Improving behaviours around face washing and environmental sanitation

Guest Blogger, December 2014
A women has a bandage over one eye.

“The workshop provided an opportunity to energise stakeholders about the upcoming F&E initiative”

Leah Wohlgemuth is a senior eesearch assistant at Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHUCCP), which was given a grant by Sightsavers to investigate how best to improve facewashing and sanitation to prevent trachoma. Here are her findings.

Trachoma is endemic in 34 districts in Uganda, causing blindness in almost 47,000 people in the country.  An estimated 700,000 children under 10 have active disease, and about seven million people are at risk of being infected.

JHUCCP was provided an innovation grant by Sightsavers to find innovation solutions to implementing the facial cleanliness and environmental change components of the WHO SAFE preventative strategy for trachoma controls, by focusing on change at the level of the individual and environment. JHUCCP worked to facilitate social and behaviour change communication within affected populations to improve normative behaviours around face washing and environmental sanitation.   This grant afforded JHUCCP the opportunity to complete many activities in the fight against trachoma, which included:

  • A situational analysis and formative research in two regions in Uganda with high trachoma prevalence, namely, Busoga and Karamoja, to take full advantage of trachoma-related experiences in different geographical and environmental terrains. The findings were then presented to key stakeholders during the dissemination workshop in October 2013 and published to the eToolkit.
  • The development of an e-toolkit for the facial cleanliness and environmental change components of trachoma prevention, based on the findings of the situation analysis and formative research.  The e-toolkit also includes tools and materials, print and mass media developed under the current project in the English, Lusoga and Nkarimajong languages.  Since the e-toolkit was launched in November 2013, there have been more than 1,000 visits to the site, with each visitor visiting a minimum of two documents per visit.
  • The production of a physical toolkit of communication materials promoting Facial cleanliness and Environmental change to prevent trachoma.  The materials were reviewed, pre-tested and revised based on the pre-test results and approved by the Ministry of Health – Uganda.  These materials and tools have been uploaded on the e-toolkit and are available at

The various activities throughout this project allowed for an array of key learnings.

Context is key

The research was conducted in two regions of Uganda with very different cultural, environmental, and social characteristics in hopes of better understanding how factors such as water, trachoma prevalence, and lifestyle influenced trachoma.  JHUCCP’s research showed that it is extremely important to understand the community in which you are working and plan to implement programs in prior to developing them.

Understanding the nuanced information regarding trachoma in Uganda, and specifically, each region’s culture, lifestyle, and norms was paramount to developing a successful and sustainable campaign. Although there were some similarities in the two regions, the intricacies discovered between them allowed JHUCCP to determine key messages and tools that addressed specific contextual issues faced by those populations. It was evident from the research findings that awareness around trachoma transmission and prevention is generally low in high prevalence districts. The materials and tools developed and uploaded include: Charts, VHT Cards, Information Sheet, Trachoma Logo, Teacher’s Guide, User’s Guide and radio spots.

Things are not always as they seem

JHU?CCP originally selected communities for our research based on the prevalence of trachoma, prevalence of dirty faces, availability of water and sanitation resources, and latrine access.  Both high and low trachoma prevalence parishes were selected to discover any positive deviance behaviors.  Field visits revealed that while many communities that had been classified as having good water resources often did not, as many of their water sources (boreholes) were not functional. Therefore, it is important from researchers and program managers alike to recognise that things may be very different in the field than what is presented on paper or from existing data sets.  These differences and how public health professional address them is one of the keys to the artful implementation of prevention efforts.

Involve various stakeholders

After JHU?CCP’s research was complete, a dissemination workshop was held in Kampala to present the findings and begin developing the health communication campaign.  Ministry of Health officials, local government leaders, community members, and representatives of partner organisations and other academic institutions attended the workshop.  Having these different stakeholders present not only helped to validate the results, but also provided invaluable insight into what audiences should be targeted in the campaign and the different ways to overcome audience-specific behaviors.  The workshop provided an opportunity to energise stakeholders about the upcoming F&E initiative and seek their insight based on these latest scientific findings.  Participants advised on a multi-phased behavior change communication approach that blends behavior change for communication tool development, the appropriate training of community health workers, and the dissemination of tools to those workers in high prevalence communities.

This Innovations Grant allowed JHU?CCP to address a critical gap in trachoma prevention in the field that has been primarily dominated by investment in treatment-based solutions.

Next steps in tackling trachoma through behaviour change and communication

  • Continued advocacy is needed within and among trachoma professionals about the importance of a balanced SAFE strategy that equally invests in both treatment and prevention aspects of elimination.
  • While social and behaviour change communication (SBCC) has mainly been thought as a tool to complement F&E interventions, there is an untapped opportunity to fully integrate SBCC within the context of S&A as well (especially as it relates to reducing rates of remission and combating stigma/resistance to surgery).
  • SAFE’s monitoring and evaluation systems have historically underemphasised the need to include intermediate variables that track the progress of audiences with respect to F&E behaviours. This lack of foundational F&E indicators prevents program managers and other trachoma decision makers from adequately addressing quality control/quality assurance in F&E activities.
  • All SBCC initiatives (regardless of size) require local buy-in and support to achieve long-standing success.  Therefore, programme managers should make sure that relevant stakeholders and primary audience are included through the project development process and that all SBCC deliverables address local needs.
  • Knowledge management (or the curation and sharing of information) among neglected tropical disease or trachoma stakeholders is essential.  Too often, individual groups, MOHs, or individuals produce information and/or content that is important to share with the broader trachoma community.  In Uganda, there is an opportunity to strengthen the systematic process that encourages all relevant tools to be shared widely (in print, but more importantly, in electronic format) such that efforts are not duplicated and each party can build off the learning of others.


Click here for more information on the International Trachoma Initiative’s: “WASH and the NTDs: A Manual for WASH Practitioners.”

Project title: Development of a multi-component toolkit for effective integration of relevant NTD control activities into current WASH programs.

This project aims to create a permanent resource to help Water, Sanitation and Hygiene (WASH) organisations to incorporate compatible neglected tropical disease control activities into existing WASH programming. The project intends to increase the knowledge base within the WASH sector, and among WASH practitioners and governments regarding trachoma, the soil transmitted helminths (STH) and other NTDs. Increased information will allow WASH organisations to directly incorporate compatible NTD control activities into existing WASH programmes, as well as potentially target endemic areas as priority sites for WASH programmes.  Joint monitoring tools are expected to help WASH organisations establish links between WASH improvements and the reduction of trachoma and other NTDs.  Advocacy tools will also allow WASH organisations to petition governments for increased funding for the WASH sector based on health-related impacts, as well as increased coordination mechanisms between the Health and water-related government sectors.

By Leah Wohlgemuth, Senior Research Assistant at JHUCCP

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