Hygiene promotion through immunisation

In a groundbreaking new approach to hygiene promotion, we’re working with the Government of Nepal to reach thousands of mums and babies at immunisation clinics.

In Nepal, a new mother will take her baby to an immunisation clinic at least five times in the first nine months of the child's life – making these clinics an excellent point of contact for promoting hygiene behaviour change and improved health.

By embedding hygiene promotion in Nepal’s existing routine immunisation programme, this innovative project has the potential to revolutionise the way the hygiene and public health sectors work together.

About the project

Currently being piloted in four districts of Nepal – Bardiya, Jajarkot, Myagdi and Nawalparasi – the project aims to:

  • Integrate hygiene promotion into the national routine vaccination programme, ahead of the introduction of the rotavirus vaccine post-2017.
  • Demonstrate best practice for scaling up the model across Nepal.

The project also aims to address the following key questions: 

  • Is integrating hygiene promotion through a regular service delivery mechanism feasible? 
  • Is this approach effective in changing five key hygiene behaviours, targeting new mothers and their families? 
  • Does the approach increase the effectiveness of immunisation efforts?
  • Is this approach cost-effective?
  • Is the model being used scalable across the whole country?

The project will contribute to the strengthening of the routine immunisation system in Nepal by improving trust in, and the use of, immunisation services, and by potentially contributing to the effectiveness of oral vaccines, including the rotavirus vaccine when it is introduced. Rotavirus is thought to cause a third of deaths linked to diarrhoea.

Read the project briefing note >

To achieve the project’s aims, address key questions and demonstrate effective hygiene behaviour change programming, the project has been set up using a rigorous programmatic approach and step-wise process. The design, implementation and evaluation of the programme are all based on a Behaviour Centered Design approach.

The following five key steps map the design and implementation of the project:

Nepal: hygiene promotion through immunisation project
  • In 2012 we conducted a scoping study, which demonstrated sufficient interest for piloting and developing an appropriate hygiene promotion intervention. The findings are available in this briefing paper and article for the Journal of Water, Sanitation and Hygiene for Development and were shared widely with the relevant stakeholders.
  • The concept for the pilot project and a memorandum of understanding were then agreed between the Government of Nepal, the Ministry of Health and Population (MoHP), the Child Health Division and WaterAid.
  • A project management structure was developed, with WaterAid supporting the creation of a Technical Support Unit under the MoHP/Child Health Division.
Nepal hygiene promotion through immunisation project
  • We conducted formative research to build our understanding of the current routine immunisation system; to examine the determinants of hygiene behaviours, norms and habits; and to map out the barriers and motives around hygiene behaviours.
  • This approach enabled us to understand the project’s target settings and focus population better, and to prioritise five key hygiene behaviours.
Nepal hygiene promotion through immunisation project
  • We have created an innovative but simple, emotional and scalable hygiene behaviour change intervention package, through a creative process targeting all five key hygiene behaviours.
  • A multidisciplinary creative group worked to design a hygiene behaviour change intervention, which used creative sciences such as emotions (nurture, disgust, affiliation, status) and attractions.
  • The whole intervention was designed using a single brand. It has its own programme logo and features the theme ‘clean family, happy family’, with the inspirational goal of being an ‘ideal family’.
  • The package was pre-tested and produced locally. Central to the project is a hygiene promotion package, made up of resources tailored to the national context.
Nepal hygiene promotion through immunisation project
  • We have started implementing the project in four districts through the government’s routine immunisation sessions, mobilising 2,193 Female Community Health Volunteers (FCHVs) and health staff.
  • Around 35,000 new mothers or guardians with a young child (aged 0-12 months) will be reached at least five times through a hygiene session, according to their child’s immunisation schedule.
  • During each session, mothers and guardians will be encouraged to follow the five key hygiene behaviours, using the intervention package and novel approaches.
  • We are currently running 900 immunisation sessions every month.
Nepal hygiene promotion through immunisation project
  • After the completion of the project, we will measure all the key indicators and their success at the baseline (established before the start of the project) and end line.
  • To establish the baseline, all key indicators, including key hygiene behaviours, were structurally observed, immunisation practices were monitored and the capacity of FCHVs/health workers were assessed.
  • The same indicators will be assessed establish the effectiveness of the intervention after completion of the implementation phase.
Swala Kumari is a Female Community Health Volunteer (FCHV) in her village in Nepal.

Swala Kumari

“I have been working as a Female Community Health Volunteer for 20 years. My main duty is to raise health awareness among children under five and pregnant women. I also advise mothers about their environment, hygiene and health.

Diseases like pneumonia, malnutrition and diarrhoea are very common in our village. The water source is not well protected and it gets contaminated easily, and hygiene behaviour is not good at all. It is sad that some children are still dying due to malnutrition and diarrhoea.

I am glad to be involved in the government’s immunisation campaign. I feel great serving children and pregnant women in the community. We are improving, but there are challenges as well.”

Ashmita with her new born baby girl, Nepal.


“This is my second baby. She is nine days old. My elder daughter got all the immunisations. But immunisation is not sufficient for staying healthy. We have to maintain personal hygiene.

For my new baby, I have to change my clothes every day. The kitchen where we prepare food has to be clean. The utensils, washing point and surroundings have to be clean. If we do not maintain cleanliness, the baby gets infected with lots of diseases, so hygiene plays very important role in our life.

The first thing about changing our behaviour is to start within ourselves. If I want to keep my daughter clean and healthy, then I have to do it in my daily life so that my daughter can learn.”

Mandari, 26, with her younger daughter at home in Nepal.


“This is my second daughter. She is four months old now. It’s very important to keep the baby clean and healthy. I do not let her play in the mud and if she touches some rubbish then I must wash her hands with soap and water. Along with this, I have to keep the utensils clean in the kitchen.

In the same way I have to keep her clothes clean and the room also has to be kept clean. I have to eat clean and hygienic food. I have to give her a bath and put her in warm, clean clothes. 

We also shouldn’t defecate in an open area as it makes our surroundings dirty.”