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Dear Paul et al,

In general, there is very few rigorous or large-scale evaluations of hygiene promotion (not least because it is both hard and expensive to measure effectiveness reliably). Even where decent evaluations do exist, it is often difficult to attribute positive outcomes and impacts to specific activities, approaches or elements (e.g. community participation) due to the integrated nature of the interventions (most programs and projects use multiple, over-lapping approaches to promote many different areas of sanitation and hygiene improvement but make little effort to unpick which of these is working or is most cost-effective, and often monitor only one or two generic outputs or outcomes).

And I'm not aware of any specific evaluations in emergency contexts. I'd guess that if we struggle to do this well in a development context then it is even less likely that there is decent evidence available from emergency contexts?

That said, most practitioners and researchers would agree that community participation is a good thing for all of the intuitive reasons. But there is growing evidence that intensive community participation approaches are often expensive and difficult to scale up, and may not be the most cost-effective solution to improving WASH behaviours at scale.

As a result, more structured, targeted and cost-effective approaches to sanitation and hygiene promotion are gaining widespread support - such as the CLTS approach mentioned by John (UNICEF's version is called CATS: Community Approaches to Total Sanitation), which is a community-led process with a very specific focus that uses practical and cost-effective triggering tools; and also promotion using social marketing techniques (sanitation marketing and handwashing campaigns), structured promotion through community health clubs and so on.

Most of these approaches recognise that we must move away from the simplistic assumption that imparting knowledge about germs and disease will change behaviour (i.e. top-down health and hygiene education does not work very well), and that simple interventions focused on one behaviour change tend to be more successful (and are easier to replicate and scale up) than those that try to promote too many messages and behaviour changes at one time (thus require highly skilled facilitators). Regards Andy