Do they have any locally organ-ized groups, such as religiousgroups, nurseries, informal daycares?

■ What positive behavior currentlyexists within the target group?Why? For example, why do peoplewash their hands and faces now?

Mass Media Behavior

■ Do they listen to the radio,watch television, or attend videoshows? If so, when?

■ What channel do they like andwhat is their favorite type of program?

■ Are there any audience researchfigures?

■ What are the local and nationalnewspapers and magazines?What are their circulation figures?

Table 5.1Questions About Target Groups

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Interviews or Discussions with Key InformantsThe questionnaire should identify some issues thatneed more in-depth (qualitative) discussion with keymembers of the target groups. These discussions canshed light on what motivates these individuals. Forexample, if your target group is children ages 10–15,interviews may reveal their dreams and aspirations.Perhaps they would like to be good in school, bepopular with other children, excel in sports, or maketheir parents happy. This information will be usefulin finding the emotional hooks necessary for thedesign of the social marketing messages. The cam-paign aimed at the children can use these hooks toshow how being clean makes children popular withother children or how using a latrine will make par-ents happy and proud of their children. These discus-sions will also reveal which media will work best forthe campaign. For example, there would be no pointin producing expensive television slots for children ifthey do not watch television. Some of the questionsto cover in discussions are listed in Table 5.3.

Step 2: Message Development and PretestingOnce the research is complete, it is time to developthe themes and messages central to the social mar-keting strategy. The goal is to use the research tofind the emotional hook on which to hang messagesthat will generate and hold the interest of your tar-get groups and encourage action.

Themes and MessagesIt is important to develop an overall theme that willappeal to and attract target groups. Themes shouldbe positive, avoid blaming and stigmatizing, callattention to the campaign, and link its various ele-ments together. The theme will provide overall guid-ance for the development of messages, all of whichwill therefore be consistent.

Individual messages contain carefully craftedinformation that is targeted at specific groups. Theyshould meet behavior-change objectives and stimu-late discussion and action. Messages are the mostimportant element in a communication strategy, and

Media Habits

1. Do you have a working radio in the house?(Yes/No)

2. How often do you listen to the radio? (every day/every few days/rarely/never)

3.Which radio station do you prefer?

4.What are your favorite programs?(name of program/time of program)

Similar questions can be asked about television, videoshows, posters, or other forms of mass media used inthe country.

Motivation

What are your dreams and aspirations?

When do you feel happy, sad, worried, or angry?

Who in the country, region, and community doyou most admire?

Health and Hygiene Practices

1.Where do you collect water for the household?

2. How often do you collect water for your home? (every few days/every day/more than once per day)

3. How do you use water each day?

4. How often have you been to the clinic in the past year?(0, 1, 2, 3, 4, 5, 6+)

5. How often has a health worker come to your house inthe last year? (0, 1, 2, 3, 4, 5, 6, 7+)

Literacy

Please read this sheet for me.(read easily / read with difficulty /not able to read)

Table 5.2Questions for Structured Questionnaire

Media

How do people get messages about local and world events?

How do local groups and associations function?

Who are the main influences on household behavior?

Who are the right people to promote hygiene?

What, how, and when is the best way to send messages?

Table 5.3Questions for Key Informants

they are where most communication strategies fail. The following information can be used to devel-

op the overall theme and key messages. The infor-mation needed for each of these three steps shouldbe drawn from the research conducted in Step 1.

■ Understand how culture and situation couldaffect the action and decision making of the targetgroups. Even if the target group members under-stand, relate to, and are motivated by the message,there may be other factors that stop them fromadopting the proposed behavior.

■ Identify and stick to the key fact that should beconveyed to the target group. The key fact shouldprovide information about the problem and provideopportunities for solving it. The key fact may notrelate directly to trachoma. For example, a key factaimed at household heads could be: “Having a mod-ern latrine is convenient, clean, and will make yourespected by your neighbors.” A key fact aimed at

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mothers may be: “Your child’s sight may be pre-served if you get treatment for mild eye problems.”

■ Develop messages from the key fact. Messagesshould be simple, attractive, and clear about thebenefits of what is being promoted and conveyed inwords or images. All messages should contain thesame core information. Messages that promote serv-ices or facilities, such as wells, must include infor-mation on how to access them.

Case Example 5.2 shows the steps involved inmessage development, applied to trachoma control.

PretestingPretesting is a way to ensure that themes and mes-sages reach the intended target groups. Messagesshould be pretested with all target groups for whomthe communication is intended, both primary andsecondary. To pretest a theme and message, a pro-gram designer should take it to members of the tar-

■ There may not be a close source for water near the household, andtherefore collecting water is a time-consuming activity.

■ Women may feel that hand and face washing is not the best use ofthis scarce resource.

Many people in trachoma-endemic communities are not preventingtrachoma and other diseases through face and hand washing. Limitedaccess to water sources and a lack of knowledge about trachoma andhygiene practices are key problems. Benefit statements for the mes-sages are as follows:■ If I wash my face and hands, I will prevent trachoma and other diseases.■ If I help my family members wash their faces and hands, I will have a

healthy family.

For children:■ Face and hand washing can be done with small amounts of water.■ Individual towels and cloths should be used for each person in the

household.■ Face and hand washing will lead to being happy, healthy, and popular.For mothers:■ Face and hand washing can be done with small amounts of water.■ Individual towels and cloths should be used for each person in the

household.■ These hygiene practices prevent trachoma and other diseases.■ Face and hand washing will lead to happy, healthy, respected, and

united families.

Step 1: Determine the factors that could limit people’s ability toadopt the proposed behavior.

Step 2: Determine the key fact to address in the messages.

Step 3: Determine the key message points that will be included incommunication delivery.

Case Example 5.2Steps to Theme and Message Development from Vietnam Campaign

Based on the research by International Development Enterprisesin Vietnam (see Case Example 5.1), themes and messages for asocial marketing campaign that aims to increase hand and facewashing could be developed through the steps below.

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get groups and ask, observe, discuss, and measurethe following:

■ Clarity■ Recall■ Interest■ Persuasion■ Cultural appropriateness■ Audience members’ degree of identificationIf possible, pretesting and discussions also should

be conducted with stakeholders because their viewsmay differ from those of the target population, anddisagreement with stakeholders can derail or com-promise a program.

Step 3: Materials Development and PretestingThe next step in developing a social marketing cam-paign involves developing materials for the campaignand then pretesting them with the target audience.

Choosing Channels of Communication The assessment of media habits conducted in Step1 will help decide which channels are best suited tothe messages developed in Step 2. Other ways tochoose communication channels include the fol-lowing:

■ Select channels that reflect patterns of use ofthe target groups. The channels must be those thatreach target groups with the greatest degree of fre-quency, effectiveness, and credibility.

■ Know that different channels play different roles.■ Use several channels simultaneously.■ Select media that match the program’s human

and financial resources.Channels of communication can be divided into

three types: interpersonal (individual and group),mass media, and traditional media.

Interpersonal. One-to-one communication

between skilled communicators and target audi-ences is probably the most effective way of getting a message across. However, it is likely to be verytime consuming and require many staff. Examplesof one-to-one communication include home visitsby health workers and peer education. Less effectivethan one-to-one communication, but less costly, isto address target groups through, for example, villagemeetings, schools, community-level animation/motivation sessions, mobile marketplace demonstra-tions, and small-group discussions. Table 5.4 lists thestrengths and limitations of interpersonal channels.

Mass media. Mass communication channels suchas radio and television are commonly used for healtheducation because they can reach many people atlower cost per person. However, they have a lessenedcapacity to affect behavior because there is noopportunity for dialogue. Mass media include radioand television appeals, testimonials from celebrities,dramas, soap operas, and cartoons. Other massmedia examples are cinema, video, newspapers,magazines, journals, leaflets, posters, recordings ofpopular music, and school curricula and materials.Table 5.5 lists the strengths and limitations of massmedia channels.

Traditional Media. Traditional media channelsinclude street theater, dance, storytelling, songs, andfilm. An example is the use of traveling film shows.In some trachoma-endemic communities in sub-Saharan Africa, men travel between villages to showthe latest movies using generators, televisions, andVCRs loaded onto their horses or camel carts. Thesemen could be involved in the social marketing cam-paign by showing movies on trachoma control orhygiene behavior as part of their film shows in vil-lages. Table 5.6 shows the strengths and limitationsof traditional media channels.

Strengths

■ Provides credibility to messages

■ Provides detailed information

■ Creates supportive environment

■ Provides opportunity to discuss sensitive, personal topics

■ Creates support at community level for recommendedbehaviors, ideas, products

■ Allows immediate feedback on ideas, messages, practices

Limitations

■ Time consuming with a high cost per person orcontact.

■ Reaches small number of individuals

■ Requires practical skills training and support offield workers

Table 5.4Strengths and Limitations of Interpersonal Channels

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Developing Communication MaterialsOnce the most appropriate communication channelshave been chosen, specific communication supportmaterials can be developed. These may include thefollowing:

■ Print materials for peer educators such as flipcharts and posters.

■ Pamphlets or information sheets to supporthealth workers.

■ School materials such as lesson plans, calendars,timetables, books, rulers, pens, and pencils that dis-play the campaign logo or key messages.

■ Television spots for general broadcast.■ Promotional materials such as T-shirts, face

cloths, towels, caps, and buckets that display thecampaign logo or key messages.

■ Scripts for theater and street theater.■ Video spots for traveling film shows.

Strengths

■ Can use local jargon and slang

■ Puts messages and situations in familiar context

■ More relevant than other media

■ Uses local talent and gets community involved

■ Has potential to be self-sustaining at low or no cost

■ Stimulates discussion of topics among families, friends,neighbors, and the community

Limitations

■ Reaches relatively small group

■ May not be available when needed

■ Requires investment in training and support

■ May have difficulty broaching highly sensitive issues

■ May be difficult to guarantee and monitor accuracyof messages

Table 5.6Strengths and Limitations of Traditional Media Channels

Strengths

■ Reaches many people

■ Allows messages to be delivered frequently

■ Can create a demand for services or products on thepart of innovators, early acceptors, and some of theearly majority

■ Reinforces important messages delivered throughinterpersonal communication channels

■ Stimulates discussion of topics among family, friends,and neighbors

■ Reaches those with limited literacy

■ Can provide protective impersonality in dealing withsensitive issues

Limitations

■ May have limited rural distribution

■ Difficult to tailor program to special groups

■ Difficult to obtain group feedback

■ Requires access to radio, television, cinema, printmedia, and so forth

■ Requires technical knowledge

■ Can be expensive

Table 5.5Strengths and Limitations of Mass Media Channels

■ Radio programs that can be recorded on tapeand distributed to local stations, including those thatare purely informational, in a question-and-answerformat, or a combination of music and information.

■ Soap opera scripts for radio or television.■ Murals to decorate schools, wells, and other

water sources provided by the program that conveykey messages or the campaign logo.

Case Example 5.3 shows how materials weredeveloped and communication channels chosen forthe social marketing campaign in Vietnam.

PretestingLike themes and messages, campaign materials,training packages, and support tools should bepretested using the same methodology as describedin Step 2. The target groups can give feedback onthe materials, which can then be modified to bettersuit the audience.

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Step 4: Campaign Delivery andEvaluationThe final step in conducting a social marketing cam-paign is to deliver the materials and evaluate thecampaign’s results.

Campaign Management and DeliveryIn the delivery phase of the campaign, all elementsof the social marketing strategy go into action. Thefollowing activities will need to be carried out toensure smooth delivery of the campaign:

Identification of collaborating partners. The part-ners will vary, depending on the communicationchannels and materials chosen. For example, anadvertising agency can be hired for assistance indeveloping materials and buying media time,although most rural FM radio stations will be happyto play slots for free. Community groups can serveas partners for community-based group activities.The roles and responsibilities of each partner shouldbe clarified before the campaign unfolds.

Campaign management. All partners, program-mers and channels of the campaign must be closelycoordinated. The manager must decide how oftenthe partners will meet to discuss the progress of thecampaign. Furthermore, the program and campaignelements must be closely linked or the overall pro-gram will suffer. For example, if services are beingpromoted through the campaign, they must beavailable immediately.

Staff training. Training allows campaign imple-mentation to go more smoothly. For example, those

involved in radio slots need to learn, among otherthings, the schedule of broadcasts. Supervisors mayneed to learn how to evaluate staff performance andhow to collect and compile monitoring data.Community health workers need to know how touse new messages and materials.

Press coverage and public relations. Whereapplicable, a staff member should be responsible forworking with the press to ensure adequate coverageof the campaign.

Timeline. Timing and coordination are keys toeffective program management. Campaign materialsmust be delivered to designated locations at theappropriate times. Because the social marketingcampaign is linked to other parts of the trachomacontrol program, the campaign must be part of andcoordinated with the broader program implementa-tion plan.

Budget. It is essential to budget adequately for allsteps of the campaign. Managers can save significantmoney by using materials developed by programs inother countries or producing large quantities of pro-motional material. Campaigns are possible at anybudget, it is simply a matter of balancing objectivesand resources.

Monitoring and EvaluationA plan for monitoring and evaluation needs to bedesigned at the initial stage of message and cam-paign development. Monitoring and evaluation areimportant for improving delivery of the campaign,improving the messages, updating the messages toreflect a changing context, and measuring impact.

Monitoring is part of the ongoing managementof communication activities, and it usually focuseson the process of implementation. The followingquestions should be asked regularly to ensure thecampaign is as effective as possible:

■ Reach: Is an adequate number of the targetaudience being reached over time?

■ Coordination: Are messages adequately coordi-nated with service and supply delivery and withother communication activities? Are communicationactivities taking place on schedule and at theplanned frequency?

■ Scope: Is communication effectively integratedwith the necessary range of audiences, issues, andservices?

■ Quality: What is the quality of communica-tion, including messages, media, and channels?

■ Feedback: Are the changing needs of the targetgroups being captured?

Schools inMorocco useseveral types of materials.

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The answers to these questions can be monitoredthrough reports, site visits, and reviews of materials.Periodic key informant interviews can help assess theperceptions of target groups. Peer educators can col-lect responses from target groups to help identifychanges that may have to be made.

Evaluation refers to the assessment of a project’simplementation and its success in achieving statedbehavior-change objectives. The social marketingcampaign should be evaluated against its statedobjectives and in reference to a baseline that may bequantitative or qualitative, or both. Step 2 discussedcarrying out a household survey for research purpos-es. For large-scale interventions, household surveys

can be used to collect baseline information onknowledge, attitudes, and reported behaviors in rela-tion to communication and project-level behavior-change objectives. These surveys may be repeated todemonstrate changes over time. Change can also beassessed through qualitative research into target-group responses to interventions. Qualitative evalua-tion involves examining data that are designed toillustrate changes in audience behavior.

All monitoring and evaluation of the social mar-keting campaign should be coordinated with the over-all evaluation of the trachoma control interventions.

These posters were part of the marketing campaign.

International Development Enterprises (IDE) decided to promotehand and face washing through a campaign focused primarily onchildren but also on mothers. Because of the focus on children,

IDE developed a central character for the campaign – a “funny-haired” boy modeled on a Vietnamese folktale about the Buffalo Boy,who has a lot of adventures and is well regarded among children.This character became the campaign logo and was incorporated intoall materials.The main slogan of the campaign was incorporated intothe logo. It reads “Clean eyes – healthy eyes” above the boy and “Abright future” below him.

The channels used to reach the children included school, television,and commune loudspeakers.The communication materials developedincluded video spots broadcast to children in school and on television,a song taught in schools that focuses on how having clean and healthyeyes results in success in school and happiness for the whole family,and school exercise book covers that read, “Have you washed yourface?” “Wash your hands and clean your face with your own towel.”IDE designed a cartoon based on the campaign logo that showedthe “funny-haired boy” waking up, washing his face with his owntowel, and happily going to school. No words are spoken, trachomais not mentioned, but the background music is the trachoma song.IDE also developed a video slot targeted to boys. In this video, a boyis watching television and sees a football star washing his face andtalking about the importance of hygiene.This boy decides to washhis face before playing football with his friends. He goes on to scorea goal and is lifted into the air by the other boys.

The main channels IDE used to reach mothers were television,women’s groups, and commune loudspeakers.They developed avideo slot that featured a trachoma poem composed and performedby a famous balladeer. This video was shown to women on television,in women’s union meetings, and village meetings.

The campaign logo also appeared on T-shirts, face and hand towels,plastic rulers, stickers, calendars, wall clocks, and posters.

Case Example 5.3 Channels and Materials for Vietnam Campaign

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Although monitoring and evaluation areoften mentioned together, they are differ-ent. Monitoring refers to the ongoing

process of recording the day-to-day progress of theprogram. Evaluation, on the other hand, refers toassessing the total program achievement against theinitial objectives. In a simple example, if the initialobjective of a program is to build 3,000 householdlatrines during a three-year program, monthly orquarterly recordkeeping (i.e., monitoring) will allowthe program manager to revise activities throughoutthe program to work toward the target. After threeyears, the program can be evaluated against the ini-tial objective: If 3,000 or more latrines have beenconstructed, the main target has been met. Mostprograms typically have several initial objectives thatwill be monitored and evaluated at the same time.

Monitoring and evaluation can also be used foradvocacy because they demonstrate the progress, out-put, and impact of the program, which gets policy-makers more involved. Furthermore, monitoring andevaluation helps show donors how their funds havebeen put to good use. And finally, but possibly mostimportantly, evaluations can serve as tools toempower beneficiary communities by demonstratingthe positive impact and improvements made by theirefforts and also by identifying remaining hurdles.

Importance of the BaselineBaseline data is basic information gathered before aprogram begins or when a new phase is launched. Itis used later to provide a comparison for assessingthe impact of the entire program or a phase of theprogram.

Conducting a baseline study is essential for theproper planning and evaluation of F and E interven-tions. Baseline studies help to analyze the currentlyexisting problems concerning trachoma, hygiene,and sanitation in the target area, while taking intoconsideration different age groups, sexes, ethnicgroups, and social classes. After a program or inter-vention has been launched, comparisons with base-line data will reveal the impact the program hasmade.

A baseline study on trachoma typically will reportthe following information:

■ Prevalence of trachoma in the target communities

■ Communities’ knowledge about trachoma and hygiene

■ Behaviors that increase the risk of trachomacurrently practiced by the target communities

■ Environmental factors in the communities that increase the risk of trachoma

■ Population of the risk groups■ Main communication channels

in the communities■ Primary motivators for behavior change

in the communities■ Capacity of local health and hygiene

professionalsOnce the above information has been collected

and analyzed, the basis for program planning andfuture monitoring and evaluation has been set. Keepin mind that even if the project is well underway, itis never too late to start a new phase and collectbaseline data.

Steps for Monitoring and EvaluatingInterventionsThere are four steps for monitoring and evaluating Fand E interventions for trachoma control: (1) devel-op a purpose and plan for the evaluation, (2) gatherdata, (3) analyze data, interpret findings, and makeconclusions and recommendations, (4) present find-ings and act on recommendations. These steps aredescribed in detail next.

Step 1: Develop a Purpose and PlanArticulating the purpose of an evaluation is animportant first step because it has implications forlogistics, data collection, and uses of the final con-clusions. The purpose will depend on factors such asthose listed below:

The specific interventions being implemented.In general, the following should be evaluated if theyare relevant to the program: trachoma prevalence;hygiene practices (including number of clean faces in

6 Monitoring and EvaluatingInterventions

41

children); trachoma knowledge; physical attributessuch as presence and condition of water supply andsanitation facilities; variation between gendergroups, age groups, households and communities;and effect of social marketing or communicationcampaigns.

The planned uses for the evaluation. Is theevaluation intended to assess effectiveness of pro-gram interventions for the purposes of deciding howbest to allocate new resources? Is the evaluationintended to influence and educate policy-makersand donors? Is the evaluation going to be used toempower beneficiary communities to stimulate dia-logue and raise awareness regarding trachoma andhygiene issues?

Once the purpose is articulated, the questionsthat will be asked in the evaluation can be written.Some sample questions are listed below.

On scope: What is being done? On scale and coverage: Are we operating on a suffi-

ciently large scale or reaching enough people in ourtarget to have a significant effect?

On quality: How well is the program being deliv-ered?

On success: Is the program working? Can we showthat we are making a difference?

Once the purpose of your evaluation has beendetermined, an evaluation plan can be devised. Someof the factors to consider include the following:

Types of information to be gathered. Whattypes of data are needed to answer the evaluationquestions? What evaluation techniques are mostappropriate and feasible?

Study team. Who will participate on the studyteam? What are the terms of reference for the studyteam? Evaluation of F and E interventions is laborintensive and in many cases will need a professionalstudy team. Once the team has been recruited, train-ing should be undertaken to sensitize the teamabout the project and develop a common under-standing of the evaluation purpose and design.

Timing. What is the timing for the evaluation?Budget. Evaluation costs should be factored into

overall F and E program costs and may include trav-el, fees, and accommodation of the study team, aswell as field work costs such as fuel, equipment, andtraining.

Before an evaluation has begun, the communityshould be adequately sensitized, but it is probablybetter not to talk specifically about evaluating a pro-gram because that can influence how people

respond. It is better to say that “more information isneeded to improve the program” and that “we wouldlike to conduct some interviews and hold some dis-cussions.” The key findings of the evaluation shouldbe delivered back to the participants, which canstrengthen the relationship between the programand the community.

Step 2: Gather DataIndicators are tools that show how far a program hascome in achieving its goals. The right indicatorsallow program managers to measure success anddetermine if the program is heading in the rightdirection. There are two general types of indicators:process indicators and outcome indicators. Theselection of specific indicators will depend on thesituation, but the following should be considered:

■ The indicator should be relevant.■ The indicator should be easily understood by

everyone interested in the program.■ The indicator should be easy to measure.■ The indicator should give valid information

(i.e., the truth) and should be repeatable by thesame program team or another team in the future.

Process IndicatorsProcess indicators assess the program activities thathave been conducted in pursuit of the programgoals. Because they measure activities at the programlevel, they usually are derived from monitoring dataand reports, but are best backed up with verifica-tion. Process indicators can be verified by follow-upstudies that prove the reported activities actuallytook place. Two examples of program aims, suggest-ed process indicators, and verification methods areshown in Table 6.1.

Outcome IndicatorsOutcome indicators measure the impact of a pro-gram in the target population against the aims. Anepidemiologically sound collection of outcome indi-cators allows assessment of the program effect todate and generates a new baseline against which tocompare further progress. Examples of tools to useto generate outcome indicators include field-basedsurveys and formal interviews. The tools used shouldproduce valid and repeatable data; that is, the datashould be true and the tools usable by the currentteam or another team in the future. The two exam-ples of program aims used previously are listed withsuggested tools and outcome indicators in Table 6.2.

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Step 3: Analyze Data, InterpretFindings, Draw Conclusions, andMake RecommendationsThe analysis of the data should yield evidence of thesteps being taken toward the project aims (theprocess indicators) and the impact of the programagainst the aims (outcome indicators). These thenhave to be interpreted with the overall goal of theprogram in mind. The interpretation will use bothprocess and outcome indicators to inform the rec-ommendations.

Using the first example in Tables 6.1 and 6.2(ensure all people in the target area have access to alatrine at home), consider that the program has setits target to train 15 builders, construct 300 demon-stration latrines, and satisfy all other demand forlatrines generated by the program. Process indicatorsmay reveal that 15 builders have been trained, theyhave built 260 demonstration latrines, and 50latrines have been built in response to communitydemand. Verification from the baseline survey showsthat the target population is 180,000 people in3,000 households and that only 12% had latrines atbaseline. The target of 300 demonstration latrinesappears realistic, provided that they generate

demand, and progress has been good (260/300 =87%). Only 50 other households have requestedlatrines, and the builders have been able to satisfy100% of demand. The program appears to be doingwell. However, comparison against baseline showsthat the program must ensure that 2,640 latrines areconstructed to achieve the aim. The construction of310 covers only 12% of the need. There is still aneed for more than 2,000 household latrines, and itlooks unlikely that this target will be met. Suitablerecommendations in this circumstance may be asfollows:

1. Because the demonstration latrines have failedto generate demand, interviews should be conductedto find out why people have not been employing thebuilders to make latrines for them.

2. Assuming that there is demand, but the partic-ipants cannot afford to employ the builders to makelatrines, subsidies or cost-sharing schemes should beinvestigated.

Step 4: Present Findings and Act onRecommendationsEvaluation findings should be shared with the mainstakeholders so that their feedback and additional

Table 6.1Sample Process Indicators

Program Aim

Ensure all people in tar-get area have access to alatrine at home

Promote knowledge oftrachoma throughschools

Process Indicator

1. Realistic goal and planof action

2. Number of builderstrained

3. Number of demon-stration latrines built

4. Number of otherlatrines built by buildersbut paid by participants

1. Realistic goal and planof action

2. Suitable curriculumand support materials

3. Number of teacherstrained

4. Number of classestaught and studentsreached

Verification Method

1. Check calculation.Total need = Number ofhouseholds in target area minus the number thatalready have a latrine. Confirm plan of action isreasonable and achievable.

2. Check participant lists for training. Examinepost-training knowledge.

3.Visit a random sample of households that arelisted as having received demonstration latrines.

4. Check builder’s records.Visit a sample of house-holds listed as building their own latrines.

1. Check plan of action. Confirm that resourceallocation and teacher training is sufficient to meetneed.

2. Check curriculum for content and age appropri-ateness. Examine teaching materials.

3. Examine lists of training participants. Confirmwith some teachers that they actually attended.

4. Discuss with trained teachers, class, and schoolregisters.

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insights can be incorporated. Ideally all stakeholderswill agree with the main findings and recommenda-tions before they are widely distributed. Final find-ings and recommendations should be communicatedto relevant audiences in a timely manner throughappropriate means such as written reports for donorsand village meetings for participating communities.

Where findings and recommendations are sup-ported by verifiable evidence, it is much easier to acton them. Using the example of the latrines, thenational program may wish to conduct a series ofinterviews with participants who have seen thedemonstration latrines but have not employedbuilders to make them. The program planners maydecide to allocate resources to subsidize latrine pro-vision, perhaps by donating the cement. The donormay give financial support for latrine provision so

Outcome Indicator

1. Proportion of households with access to ausable latrine at home (can be compared againstbaseline to demonstrate program impact)

2. Proportion of people in target area withaccess to a latrine at home (can be comparedagainst baseline to demonstrate program impact)

1–3. Proportion of teachers/students/other com-munity members able to identify trachoma, nametransmission routes, explain how to avoid ortreat trachoma, and so forth (can be comparedagainst baseline to demonstrate program impact)

Tool

1. House-to-house survey ofa random sample of housesin the target area; visualinspection for a usable latrine

2. Structured interviews withhomeowners to determinewho has access to a latrine.

1–3. Structured questionnaireof the knowledge of teach-ers/students/other communitymembers about trachoma

Program Aim

Ensure all people in target area haveaccess to a latrine at home

Promote knowledge of trachomathrough schools

Table 6.2Sample Outcome Indicators

that they can be built for free.Whatever the outcome, an open and transparent

process of monitoring and evaluation allows evidence-based decision making and the allocation ofresources in response to need. Programs managed insuch a way are likely to be both strong and success-ful. Before publishing the findings, a draft should beshared with the main stakeholders. This step pro-vides opportunity for feedback, additional insights,and assessment of their agreement with the findings.The primary result of the evaluation is a completestudy report. To make findings more accessible forgroups, such as community members and policy-makers, however, other presentation methods alsomay be used, including a summary report, abrochure, or verbal presentations.

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Cited Resources

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Cairncross S (1992) Sanitation and Water Supply:Practical lessons from the decade. UNDP-WorldBank Water and Sanitation Program, Washington.www.wsp.org/publications/Lessonsfromthedecade.pdf

Emerson PM, Cairncross S, Bailey RL & Mabey DC(2000) Review of the evidence base for the F and Ecomponents of the SAFE strategy for trachoma con-trol. Trop Med Int Health, 5, 515-27.

Emerson PM, Lindsay SW, Alexander N, Bah M,Dibba, S-M., Faal HB, Lowe KO, McAdam KPWJ,Ratcliffe AA, Walraven GEL, & Bailey RL (2004)Role of flies and provision of latrines in trachomacontrol, a cluster-randomised controlled trial.Lancet, 363, 1093-1098.

Family Health International. (2002) BehaviorChange Communication (BCC) for HIV/AIDS: AStrategic Framework. Family Health InternationalInstitute for HIV/AIDS: Arlington, VA.

Frick KD, Basilion EV, Hanson CL & Colchero MA(2003) Estimating the burden and economic impactof trachomatous visual loss. Ophthalmic Epidemiol,10, 121-32.

Holm SO, Jha HC, Bhatta RC et al. (2001)Comparison of two azithromycin distribution strate-gies for controlling trachoma in Nepal. Bull WorldHealth Organ, 79, 194-200.

Lietman T, Porco T, Dawson C & Blower S (1999)Global elimination of trachoma: how frequentlyshould we administer mass chemotherapy? Nat Med,5, 572-6.

Mabey DC, Solomon AW & Foster A (2003)Trachoma. Lancet, 362, 223-9.

Mooijman AM (2003) Evaluation of HygienePromotion. WELL Fact Sheet.www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-pdf/ehp.pdf.

Munoz B & West S (1997) Trachoma: the forgottencause of blindness. Epidemiol Rev, 19, 205-17.

Newbigging A (1998) A summary of focus groupdiscussions with hand pump users & non-users.International Development Enterprises: Hanoi,Vietnam.

Mariotti SP & Prüss A (2000) The SAFE strategy,Preventing trachoma: A guide for environmentalsanitation and improved hygiene. Geneva: WorldHealth Organization. WHO/PBD/GET/00.7.

Prüss A & Mariotti SP (2000) Preventing trachomathrough environmental sanitation: a review of theevidence base. Bulletin of the World HealthOrganization, 78, 258-266.

Solomon AW, Holland MJ, Burton MJ et al. (2003)Strategies for control of trachoma: observationalstudy with quantitative PCR. Lancet, 362, 198-204.

United Nations Children’s Fund (1999) Towardsbetter programming: A Manual on Communicationfor Water Supply and Environmental SanitationProgrammes. Water, Environment and SanitationTechnical Guidelines No. 7. UNICEF: New York.

United Nations Children’s Fund & The LondonSchool of Hygiene and Tropical Medicine (1999)Towards Better programming: A manual on hygienepromotion. Water, Environment and SanitationTechnical Guidelines Series No. 6. UNICEF: New York.

WELL (1998) Guidance manual on water supplyand sanitation programmes. Prepared for theDepartment of International Deevelopment. Water,Engineering, and Development Centre:Loughborough, UK.www.lboro.ac.uk/well/resources/Publications/guid-ance-manual/guidance-manual.htm.

West S, Munoz B, Lynch M et al. (1995) Impact offace-washing on trachoma in Kongwa, Tanzania.Lancet, 345, 155-8.

West SK (2003) Blinding trachoma: prevention withthe safe strategy. Am J Trop Med Hyg, 69, 18-23.

West SK (2004) Trachoma: new assault on anancient disease. Progress in Retinal and EyeResearch, 23 (4), 381-401.

Resources

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Web Sites for Further Information

WELLhttp://www.lboro.ac.uk/well/WELL is a resource center network providing accessto information and support in water, sanitation, andenvironmental health for the Department forInternational Development (DFID) of the BritishGovernment. The WELL Web site provides a widerange of publications including WELL Fact Sheetson various topics such as hygiene promotion(http://www.lboro.ac.uk/orgs/well/resources/fact-sheets/fact-sheets-htm/hp.htm) and evaluation ofhygiene promotion(www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-pdf/ehp.pdf ).

UNICEF Water, Environment, and Sanitationhttp://www.unicef.org/wes/The UNICEF water, environment, and sanitationWeb site provides fact sheets and technical, policy,and advocacy documents including “A Manual onHygiene Promotion”(http://www.unicef.org/wes/hman.pdf ) and “AManual on Communication for Water Supply andEnvironmental Sanitation Programmes”(http://www.unicef.org/wes/com_e.pdf ).

The Center for Communication Programs http://www.jhuccp.orgThe Center for Communication Programs at theJohns Hopkins Bloomberg School of Public Healthfocuses on the central role of communication inhealth behavior change. The site provides healthcommunications resources including “A Field Guideto Designing a Health Communication Strategy: AResource for Health Communications Professionals”(http://www.jhuccp.org/pubs/fg/02).

World Health Organization Water, Sanitation, and Healthhttp://www.who.int/water_sanitation_health/The water, sanitation, and health Web site of theWorld Health Organization provides diverseresources including information about participatorytechniques in water and sanitation programs such asthe “PHAST Step-by-Step Guide: A ParticipatoryApproach for the Control of Diarrhoeal Diseases(http://www.who.int/water_sanitation_health/hygiene/envsan/phastep/en/).

The Francophone Network on Water and Sanitationhttp://www.oieau.fr/ReFEAThe Francophone Network on Water and Sanitationprovides resources in French on the provision ofwater. In the Low-Cost Technologies section of thesite, technical publications are available on waterprovision technologies for surface, underground, andrainwater, and on the treatment and analysis ofwater (http://www.oieau.fr/ReFEA/module3.html).

Environmental Health Projecthttp://www.ehproject.orgThe Environmental Health Project (EHP), fundedby USAID, provides resources on a wide range ofenvironment and health issues. Though the EHPproject ended in September 2004, its publicationsand resources remain on its Web site, including“Strategic Report 8: Assessing HygieneImprovement: Guidelines for Household andCommunity Levels”(http://www.ehproject.org/PDF/Strategic_papers/SR-8-HISGPaperVersion.pdf ).

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