THE HANDWASHING HANDBOOK A guide for developing a hygiene promotion program to increase handwashing with soap The Handwashing Handbook A guide for developing a hygiene promotion program to increase handwashing with soap TABLE OF CONTENTS FOREWORD 5 EXECUTIVE SUMMARY 7 INTRODUCTION 8 Context and Purpose of This Handbook The Leading Causes of Child Mortality Handwashing with Soap: The Most Effective Vaccine Against Childhood Infections? The Challenge of Handwashing Promotion What's New about This Approach? SECTION 1 13 Laying the Foundation for a National Handwashing Program Getting Started: Is This the Right Place at the Right Time? Conducting a Rapid Situation Analysis Public-Private Partnerships Making the Case for Handwashing Making the Case to Government Making the Case to Industry Making the Case to Financiers Financing Issues Organization and Coordination SECTION 2 21 Understanding the Consumer The Marketing Approach Understanding Behavior Designing and Implementing the Consumer Research Managing and Supervising the Consumer Research Analysis and Reporting of the Results 2 The Handwashing Handbook SECTION 3 33 Program Implementation Designing the Campaign Applying the Marketing Mix Developing the Promotion Target Audiences and Segmentation Agencies, Concepts, and Testing Multiple Strategies for Behavior Change Public Relations and Advocacy The PR Plan The Media Mix Monitoring and Evaluation SECTION 4 43 Program Organization The Partnership Mix A General Partnership Model The Business Plan CONCLUSION 49 REFERENCES AND RESOURCES 51 TOOLS AND TERMS OF REFERENCE 53 ABBREVIATIONS 76 The Handwashing Handbook 3 LIST OF TABLES AND FIGURES Figure 1: Distribution of Global Child Deaths by Cause Figure 2: The F-Diagram: Major Transmission Routes of Fecal-Oral Diseases Table 1: Observed Rates of Handwashing with Soap Around the World Table 2: SWOT Analysis Factors Table 3: SWOT External Factors Box 1: The Cost-Effectiveness of Handwashing Programs Box 2: The Central American Initiative Figure 3: Consumer Research Process Figure 4: Drivers, Habits, and Environment in Behavior Change Box 3: Cultural Beliefs Inhibiting Handwashing with Soap in Senegal Table 4: Drivers, Habits, and Environments for Handwashing with Soap (Four Areas) Table 5: Identifying Barriers and Drivers to Handwashing with Soap at Key Events Box 4: Ghana Consumers Prefer Multipurpose, Long-Lasting Soaps at Economy Prices Figure 5: How Mothers Communicate in Kerala, India: Monthly Contact Profile Box 5: A Note on Schools Table 6: Summary Design for Consumer Research Box 6: Outline of Study Methods Box 7: Key Points for Contracting Consumer Research Box 8: Consumer Research: The Rational Bias Box 9: The Perfect Brief Table 7: Advantages and Disadvantages of Different Approaches to Communication Box 10: A Lesson in Public Relations: Handwashing in Kerala, India Table 8: The Ghana National Handwashing Initiative: Phase 1 Evaluation Results (in Percentages) Figure 6: Monitoring and Evaluation: Program Activities and Impact Box 11: Handwashing in Action: The Handwashing Partnership in Peru Box 12: Private Sector Handwashing Activities Box 13: Elements of the Business Plan 4 The Handwashing Handbook FOREWORD Hygiene is essential to the public health mission of reducing the transmission and consequences of disease. The sharp decline in deaths from infectious diseases observed in wealthy countries last century could not have been achieved without vastly improved public hygiene. Raising living standards allowed people to become more hygienic once clean water was piped into their homes, and soap became cheap enough to put at every sink. Eventually, the collective efforts of both the public health movement and private industry ensured that clean hands, clean homes, and clean lives, became a social norm. Unfortunately, the story in poor countries could not be more different. By the end of the 20th century, two billion people still had inadequate access to sanitation, and one billion were without enough clean water to drink. Efforts at promoting effective hygiene have been piecemeal and ineffective. Though industry has succeeded in getting soap into almost every home, it has not consistently promoted good hygiene or handwashing to accompany their products. This is a missed opportunity for public health. The two biggest killers of children in the developing world today are diarrheal disease and respiratory tract infections. The simple act of washing hands with soap can cut diarrhea risk by almost half, and respiratory tract infection by a third. This makes handwashing a better option for disease prevention than any single vaccine. If developing countries are to achieve their 2015 millennium development targets for reductions in child mortality, this unfinished agenda of the 20th century must be completed. Not only must water and sanitation become universal, but so must the habit of handwashing with soap. This requires Ministries of Health, Education, and Water, in addition to non-governmental organizations (NGOs) and community-based groups, to exploit every opportunity to promote handwashing with soap. Moreover, private industry, which played such a large part in creating standards of good hygiene in rich countries, can do the same as it expands its business in developing countries. Handwashing with soap can and must become commonplace in developing countries. To do this we have to: ! Make sure everyone knows the importance of handwashing ! Build alliances between the public and the private sectors ! Mobilize the necessary resources and expertise ! Use proven high-impact communications outreach to promote handwashing to a mass audience ! Demonstrate that measurable changes in behavior can be achieved cost-effectively. In a noisy world of competing messages aimed at people from all directions, only the most effective, best-designed campaigns will lead to behavior change. This handbook seeks to meet this challenge. It describes a new approach to handwashing promotion, building on the pioneering work of the Public-Private Partnership for Handwashing with Soap. It explains how the latest thinking in industrial marketing can be combined with the latest research in public health to provide powerful new insights to drive effective handwashing campaigns. It offers lessons from national programs in Ghana, Peru, Senegal, and other countries. Early indicators suggest that this may be the start of an exciting new field in public health in the 21st century. Several members of the Global Public-Private Partnership for Handwashing Initiative must be acknowledged for making this handbook possible. We would especially like to thank Beth Scott, Val Curtis, and Jason Cardosi for compiling this guide. We are grateful to Ali Diouf, Rocio Florez, and Nana Garbrah-Aidoo for providing country examples. Special thanks go to Peter Kolsky, Mariam Claeson, Stéphane Legros, and Nancy Lee for their in-depth peer reviews. Valuable contributions were also made by Steve Luby, Eckhard Kleinau, Suzanne Reiff, Camille Saade, Myriam Sidibe, Barbara The Handwashing Handbook 5 Evans, Sandy Callier, Joana Godinho, Wendy Wakeman, Merri Weigner, and Henk Van Norden. The private sector partners, Yuri Jain from Hindustan Lever, Diana Grina from Colgate-Palmolive, and Tim Long from Procter and Gamble, provided expertise and technical advice. Finally, we would like to acknowledge the guidance and leadership provided by the Task Team Leaders, Jennifer Sara and Param Iyer. Jamal Saghir Jacques Baudouy Director, Energy and Water Director, Health, Nutrition and Population 6 The Handwashing Handbook EXECUTIVE SUMMARY Handwashing is one of the most effective means of preventing diarrheal diseases, along with safe stool disposal and safe and adequate household water supply. Evidence suggests that improved handwashing can have a major impact on public health in any country and significantly reduce the two leading causes of childhood mortality ­ diarrheal disease and acute respiratory infection. Because handwashing with soap can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine or hygiene behavior. Promoted broadly enough, handwashing with soap can be viewed as an essential do-it-yourself vaccine. Almost every household in the world, regardless of economic status, has soap. Handwashing with soap at key times, however, is not widely practiced. If the millennium development targets for reduction in child mortality are to be met, handwashing habits must be improved along with access to safe water and sanitation. The Global Public-Private Partnership for Handwashing has brought together various organizations and sectors to promote handwashing with soap on a large scale. The partnership includes: ! governments who, by prioritizing hygiene, enable handwashing to move from piecemeal, village-by-village, efforts to national programs; ! donor organizations who increasingly include handwashing in their water, sanitation, health, and education programs; ! the private sector which has brought state-of-the art marketing knowledge and techniques to the table; ! academic and scientific organizations who are contributing the latest behavior change theory and scientific evidence of the effectiveness of handwashing; and ! non-governmental and community-based organizations who are aiming to integrate handwashing messages into their own work programs. The Handwashing Handbook lays out the experiences of this global partnership in a practical guide. While countries are still optimizing and experimenting with approaches, it is important to disseminate what is currently known. This way others can begin designing programs and contributing to the global body of knowledge and experience in the fight against child mortality. This guide is for staff in governments and development organizations charged with carrying out handwashing programs. Decision makers in ministries and funding agencies will also find assistance in this book for designing policies and programs to improve public health. The approach to large-scale handwashing promotion covers the following components: Laying the Foundation for a National Handwashing Program To be successful, handwashing programs must address a recognized health need and have the support of key stakeholders. Government, industry, and donors can all offer unique resources which are necessary to ensure the success of a large-scale program. Conducting a situation assessment and, where needed, making the case for handwashing on topics ranging from cost- effectiveness to health impact will give the handwashing program a solid foundation. Understanding the Consumer In order to change long-held habits related to behaviors such as handwashing, a firm understanding of the factors the drive and facilitate behaviors in target consumers must be established. This means putting the needs of the target audience ­ primarily mothers and caretakers of children under five years old as well as school-aged children ­ at the center and having their perspective determine the nature and scope of all promotion activities. Carrying out consumer research provides a baseline for measurement and understanding of the target audience by answering four broad questions: What are the risk practices? Who carries out the risk practices? What drivers, habits, and/or environmental factors can change behavior? How do people communicate? Program Implementation The results of consumer research drive program implementation including which environmental factors related to handwashing need to be addressed, what is the most appropriate and appealing way to promote handwashing, and what is best mix of communication channels to reach the target audience. Implementation also includes the careful monitoring of the program and periodic evaluation and adjustment. Program Organization When partners from different backgrounds and sectors are not accustomed to working together, establishing common aims and trust takes time and effort. Placing a program coordinator in a trusted organization is an effective approach to steering diverse partners towards a common objective. Throughout the handbook, references, case study information, and tools are provided to support handwashing programs. Users are encouraged to combine their creativity with existing knowledge in order to innovate and optimize approaches to large-scale handwashing promotion. The Handwashing Handbook 7 INTRODUCTION Purpose of This Handbook This handbook grows out of the experience of the Global Public-Private Partnership for Handwashing with Soap (PPPHW) and its predecessor, the Central American Handwashing for Diarrheal Disease Prevention Program. These efforts demonstrated that mass programs with public and private sector involvement can be successful in promoting handwashing and reducing disease. With core support from the Bank Netherlands Water Partnership, the PPPHW has brought together global public and private agencies to consolidate approaches while initiating large-scale handwashing promotion in Ghana, Peru, Senegal, and Nepal. While much has been learned about handwashing promotion in recent years, especially in the areas of research and program design, countries are still experimenting with, and optimizing approaches to implementation. It is important to lay out what is known so that others can begin designing programs and contributing to a global body of knowledge and experience in the fight against child mortality. This handbook is intended for staff in government and development organizations charged with carrying out handwashing programs. Decision-makers in Ministries and funding agencies will also find assistance in designing policies and programs to improve public health. Context Handwashing is one of the most effective means of preventing diarrheal diseases, along with safe stool disposal and safe and adequate household water supply. This handbook focuses entirely on handwashing and advocates for stand-alone handwashing-with-soap programs. It is not the intention of this guide to detract from hygiene behaviors other than handwashing. On the contrary, each has a place and should be addressed distinctly, carefully, and in the right context. However, it is axiomatic in communications programs that messages have to be single and simple: economies of scale do not operate at the level of message delivery. For example, conveying two messages in a single communication reduces the effectiveness of each by half. Consequently, lumping the three key hygiene behaviors together is inadvisable. The handwashing promotion approach described in this book involves careful consumer research followed by up-to-date marketing efforts. This approach adapts itself well to other health issues, and lessons learned from carrying out a handwashing program could clearly be applied to other programs using similar technical and institutional approaches. Current efforts to promote good hygiene, including handwashing, have not been sufficient to engender mass behavior change. Many public health programs include improved hygiene among their objectives: in any country at any time, one might find a diarrheal disease control program, a school health education program that includes hygiene, a water supply and sanitation program that invests in raising hygiene awareness, and sporadic local-level hygiene education. All these efforts share the weakness of treating hygiene as a side issue, rather than a central one. Sufficient resources are lacking; imagination, human skills, and enthusiasm are not fully engaged; and the approaches may be outdated. No one agency champions hygiene, and financing bodies do not see its importance. Objectives committed to paper are never fully operationalized, resourced, evaluated, or monitored. Successes have largely been confined to individual villages, achieved by approaches that cannot be scaled up countrywide. Worse, confusion reigns at the most basic level as to what good hygiene is: different actors define it differently, and prejudice and local preference take precedence over evidence. The approach outlined here aims to resolve all of these problems: it raises awareness, enhances political commitment and resource allocation for hygiene, offers a route to a coordinated national program, combining them all under one umbrella. It also uses high-profile and up-to-date methodologies to change the hygiene behavior which consistently demonstrates the greatest potential impact on overall public health; handwashing with soap. 8 The Handwashing Handbook Just as every child has a right to vaccination, each should also have the right to protection from hand- transmitted disease. This means simply washing hands with soap after using the toilet or cleaning a child and before handling food. The Leading Causes of Child Mortality The World Health Organization (WHO) estimates that diarrhea and respiratory infections are responsible for two- thirds of child deaths (figure 1). UNICEF estimates that diarrhea alone kills one child every 30 seconds. The vast majority of child mortality occurs among the world's poorest populations in low- and middle-income countries. Figure 1: Distribution of Global Child Deaths by Cause Measles 2% Other 13% Diarrheal AIDS Diseases 5% 35% Malaria 13% Acute Respiratory Infections 32% Source: WHO 2001 Handwashing with Soap: The Most Effective Vaccine against Childhood Infections? Human feces are the main source of diarrheal pathogens. They are also the source of shigellosis, typhoid, cholera, all other common endemic gastro-enteric infections, and some respiratory infections: just one gram of human feces can contain 10 million viruses and one million bacteria. These pathogens are passed from an infected host to a new one via various routes, as shown in figure 2. While the routes are numerous, they all emanate from one source: feces. While secondary measures (food handling, water purification, and fly control) may have an impact, far more important are the primary barriers ­ sanitation and handwashing ­ after fecal contact. These barriers prevent fecal pathogens from reaching the domestic environment in the first place. Handwashing interrupts the transmission of disease agents and so can significantly reduce diarrhea and respiratory infections, as well as skin infections and trachoma. A recent review (Curtis and Cairncross 2003) suggests that handwashing with soap, particularly after contact with feces (post-defecation and after handling a child's stool), can reduce diarrheal incidence by 42-47 percent, while ongoing work by Rabie et al. suggests a 30 percent reduction in respiratory infections is possible through handwashing. This remains true even in areas that are highly fecally contaminated and have poor sanitation. Another current study found that children under 15 years living in households that received handwashing promotion and soap had half the diarrheal rates of children living in control neighborhoods (Luby et al. 2004). Because handwashing can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine. Promoted on a wide-enough scale, handwashing with soap could be thought of as a `do-it-yourself' vaccine. The Handwashing Handbook 9 Figure 2: The F-Diagram: Major Transmission Routes of Fecal-Oral Diseases Fields Fluids New Feces Foods Host Flies Fingers Source: Wagner and Lanois, 1958 Feces are the source of diarrheal pathogens, microscopic `bugs.' As the figure shows, these bugs enter the environment if not disposed of safely, and are then spread by the four F's: flies, on fingers, in fluids, and via surfaces, such as fields. Cutting these routes of transmission is key to the prevention of diarrheal disease, but which of the many possible hygiene practices would eliminate the most disease? Boiling or sterilizing water in the home would reduce diarrhea, but preventing fecal pathogens from ever reaching household water is likely better and more cost-effective. Similarly, foods should clearly be reheated carefully to kill any bugs that multiplied during storage, but preventing fecal pathogens from ever reaching food is more effective. Two key actions isolate fecal material and prevent its reaching the environment and then the four F's. These actions are adequately disposing of adult and child feces and handwashing with soap after touching feces. Such touching occurs after using a toilet or when cleaning a child after defecation. Some respiratory tract infections, including the SARS-causing coronavirus, are also transmitted via the fecal-oral route or simply on hands, so handwashing helps prevent these infections as well. How should hands be washed? The evidence suggests that soap ­ any soap ­ and water adequately remove microbe-containing dirt from hands. Antibacterial soaps or other hand-sanitizing technologies have no additional advantage. Hands have to be fully covered with soap and then rinsed off. 10 The Handwashing Handbook The Challenge of Handwashing Promotion If handwashing with soap is so important, why doesn't everyone do it? Table 1 suggests that worldwide rates of handwashing with soap are very low. While many wash their hands with water, only a small percentage use soap at critical times. Table 1: Observed Rates of Handwashing with Soap Around the World Setting Handwashing with Soap Prevalence Reference Kerala State, India After defecation 34 percent PPPHW After cleaning up a child 35 percent Ghana After defecation 3 percent PPPHW After cleaning up a child 3 percent Peru After defecation 6 percent PPPHW After cleaning up a child 30 percent Senegal After defecation 31 percent PPPHW After cleaning up a child 26 percent Kolkata, India (slums) After defecation 16 percent Sircar et al. 1996 Kyrgyzstan (rural) After cleaning up a child 0 percent Biran 1999 After using a toilet 18 percent Nigeria (rural) After cleaning up a child 10 percent Omotade et al. 1995 Burkina Faso (urban) After cleaning up a child 13 percent Curtis et al. 2001 After using a toilet 1 percent Brazil (childcare centers) After cleaning up a child 16 percent Barros et al. 1999 Lima, Peru (shanty town) After defecation 12 percent Gilman et al. 1993 (soap use `rare') Northern England (peri-urban) After cleaning up a child 47 percent Curtis et al. 2003 Note: All prevalences are observed, except Sircar et al., which used soap measurements. The Handwashing Handbook 11 The cause of low handwashing rates is rarely a lack of soap. Soap is present in the vast majority of households worldwide, but it is commonly used for bathing and laundry, not handwashing. Lack of water is usually not a problem either, as hands can be effectively washed with little, or recycled, water. In studies around the world, the main reason given why rates of handwashing with soap are so low is that it is simply not a habit. The challenge remains ­ to make handwashing with soap a habit and a social norm on a worldwide basis. What's New about This Approach? This handbook outlines how handwashing behavior can be changed on a large or national scale by providing lessons from industrial marketing approaches as well as from current public health thinking. Its core feature is a focus on the potential handwasher as a consumer, who has many choices to make. With the handwasher as the focal point, this handbook explains how to: ! Research consumer needs to delve into handwashing habits, barriers and drivers of behavior change, and the best ways to communicate to the target audience; ! Design appropriate and appealing messages; and ! Implement a promotion program that makes use of all suitable channels, including outreach workers, citizen networks, special events, soap distributors, schools, and mass media. Section 1 of this handbook describes the foundations for a national handwashing program. Section 2 discusses how to understand consumers so that the handwashing campaign can be designed around their reality. Section 3 explains how new insights can become a campaign that is effective in changing handwashing behavior. Section 4 outlines the organization of a handwashing program, providing information that spans the other stages; it is designed to be read in parallel with previous sections. The annex provides examples of tools, such as study instrument and terms of reference. 12 The Handwashing Handbook SECTION 1 Laying the Foundation for a National Handwashing Program CURTIS VAL The Handwashing Handbook 13 SECTION 1. Laying the Foundation for a National Handwashing Program Getting Started: Is This the Right Place ! Firms are looking to enhance their profile and at the Right Time? corporate image. A strong handwashing program can make a big contribution to public health, but building that program Donors and Other Partners takes time, resources, effort, and commitment. To be ! There are programs in health, water, sanitation, or successful, handwashing programs must address hygiene within which handwashing could fit; a recognized health need and have the support of key stakeholders. ! Donor organizations are looking to develop new models of partnership; Conducting a Rapid Situation Analysis ! NGOs can integrate handwashing into existing A situation analysis can determine whether a country programs; and has a supportive environment for a handwashing program and whether champions exist or can be created in ! Others, such as healthcare providers, water government, among donors, and in the private sector. companies, and religious and community groups, are looking to play a major role in public health. The first determinant of success is a health need, such as: The likelihood of a successful, large-scale, and timely program will increase with the number of factors that ! Diarrheaandrespiratorytractinfectionsaresignificant exist or can be created. causes of morbidity and mortality; ! Rates of handwashing with soap at key junctures are Public-Private Partnerships low, or at least suspected to be; or Because both the public and private sectors have an interest in promoting handwashing, country programs ! Cholera,typhoid,orSARSisrecognizedasaproblem. usually take the form of a public-private partnership If a health need exists, assessing interest and capacity (PPP). While the public sector can be wary of working within key stakeholder groups will help determine the with industry and the private sector skeptical that working viability of an initiative and how it can best be organized. with government would produce significant results, both Typical groups and issues to consider include: sectors stand to gain from cooperation. First, industry typically invests a significant portion of its Government energiesintounderstandingtheconsumerinordertomake ! ThecountryhascommittedtomeetingtheMillennium and promote appropriate products. Hygiene promotion Development Goals (MDGs) and has a Poverty programs generally lack this expertise, which is not widely Reduction Strategy; available in the public sector. ! Water, sanitation, and hygiene are government Secondly, industry has already brought soap for bathing priorities; and and laundering into over 90 percent of households worldwide, showing how successful it can be at making ! Potential champions exist in Ministries of Health, soap and its accompanying behaviors almost ubiquitous. In Education, and Water. developed countries, industry was instrumental in changing domestic hygiene practices; it can do the same in poorer Industry communities while benefiting from market expansion. ! A soap market exists; The private sector stands to gain from a PPP, mostly ! There is room for growth in the soap and related through market expansion. In addition, the benefits of industries (e.g., plastics companies producing water being seen as contributing to social goals and of being at tanks), especially in poor market segments; and the table with development partners and international 14 The Handwashing Handbook experts can also be substantial. In addition, many soap Where skepticism might deter private sector company executives are glad to be involved in efforts to involvement, it may be advantageous to label a public- improve social well-being. private partnership an `Alliance for Handwashing.' In summary, the public sector gains from the marketing expertise and resources of industry. Teamed, both parties Making the Case for Handwashing can produce public health campaigns that rival ­ or surpass If a handwashing program is to succeed, advocates will ­ industrial marketing efforts. have to sell the idea to stakeholders, including government, industry, and potential funders. A SWOT Industry is already making efforts to promote handwashing (strengths, weaknesses, opportunities, and threats) as part of ongoing marketing or social responsibility analysis can determine which factors need to be programs. Colgate-Palmolive, Procter and Gamble, and addressed when engaging these stakeholders. First, the Hindustan Lever have school-based programs in many SWOT analysis looks at factors that can potentially be countries that educate children about handwashing (see controlled by the stakeholders as potential partners in box 11 for details). Such companies may already be the initiative (table 2). converts to the handwashing message and ready to participate in partnerships with the public sector. Issues Second, external factors are assessed. These factors of branding and exclusive rights will often need to be are outside the influence of the initiative but may discussed and agreed upon. have a positive or negative impact on the target audiences. Table 3 will help an initiative develop a Other industries may be willing and able to contribute list of external factors. resources, expertise, or in-kind contributions to PPPs. These sectors include the water industry, media Third, stakeholders can be engaged in partnership in order companies, manufacturers of tanks and pipes, and to address weaknesses, build strengths, recognize transport companies, etc. For example, in Ghana, opportunities, and mitigate threats. Polytank, a plastics company that manufactures water storage tanks, intends to provide tanks to schools at cost Making the Case to Government or lower. Companies that do not contribute directly Key issues that will drive government interest are the might be encouraged to carry the handwashing message scale of the health problem and links to targets such as on their products, such as on soap, handwashing buckets, the MDGs, the economic costs of disease caused by not or toilet paper rolls. This increases the intensity of the washing hands, links to poverty reduction, and costs of handwashing message in the environment. treatment and work time lost. REIFF SUZANNE The Handwashing Handbook 15 Table 2: SWOT Analysis Factors Factors within Sphere of Control Strengths Weaknesses Sources of funding Experience Expertise Ability to reach and serve target audiences Management and political support Issue priority for the organization Current alliances and partnerships Others Table 3: SWOT External Factors External Factors Opportunities Threats Cultural forces (including trends and events that affect the country's values and norms) Technological forces (noting the potential for new technologies that might be leveraged) Demographic trends (relevant to the campaign) Economic forces (that could impact success) Political and legal forces (that may affect campaign efforts or target audiences) External publics (groups outside the initiative and its alliances that could have an impact on the target audience or the plan) 16 The Handwashing Handbook Investigating these issues will produce the arguments to As mentioned, industry can, and should, play a key role convince decision-makers to support handwashing in promoting handwashing in the countries where it is programs. Good sources for information on disease rates most needed. Attracting industry support has not always include national community-based surveys, such as proved as straightforward as expected. When economic Demographic Health Surveys. (Health facility reporting times are good, soap companies have some latitude in is a poor data source because it fails to capture a spending, but during downturns, all available resources community's infectious disease rates.) The costs to society tend to be targeted at brand support. and to an economy of not washing hands can be estimated by calculating the cost of (a) treatment for hand-borne Because the current PPP model proscribes the use of infections; (b) working days lost; and (c) deaths due to branding in programs with public funding, industry's diarrhea and respiratory infection. In addition, a national interest is reduced. program can save money by replacing piecemeal hygiene The problem can be resolved on several fronts. High- promotion activities with a broader, more cost-effective level, headquarters commitment and support may be approach (see box 1). essential to ensure commitment of funds and technical Water and sanitation programs are attractive to resources at country level. Companies often ask for an governments because they involve the purchase and exclusive deal with the partnership in return for substantial installation of hardware. It can be very difficult to make support. It may be possible to unlock this source of the case that some of this funding be diverted to what is resources by splitting particular activities and allowing seen as a `soft' issue, that of handwashing. Though some branding within them. So, for example, in Ghana, Unilever international organizations and governments are swinging might support a schools program and PZ-Cussons a towards increased investment in hygiene, acceptance is maternity hospital bounty-pack scheme. slow. Advocacy efforts as to the relative importance of the software issues have to be made repeatedly and at Making the Case to Financiers every opportunity. Though they technically work through governments, external support agencies often have their own agendas Making the Case to Industry andusuallytheirownfundingcycles.Ashandwashingmoves Though industry likes to be a good citizen, what drives up the international list of priorities, more and more country-level activities is profit. Industries invest time, organizations are preparing to invest in handwashing expertise, and resources where they see a potential promotion. To obtain donor support, it is important to profit. It is therefore vital to make estimates of determinedonors'priorities,wheredecision-makingability potential growth in the whole soap market. For lies, and the mechanisms for obtaining funding. example, one could estimate that each handwashing Decision-making about the use of funds from bilateral event uses 0.5 grams of soap; this factor can be agencies, such as the Danish International Development multiplied by the population of the target area, the Agency (DANIDA) and the United Kingdom Department average number of times a person would wash hands for International Development (DFID), is increasingly each day, and the number of days in the period being devolved to the national level, and accessing them may considered. The resulting estimate would show how require lobbying at local, government, and international much more soap could be sold to each individual. Note levels. Multilateral agencies, such as the United Nations that the soap brands that may benefit include laundry Children's Fund (UNICEF), may have programs that can bars and locally made soaps, not just toilet soaps or support handwashing in parts of a country. Lastly, special handwashing formulations. World Bank loans for water and sanitation may specify expenditure on hygiene. Other potential benefits to industry include being able to extend or stretch existing brands, grow existing handwashing brands, raise visibility, and Financing Issues improve political contacts. Businesses, both small and Initially, funds are needed to cover the costs of a program large, will also benefit from the market research and start-up, which usually entails an individual and/or international contact. Multinationals may see a wider organization spearheading the initiative and acting as a benefit of participating in a PPP, and involving the coordinator. Funds are next needed for consumer international headquarters can help drive country- research and then to hire a communications agency. The level investment. agency needs a budget for mass media, direct consumer The Handwashing Handbook 17 18 The Handwashing Handbook contact, and government-based programs, so and donors have few existing budget lines for such commitments for funding should be in place early. nontraditional activities. However, it may be possible to Fundraising is discussed as part of advocacy and public tap into a government or agency desire to be seen as relations efforts in sections 3 and 4. being proactive, especially when there is a perceived threat to national health, such as a cholera outbreak or Financing mass media activities has been particularly natural disaster. Similarly, agencies may be more challenging in several countries. The private sector has forthcoming with support if they are offered visible credit little spare cash not otherwise earmarked. Governments on promotional materials. Box 1: The Cost-Effectiveness of Handwashing Programs Health projects rarely focus on handwashing to policy makers are now, theoretically, able to improve value-for-money. However, there is calculate and change some original assumptions on mounting international evidence that hygiene, the effectiveness of the initiative. This can be sanitation, and health investment focused on achieved by establishing control groups to isolate handwashing and other health promotion programs the intervention and calculate disease reduction in are among the most cost-effective investments that the intervention area. canbemadewithpublicandprivateresources.Esrey (1991), for instance, demonstrated that hygiene The main results from the cost-benefit analysis promotion is often required for water supply and indicate that both handwashing initiatives save costs sanitation projects to have an impact on health. for their respective societies. The net present value (NPV) of benefits for The Central American Project A recent handwashing cost-effectiveness study is US$4.3 million in the base scenario with an developed a standardized methodology for internal rate of return (IRR) of 226 percent. For performing an economic analysis of handwashing the Peru initiative, the NPV of benefits represents interventions. First, a cost-effectiveness analysis US$8.1 million, with an IRR of 533 percent. of handwashing initiatives is conducted to establish Sensitivity analyses in both cases remain positive comparisons with the effectiveness of other and confirm the cost savings of these projects. health-related projects and with projects in other sectors. A cost-benefit analysis of handwashing The comparisons that are established reveal that initiatives is then prepared to compare their handwashing initiatives do not represent greater impact in a broader context. burdens for Ministries of Health and that the contribution of private partners is recommended This methodology found that the Central American for mutual benefits. Promotion of the initiatives Handwashing Initiative (see box 2) is cost-effective, and future participation of private actors is possible preventing diarrhea for less than US$10 per case with an estimate of benefits for each partner with and averting a cost per DALY* of US$91.30. Even respect to the investment. While the Central without the intervention, the presence of soap, American initiative demonstrates that the presence water, and certain equipment in these countries is of soap is almost universal, soap use still needs to generally high, so the economic analysis can discount be improved, recommending an appropriate these costs, thereby lowering the private costs. handwashing campaign that would incidentally The sensitivity analysis reveals that even increase soap sales. considering a lower rate of reduction of diarrhea, the handwashing initiative remains cost-effective. * DALY, Disability Adjusted Life Year, is the quantitative indicator of burden of disease that Estimates made with this methodology for the reflects the total amount of healthy life lost, Peruvian Handwashing initiative (see box 10) during whether from premature mortality or some 2003 show that preventing a case of diarrhea here degree of disability during a period of time. also cost less than US$10, and the cost per DALY averted was US$122.70. With this evaluation, Extracted from Cercone et al. 2004 The Handwashing Handbook 19 Box 2: The Central American Initiative The Central American Handwashing Initiative was ! Ten percent of mothers improved from an designed to reduce under-five morbidity and `inadequate stage' of handwashing to either the mortality through a campaign to promote `intermediate' or `optimal' stage. handwashing with soap to prevent diarrhea. Carried out in five countries, the initiative consisted ! A 10 percent decline in the number of mothers primarily of a PPP that included a number of public who agreed with the inaccurate statement: "Most players and four private sector soap producers. The times washing hands with water is sufficient." initiative promoted increased access to soap by distributing free samples, conducting promotional ! A10percentincreaseinthenumberofmothers and educational events, and sponsoring media who agreed with the statement: "When I don't activities to convey information on the link between use soap, I feel that I am not clean." hygiene and diarrhea prevention. Extrapolating from these and other findings and The public sector provided technical support and from literature on the relationship between market research to soap companies, supported handwashing and the prevalence of diarrhea, it was advertising agencies' involvement, and helped form a task force to coordinate and direct the efforts of estimated that "over the course of the intervention the various players. In the end, the greatest there was a 4.5 percent reduction in diarrheal contribution of the program may have been the prevalence among children under five." model it presented for establishing how public Source: Environmental Health Project (EHP), UNICEF/ health goals can be compatible with business goals. WES, United States Agency for International In Guatemala, where the work was most carefully Development (USAID), and World Bank/WSP and documented, the initiative resulted in: WSSCC, May 2004 Organization and Coordination or neutral party and provide drive; enthusiasm; skills in If an assessment finds favorable conditions, a first meeting marketing; and knowledge of public health, management, or workshop with potential stakeholders will help to and communications. The coordinator could be in a public consolidate ideas and interest. The agenda might include agency, a private sector body (such as the local soap experts outlining the importance of handwashing; a manufacturer's umbrella organization), an agency, or sharing of initial visions and expectations of potential NGO. In Central America a catalyst organization was stakeholders; and the establishment of initial set up to bring together public and private partners and commitments, partnership structures, and milestones. eventually phased itself out (see box 2). When setting out the vision and leading the program, it This section has outlined key aspects of starting a helps to have a country coordinator or catalyst. This program. Further details about management and structure individual or organization should be viewed as a legitimate can be found in section 4. 20 The Handwashing Handbook SECTION 2 Understanding the Consumer The Handwashing Handbook 21 SECTION 2 Understanding the Consumer The Marketing Approach Understanding Behavior Once a platform for developing the handwashing work Consumer needs are many and varied. They may include has been established and consensus reached on the desire to be respected, to be clean, to feel moving forward, the focus then shifts to the potential comfortable and fresh, and to provide the best for their handwashers, called "consumers" in marketing families. While health may seem an obvious need from terminology. The only way to change long-held habits the point of view of the health professional, it may not related to behaviors such as handwashing is to have a be the overriding or constant concern of the consumer. firm understanding of the factors that drive and Industry invests heavily in understanding consumers' lives, facilitate handwashing in target consumers. The desires, and the ways they communicate in order to develop and deliver appropriate products and promotional marketing approach means putting the needs of the messages. To market handwashing successfully, the target audiences at the center and having their following four questions about consumers must be perspective determine the nature and scope of all answered: promotion activities. ! What are the risk practices? Satisfaction of desires is at the core of marketing. According to Northwestern University Marketing ! Who carries out risk practices? Professor and author Philip Kotler, "Marketing is satisfying ! What drivers, habits, and/or environment can change needs and wants through an exchange process." behavior? Marketers thus offer the consumer something that they want and that they are prepared to make sacrifices for, ! How do people communicate? either through expenditure of money, time, or effort. The answers to these questions provide the key elements The heart of the marketing task is thus to find out what of consumer research. The process combines the insight consumers want and then to offer it to them in a way of experts in consumer behavior, health, and handwashing that will make it most attractive. with the intelligence provided by consumers (figure 2).1 Figure 3 Consumer Research Who carries Process out risk Target practices? audiences What are Target handwashing Consumers' handwashing practices? views practice What can Drives, change Experts' habits, behavior? views facilitators How do people Media mix communicate? 1Tools (such as Structured Observations and Behavioral Trials), formats, and terms of reference (TORs) referred to in this section can be found in the annex. 22 The Handwashing Handbook habit drivers environment Figure 4: Environment, Habits, and Drivers 1. Who carries out risk practices? Handwashing programs frequent handwashing is clearly protective against target those groups whose handwashing behavior can respiratory illness as well. have the largest impact on disease reduction: this is usually the caretaker who provides the child's `hygiene It is essential to have reliable data on actual rates of environment.' In most settings the primary caretaker is handwashing with soap in any particular setting in order the mother of the young child; however, it is important to determine the scale of the problem and set to document who else participates ­ grandmothers, quantitative improvement targets. Such baseline data sisters, fathers in some societies, aunts, etc. School-age also provides a point from which to measure change in children may also form a target audience, not so much handwashing habits over the life of a proposed program. because they too may provide childcare, but because Unfortunately, actual handwashing behavior is very hard they are the caretakers of the future. Furthermore, they to assess reliably. Handwashing habits are generally are more susceptible to behavior change and the uptake private and are `morally bound': people fear they will of new healthy habits. They can also act as enthusiastic be judged harshly if they admit to a weakness in their handwashing advocates. Sometimes secondary target audiences (neighbors, fathers in some societies, elder hygiene practices. Asking people if they wash their children, extended family) will also be addressed because hands with soap consistently results in overestimates of their influence on the primary audience. For example, of actual behavior. For example, in Ghana 75 percent in some societies husbands decide how much to spend of mothers claimed to wash hands with soap after toilet on soap or serve as the purchaser of these goods for use when asked, but structured observation showed their household. that only 3 percent did so. The only feasible and reliable way to obtain a valid measure of handwashing practice 2. What are the risk practices? As noted, handwashing is through direct observation, which requires a trained after contact with feces is usually the best way to observer spending several hours in the home, observing reduce the risk of fecal-oral transmission of gastro- and recording events of interest in someone's home. enteric pathogens. However, because this practice is Well-trained and supervised fieldworkers are required unlikely to ever be universal and because sanitation for consistent and reliable results. may also be poor, it is also important to wash hands with soap before contacting, eating, or feeding food. 3. What can change behavior? Three key forces are This means that handwashing at three junctures is involved in behavior change: drivers, habits, and the critical: after using the toilet, after cleaning up a child environment, which can facilitate or hinder behavior who has defecated, and before handling food. While change. As figure 4 illustrates, moving behaviors the important junctures for handwashing to prevent from one point to another requires one or more respiratory infection have not been identified, more of three things: The Handwashing Handbook 23 ! Lowering barriers in the environment so as to While habits are often learned at an early age, there are facilitate change; opportunities for change, especially at life-changing events. A key event for mothers is the birth of a baby. ! Transforming old habits into new ones; and Many mothers report that hand hygiene did not become ! Finding drivers that can create new habits. important to them until a baby was born and that if midwives or others involved with perinatal care Figure 4: Environment, Habits, recommended handwashing with soap, it would likely and Drivers take hold. Another life-changing event for many mothers is moving to the husband's home after marriage and Consumer research delves into the consumer psyche to learning the habits of the new household. identify the deep desires and motives that can drive behavior change, determine the source of habits and Habits are best documented using structured observations investigatehowbesttointroducenewones,andtoexplore (tool 2). Their origins can be explored through in-depth the factors in the environment that hinder or facilitate interviews and the process of taking on new habits behavior change. These can be established using a variety understood in behavior trials. of tools, including behavior trials and in-depth interviews. Drivers are innate and learned modules in the brain that Environmental facilitators and barriers are factors that motivate particular behaviors. They come in the form of enable or hinder the act of handwashing with soap. emotions and the feelings that people report when Facilitators might include easy access to water and the carrying out particular behaviors. Discovering drivers is low cost of soap. Barriers might include prohibitively key to successfully promoting handwashing. expensive or unattractive soap, lack of handwashing facilities, and strong cultural prohibitions against washing As with risk practices, determining drivers can be difficult on certain days. Box 4 outlines the importance of specific because (1) they may be buried in the subconscious attributes of soap in Ghana that make it acceptable (Zaltman 2003); and (2) there may be perceptions of for handwashing. shame or embarrassment in reporting them, for example, using soap to heighten sexual attractiveness. Zaltman Quantitative surveys provide basic information about the suggests that at much as 95 percent of human thought environment, such as availability of soap, distance to takes place in the subconscious. water, and access to sanitation. In-depth interviewing following behavior trials can also help reveal barriers and In-depth qualitative research into consumer motivations facilitators (see tool 1). in many countries shows a recognizable pattern of drivers of handwashing behavior, as seen in table 4. Mothers Barriers need to be first understood and then addressed tend to be driven to handwashing by pride, status, social as the communications program is developed. For acceptance, and disgust of smells and contamination. They instance, if distance to clean water is a barrier, the also regard handwashing as an act of nurturance, part of communications program can point out that a small loving and caring for children. Women often think that amount or recycled water suffices. Further, while a only visibly dirty or smelly hands are potential sources of communications campaign may not be able to directly ill health, and even then, explicit relationships between address physical barriers such as lack of handwashing dirty hands, diarrhea, and disease are rarely cited. facilities in schools, public relations (PR) and advocacy activities may convince those who can help reduce such While there appear to be some general cross-cultural barriers. Demand from primary target audiences ­ motivations for handwashing and wider hygiene behaviors, mothers and children ­ might also encourage the their nuances and how they play out will be specific to installation of handwashing facilities where necessary. particular countries, as will the relative importance of each motivation. This is also true of different segments Habits are ingrained and sustained behaviors, often of target audiences. For example, nurturance is unlikely developed in childhood. Research has shown that once to be a strong motivator among school-age children. people anywhere acquire ingrained and habitual behaviors, Consequently, country-specific consumer research is they are not easily lost. The task for handwashing needed to guide an effective marketing campaign. promotion is not to achieve a single handwashing event, Table 5 provides a simple format for identifying and but to instill a routine and sustained habit that happens notating barriers and drivers, while box 3 illustrates automatically with every contaminating event. mothers' reports of cultural norms influencing their soap 24 The Handwashing Handbook use in Senegal (note that these barriers are perceived Box 3: Cultural Beliefs Inhibiting rather than real). The barriers and drivers for handwashing Handwashing with Soap in Senegal with soap may be different for different key handwashing times. These can be captured in a format such as table 4. Consumer research in Senegal captured examples of handwashing with soap that are related to habits Behavioral trials, where volunteer mothers (and/or school and barriers. children) are given soap and asked to use it to practice handwashing with soap for seven to 10 days, are a good Ancestral and Religious Beliefs way to begin understanding local handwashing Although no longer widely believed, some Senegalese motivations. Following a trial, mothers are interviewed take a "`better safe than sorry approach" when it in-depth about their experiences, what was easy, what comes to traditional handwashing behavior. Using was hard, what was liked and disliked, etc. Focus soap during ritual cleaning prior to praying at the group discussions (FGDs) with mothers and/or school mosque removes some of the purity of the spiritual children can be used to supplement these trials to cleansing because the blessed water is not better understand the social nuances of handwashing compatible with soap. and associated motivations, as well as favored communication channels. Some women, especially in rural areas, still adhere to a practice of not washing a child under the age of How do people communicate? Finally, research has to one for fear of reduced life expectancy. They may determine where the target audience obtains information; also reduce soap use during pregnancy to avoid harm the reach of different channels of communication, both to the unborn baby. Some women also believe that traditional and modern; which channels are trusted and handwashing with soap might reduce fertility. believed; and the best language(s) to use. The potential effectiveness of different channels will differ among the Fatalism various segments of the target audiences. A more common barrier is an attitude that one There are two main sources of information on channels cannot escape one's destiny; thus, being poor is of communication. The first source is existing data. In predetermined and dirtiness is simply part most countries, commercial entities have already collected of poverty. detailed profiles of consumption of mass media, possibly even covering mothers' and children's listening and Table 4: Drivers, Habits, and Environments for Handwashing with Soap (Four Areas) Ghana Kerala, India Senegal Wirral, UK Drivers Nurture a child Disgust Pride/status Disgust Disgust of Social Disgust Status/pride contamination acceptance Nurture Nurture Social Nurture Seduction Aesthetics acceptance family Habit New baby Moving Water only, New baby Taught by household not soap, Learned from mother New baby is the habit midwife Environment: Distance to Men control Local Convenience Facilitators/barriers public toilet soap customs Forgetting The Handwashing Handbook 25 Table 5: Identifying Barriers and Drivers to Handwashing with Soap at Key Events Target Behavior (for Mothers) Wash Hands with Wash Hands with Soap Wash Hands Soap After Using After Cleaning up a Child Before Handling Food the Toilet Who Has Defecated Barriers Drivers/ benefits Box 4: Ghana Consumers Prefer Multipurpose, Long-Lasting Soaps at Economy Prices Women in Ghana were asked what features they as they thought they were longer lasting. favored in a handwashing soap for research purposes. Thepreferenceforhardsoapswassostrongthatmany In commenting on favored features for soap, they stored soap in cold or sunny places to harden them cited a range of attributes ­ smell, cost, texture, before use: "I cut it into pieces and put it on the floor and durability ­ and its capacity to be used for of a veranda to dry and harden so that it will be many purposes. long in use." Smell was the most important attribute. Overall, Liquid soaps, as well as being economical ­ only a little mild lemon/lime scents were most popular. is used each time hands are washed ­ are favored for However, soaps with stronger scents were favored convenience "with soap in its hard state, you need to for use after defecation, while as little scent as ask someone to pour water on your hands, but with possible was preferred before eating: women feared this you don't need anyone's help." a strong scent would affect the enjoyment of eating. One said, "You will not have an appetite for food if So strong was the desire for the more expensive liquid the soap lingers in it." soaps that some women made their own from bar soap: "I soaked it in water, mashed it, and poured it Cost: Overall, cheaper soaps were preferred, though into an old feeding bottle." women were sometimes willing to pay more if the soap was larger or they thought it would Multipurpose: Because it is associated with economy, last longer. many women preferred laundry bar soaps that could be used for a variety of purposes: "That is the Texture/durability: Associated with cost, women only soap I buy, since I can use it to wash my things tended to prefer harder bar soaps or liquid varieties, and have a bathing soap at the same time." 26 The Handwashing Handbook viewing habits. Demographic and Health Surveys (DHS) also collect this information. In Peru, media houses were Box 5: A Note on Schools a great source of data on coverage and listenership. Because they provide a relatively easy and When using existing data, however, it is important to sustainable route to long-term behavior change, complement it with primary research in order to learn schools are a good focus of handwashing programs. more about local channels of communication and to Schools are a key environment, not just for learning determine which communication networks, traditional about handwashing, but for introducing the habit in or modern, are most trusted and/or believed. People practice, so it lasts. Children are often enthusiastic can be skeptical of mass media, especially where there is proponents of behavior change, and research strong government control over them, and coverage questions apply to school-age children, teachers, and levels can be low among women. Thus, a second administrators as well as they do to other information source is interviews with a representative target audiences. sample of the target audiences. Such interviews focus on people's contact with different channels of In most countries, schools are the second places of communication, be they word-of-mouth, traditional, socialization after households. Children can spend governmental, social organizations, mass media, etc. up to eight hours a day for more than eight months Figure 5 illustrates different channels for women in a a year in schools and a substantial amount of time village in Kerala, India. with their peers. Consumer behavior literature shows that children do not react to brands and Qualitative research can help to map out channels of brand communication in the same way as adults, so communications from the mothers' perspective, a separate communications strategy is needed for particularly concerning local communication channels schools. The risk practices being carried out at school (which may be missed in national data sets). It can explore are also different than at home. Specific tools for which channels are likely to be most influential and researching school children's habits and motives are credible for handwashing communications. For example, in development, and some tips on researching in Burkina Faso, it was found that though `griots' school-age children are in tool 4. (traditional praise singers) were good carriers of The Handwashing Handbook 27 Figure 5: How Mothers Communicate in Kerala, India: Monthly Contact Profile Development Local Anganwaadis women & child panchayats 96% program 51% 1% Integrated rural Primary Middle Secondary dev. program school school school 57% 90% 87% 74% Community Adult TV 62% education centre 58% Community Primary centre 40% Target health mother centre 74% Fair price Health sub- shop 91% centres 79% Recall Private shop 67% doctor 88% Bank 89% Post office Milk 89% Village health cooperative NGOs 24% guide 38% 67% Traditional birth attendant 49% Box 6: Outline of Study Methods Structured observations are direct observations of observations. Focus group discussions (FDGs) involve the behavior of interest (handwashing with soap asking small numbers of people to discuss a range and what communication channels most effectively of topics relating to the behavior of interest. As transmit messages) by field workers recording what the target audience includes mothers and children, they see using a standard format. This method can each should be separately included in focus group be difficult, expensive, and intrusive, but provides discussions. FGDs are probably best used to carry more valid measures of behavior than any other out ranking exercises (ranking of daily activities, method. Observers arrive early in the morning, sit most important things in life, soap use, soap types quietly where they can see the domestic behaviors for handwashing, most effective communication of mothers and index children, and note, for channels, etc.) to allow consensus to form on issues example, exactly what happens associated with a likely to affect handwashing behaviors and to child defecation event. Behavior inevitably changes determine the proportion of people taking as a result of the observation, but if mothers are particular views. told the observers are recording domestic work or child health, they change handwashing behavior less. Behavioral trials and in-depth interviews: In behavioral Field workers need careful training to standardize trials volunteers, usually taken from FGD members, the approach and very careful support and are given soap and asked to use it regularly for supervision. Consumer interviews are standard handwashing. The mother is visited several times quantitative interviews and are useful in profiling to remind her. After seven to 10 days, she is target audiences and their environment. interviewed in depth with regard to her experiences Socioeconomic questions along with questions on using soap: what she liked and disliked, what was water, sanitation, and handwashing facilities are easy, what was hard, and what solutions she found asked, and observations are made on these issues. to any problems. These trials can usefully be A standard set of questions about exposure to all repeated after another seven to 10 days, as habits possible forms of communication is also asked. All change. Such trials followed by in-depth interviews questions are structured and employ precoded can reveal motives and barriers if done thoroughly. responses. Formats need careful pilot testing to In-depth probing is essential to reach the ultimate adapt them to local conditions. Consumer cause of a behavior. To reach such cause, researchers interviews (CIs) are best carried out with child repeat the question "Why?" until a subject cannot caregivers immediately after structured explain any further underlying cause. 28 The Handwashing Handbook Table 6: Summary Design for Consumer Research Objective Specific Questions Methods Suggested Minimum (Not Exhaustive) Sample Size 1. Who carries 1.1 What are the characteristics Questionnaire As below out risk of target audiences (socio-economic, interview practices? demographic, educational As described characteristics, etc.) in text 2. What are the 2.1 How much soap is used per Structured Representative sample risk practices? person on average? observation in eight clusters, total 2.2 What is soap used for, 400 households by whom? 2.3 What types of soap are used for what? 2.4 On what occasions and how many times are hands washed? Questionnaire 400 households With/without soap? interviews after 2.5 Where is soap procured? structured 2.6 Availability of handwashing observation facilities FGDs on soap 5 FGDs attributes 3. What can 3.1 Why do those who currently (do Behavior trials 40 volunteer households drive behavior not) wash hands with soap do so? change? 3.2 What are the perceived In-depth 40 volunteer households advantages and disadvantages interviews after of washing hands with soap? behavior trials 3.3 What constrains soap use? 3.4 What factors facilitate/bar soap use? 3.5 Context: Characterization of locality: water sources, sanitation provision 4. How do 4.1 Reach of existing channels of Questionnaire 400 caretakers of children people communication (e.g., mass interviews, communicate? media, government channels, available Sub samples of 200 male nongovernment channels, national data household members and traditional channels) 200 school-age children 4.2 Appropriatencess of existing In-depth 40 volunteer households channels of communication interviews as above 5. Schools 5.1 Existing habits Focus groups 20 schools survey 5.2 Motivations with kids, 5.3 Barriers in-depth 5.4 Key players interviews with key players The Handwashing Handbook 29 Box 7: Key Points for Contracting Consumer Research It should be made explicit from the outset and field and make sure that field work is being carried re-iterated often that handwashing promotion out to specification. Unannounced visits will programs are not traditional public health projects. help ensure rigor in the field team. Rather, they are consumer-driven programs that need to determine deep consumer motivations Qualitative work (e.g., in-depth interviews) cannot for handwashing with soap. Simple interviews are be carried out by field workers but must be not enough. For example, the contractor must executed in the field by qualified and well-trained be told that when consumers are asked whether anthropologists or psychologists. Support from they have washed their hands, the answer is the international PPP-health worker technical invariably "yes." People often respond to team may be needed to ensure effective, questionnaires as if they were being tested or quality research. judged, so they tell the interviewer what they All data, both quantitative and qualitative, are believe is the "right" answer. precious. Qualitative interviews should be recorded A team with commercial consumer research on tape, translated, and transcribed; carefully experience is preferable to one that is accustomed labeled and indexed with date, time, and to working on public health programs. respondent details; and returned to the client for safekeeping. Quantitative data should be Field workers need to speak local languages. thoroughly cleaned and a copy of the data set given to the client. Once recruited, agencies need detailed briefing and training to ensure that the right questions are asked Data analysis and reporting should focus on the in adequate detail. For example, many handwashing questions set out in the TOR. The analysis and studies find that consumers wash their hands report should specifically answer the key questions: because they want to be "clean." However, this is not a useful finding. Understanding what ! What are the characteristics of the target "clean" means in this context and all its audiences? ramifications ­ physical, psychological, and social ­ ! What are existing behaviors and habits? is more important. ! What are the handwashing with soap drivers, The research agency must stay focused on the habits, and environment? four questions and the specific information that is needed. The agency must probe to the ! What are the main channels of communication bottom of each question and ensure that used by the target audiences? findings are sufficiently detailed to allow the development of a sophisticated, creative When analyzing the data and writing the final strategy to promote behavior change among the report, the research agency must frame its work target audience. around the main research questions as presented above. Using table 5 to summarize barriers and As with all contract work, the quality of work will potential drivers is also recommended. only be as good as the client demands. The client has to understand all the issues in-depth, know Depending on the team's level of experience, the exactly what is wanted, and keep the agency client may need to set out all of the analysis that is focused on achieving this. Clients must visit the required of the contractor. 30 The Handwashing Handbook Box 8: Consumer Research: The Rational Bias We know that behavior is a product of drivers or disease." Standard health promotion programs tend motivations. They activate when the brain receives to content themselves with such answers, signals from the environment (e.g., the sight of a forgetting that there may be many more, and many juicy apple) or the body (e.g., low energy, hunger). more powerful drivers of behavior change, than Many drivers can operate at once, and the brain fear of disease. gives one or another priority for action. Actions that are easy (require the least expenditure of effort) Even if a respondent knows her own motives, there will be favored over difficult ones. Actions that have may be powerful social reasons for not admitting been done before, or are habitual, will be favored to them: Who would admit they want to look over new, less familiar ones. Though it is often attractive to the opposite sex or that they want assumed that communicating the health benefit of high status in society? handwashing is enough to drive it, it is only one Marketers know this and ensure that advertisements among many potential drivers and often not the contain both what they call a functional message strongest, though people might attempt to rationalizeandexplaintheirbehaviorinhealthterms. and an emotional one. They present a rational basis for buying a product or changing a behavior, one Consumer research is made difficult by the that the consumer can claim or persuade himself widespread tendency to rationalize and explain or herself is the reason for doing so, but also a behavior in a way that makes an individual appear deeper emotional reason that probably represents favorable to an interviewer. However, the basic the actual driver of behavior change. A major toilet drivers of human behavior are subconscious. Some paper brand in the United Kingdom gives a typical of them are felt, indirectly, as emotions. Faced by example: its advertisements claim that it is a better an interviewer, a mother feels obliged to try to brand than the others and uses a cute puppy to explain herself. She may feel as if she were in school convey the idea. The fact is, the paper is no better again, trying to give the right answer in a test. She than many other brands and is more expensive, may try to remember lessons about hygiene, germs, but the consumer is lured to it through an and disease. Asked why she washes her hands, she emotional response to the puppy (Buchholz and endeavors to give a rational explanation: "To avoid Wordemann 2001). information, they were not seen as hygienic by the (d) 5 FGDs with target mothers on soap attributes and general population and were consequently inappropriate communications;(e)40behaviortrialsfollowedbyin-depth carriers of handwashing messages. interviews; and (f) a school study module. Designing and Implementing Structured observations are costly. The number can be the Consumer Research reduced from 400 to about 200 if they are intended The objectives of the consumer research are to answer, purely to inform the program and not to provide a baseline in a valid but concise way, the four questions above: Who from which to measure changes. The higher number is carries out risk practices? What are the risk practices? necessary and is typically sufficient to provide the What can change behavior? And how do the target statistical power to detect a significant change in behavior. audiences communicate? If the study is to develop a baseline, detailed calculations must be made based on estimates of local handwashing Table 6 presents a summary design for consumer research rates and the expected impact of the program. The annex for a country handwashing program. This design involves: provides a formula and instructions on how to do this. (a) 400 structured observations (SOs) of the behavior of mothers; (b) 400 questionnaire-based interviews with the These recommended quantities will provide a good same mothers after the structured observation; (c) 200 overview of the country situation regarding handwashing questionnaire-basedinterviewswithothertargetaudiences, practices and factors inhibiting, enabling, and motivating includingmaleheadsofhouseholdsandschool-agechildren; handwashing with soap at key junctures, provided that The Handwashing Handbook 31 the methods table 6 calls for professionals to provide Analysis and Reporting of the Results cover with a full range of socioeconomic, geographical, Once collected and cleaned, the data are analyzed by and cultural backgrounds. The structured observations the research agency. Data are used to answer the four and questionnaire-based interviews provide a quantitative main questions. Quantitative data are summarized in snapshot of handwashing practices, socio-demographic tables, and qualitative data are coded according to the factors, and channels of communication. After analysis, main themes: drivers; habits; and environment motives, these data are reported as proportions and percentages. barriers, and facilitators. Several rounds of analysis and The focus groups and behavior trials use a different reporting may be needed to develop a report that meets approach: their aim is to probe a small number of the needs of the program. Raw data and transcripts of individuals at great depth concerning their drivers and FGDs and in-depth interviews must also be provided, as habits and the environment of handwashing. These data transcripts, in particular, can provide excellent raw are recorded as transcripts and present key insights into material for the development of creative strategies. the consumer's mindset in their domestic context. The methods are detailed below. It is essential that the steering or consultative committee includes people who can critically review the reports. Studies typically take two months of fieldwork with a Experts recommend reviewing the quantitative report, team of eight to 14 people, cover the whole target area/ by, minimally, checking that the data set is clean and country, and may cost on the order of US$20,000-80,000. that a re-analysis of some of the descriptive and cross- tabulated variables finds the same results as the agency. Managing and Supervising With the qualitative data it is essential to read some of the Consumer Research the raw transcripts and develop a feel for what people The agency chosen to perform the research needs a are saying. Interpretations can vary from person to person, background in consumer research and must demonstrate so it is also possible that the research agency will miss its ability to achieve a nationally representative sample some important nuances. In both qualitative and quantitative research, it is not uncommon for marketers and manage qualitative data. The study will be much themselves to re-run the analyses using the data provided improved with inputs from private sector marketing and/ by the market research agencies. or international handwashing experts to help brief and train the consumer research team; support the qualitative Qualitative research and analysis is difficult to do well, so work, if experience in this is lacking; and analyze results. it is essential that it be reviewed closely. 32 The Handwashing Handbook SECTION 3 Program Implementation -SA STUBBS/WSP GUY The Handwashing Handbook 33 SECTION 3 Program Implementation Designing the Campaign needs of each segment of the target audience. Each With a partnership framework and research results, segment will require different marketing strategies. planning for the handwashing with soap campaign can Primary target segments in handwashing programs include begin. The results of the research should provide all the (a) mothers of children under five years; (b) other information needed: the key practices to target; who caretakers of children under five years; and (c) school- the target audiences are; what the barriers, habits, and age children at school and in other settings. environment are; and details about appropriate channels of communication. Experienced soap industry marketing Further segmentation might divide those not washing professionals can provide expertise and assist with all the their hands at all (likely late adopters, likely less inclined activities described in this section. to develop the habit of handwashing with soap) from those already washing their hands, but with water alone Applying the Marketing Mix (likely early adopters, more ready to respond to handwashing messages). In some cases it might be The marketing mix, often presented as the Four P's ­ necessary to segment the target audience according to Product, Price, Place, and Promotion ­ provides a ethnic or religious group. Other segments might include framework for how to design a comprehensive rural and urban target audiences. Regardless of how handwashing program. audiences are segmented, it is important to ensure that Product refers to the tangible good or service that can messages are appropriate to all groups. facilitate behavior change; it can include environmental There are also secondary target segments, audiences that changes or aids. Handwashing-related products include can be expected to support and influence behavior change soap, water and water dispensers, and basins. among the primary group. These might include (a) fathers Price refers to monetary and nonmonetary incentives, of children under five years; (b) mothers-in-law; such as the cost of soap and water and the time needed (c) teachers; and (d) healthcare workers. to wash hands. A third segment may be the target of an advocacy/public Place refers to the distribution of products and relations campaign in support of the program. This conveniences, such as distance to a water source and includes `upstream' stakeholders who can assist in availability of soap. garnering political commitment. They may also be able to help in such areas as installing handwashing facilities in Promotion refers to persuasive communication and schools or public toilets and by adding handwashing to includes key messages, media channels, and their own programs. Such stakeholders may include (a) environmental prompts. industry; (b) government; (c) the media; and (d) development organizations (international agencies, While this document largely concerns the fourth P, bilaterals, NGOs, community-based organizations). promotion, a country program may also aim to influence product solutions (e.g., making water dispensers available Other examples of upstream targeting include lobbying in schools), pricing (e.g., lobbying a government to reduce governments to reduce import duties on soap ingredients. a sales tax on soap), and place (e.g., lobbying for tap In addition, working with development organizations to connections and soap dispensers in schools). plan infrastructure projects in coordination with hygiene promotion can ensure the placement of handwashing- Developing the Promotion related products, such as water points. Target Audiences and Segmentation Agencies, Concepts, and Testing Segmentation refers to the process of dividing the target Methodical and thorough planning is the key to a successful audiences into groups with similar behaviors and needs. campaign, and the use of a professional communications Segmentation is done so that promoters can address the agency is essential. Good agencies are skilled at turning 34 The Handwashing Handbook consumer insights into effective behavior change 3. What is the single-minded proposition, our unique programs. However, the results are only as good as the selling point? That is, What is the single focus, the brief (described below). one benefit we want to communicate to the target audience? (This benefit must be believable.) Communication agencies are responsible for turning the objectives and insights of marketers into comprehensive 4. Execution task, including the tone that communications campaigns. They begin this process communications should take. through a `creative brief,' a document designed to outline the scope of the work they are expected to undertake. Consumer research has provided the key elements for The brief should be presented to the communications the brief, notably: (a) target audience profiles; (b) current team with time for discussion and idea generation. It habits; (c) drivers, barriers, and the environment; and should be as clear and succinct as possible and typically (d) a map of channels of communication. contain four key elements: The final brief is negotiated between agency and client. 1. The business task. Lintas Ghana Ltd has provided guidance on the `The Perfect Brief' (see box 9). Alongside the brief, the client 2. The communication task: (a) Who is the target should provide a full report of the consumer research, audience?; (b) What do they do/think now?; and including verbatim transcripts of interviews and focus (c) What do we want them to do/think? groups and plenty of nuggets of insights gleaned from The Senegal Creative Strategy ADULTS CHILDREN Objectives: Objectives: !To adapt the behavior of washing hands with !Toadaptthebehaviorofwashinghandswithsoap soap after the toilets, after having changed a child, before eating and after using the toilet before eating, and before feeding a child cooking !Convey this example to others !To transfer this behaviors to children and close contacts Target Audience: Mothers and guardians of Target Audience: Children 6-12 years old children under five years of age Benefits: Benefits: !attractiveness, cleanliness, to smell good, and to !coolness and being accepted by the group be in good health !feel good (physically and mentally) !to avoid the disease, dirtiness, bad smells, and shame Tone: jovial and positive Tone: cool, `in', encouraging Desired reaction: Desired reaction: For the well-being of myself and my family, I wash I wash my hands with the soap, and I have a good my hands with soap sense of myself and it is cool. If I do not wash my hands with the soap I will not fit in with my peers Sources: Sources: !Consumer research carried out in Senegal at the !Structured observations in primary schools in end of 2003 Dakar !Experiencesfromhandwashingprogramsinother !Experiencesfromhandwashingprogramsinother countries countries !Consistency with adult strategy The Handwashing Handbook 35 Box 9: The Perfect Brief During preparation of the Ghana Handwashing Team Leader Initiative, the advertising agency Lintas was selected ! The most experienced marketer on the team to design the campaign materials. It soon became ! The driver clear to the client, Ghana's handwashing ! Empowered to make decisions on behalf of the initiative steering committee, that the successful rest of the team development of the materials was due to the well- ! In from the start, there at every milestone, designed creative brief. Lintas-Ghana shared its and there to make the final decision guidelines for designing The Perfect Brief during a ! Not a gatekeeper but an initiator global handwashing technical workshop in 2003. Content The Purpose of a Brief ! Simple: one page; no jargon ! To create good advertising ! Objective ! Create/communicateacommonunderstanding ! Who are we talking to? of the task ! What do they think now? What is their need? ! Inspire ! What do we want them to think? ! Develop a tool for measuring the results A single-minded proposition that it's important to the target's life Client/Agency Relationship ! Why should they believe us? Preparing the brief is a team process that includes: ! Executional guidelines/requirements ! Collaborating with the agency ! Receiving a draft document early on, then re- The Briefing Session working it ! Present the brief face-to-face with the ! Getting sign-off from all stakeholders creative team ! An effective team (small, consistent) ! Be creative, make it an interesting and ! Defining roles and empowering a leader memorable experience ! Creating a shared vision ! Be flexible in the face of concerns voiced ! Effective, enjoyable meetings with clear, by the team commonly understood objectives ! Make it fun Risk versus Safety Evaluating Advertising ! "If you don't get noticed, you don't get ! Measure against brief: Does it say it? Did it anything": Bill Bernbach, legendary copywriter and communicate? founder of DDB Worldwide ! Does it have a single idea that links all the ! Anodyne, unoriginal, and uninteresting executions across media? advertising is ineffective ! Is it surprising? ! Advertising that stands out carries risk ! Is it interesting? ! A small, well-led team has the courage to face/ ! Is it memorable? manage that risk and create communications that are surprising, interesting, and memorable An imperfect brief ! A verbal brief (it isn't worth the paper it isn't Planning and Research written on) Know what you want to achieve ! Is full of jargon, acronyms, and options ! Change of mind ! Is unclear on budget or timing (that is, ASAP) ! Behavior change ! Is non-negotiable ! Quantify (how many, by when) ! Asks for miracles, that is, overambitious ! Pinpoint, then know the target ­ demographic objectives despite logistical barriers and psychographic ­ relevant, insight, golden ! Hasadouble-barreledsingle-mindedproposition nugget, drivers, barriers. How they find information they trust ! Communication strategy Source: Colin Charles, Lintas Ghana (August, 2003) the research. This will contribute to the agency's the creative process is iterative with regular agency-client understanding of the behavior of interest, target meetings. It is important to be as clear and directional as audiences, and communication channels. possible throughout this process. Industry's experience is invaluable, so it is essential that private sector expertise is Followinginitialbriefingmeetings,theagencyaccountmanager used throughout development of the communications will produce internal briefs for the creative team. Thereafter, strategy. A core team familiar with all aspects of the research 36 The Handwashing Handbook Table 7: Advantages and Disadvantages of Different Approaches to Communication Approach Description Advantage Disadvantage Mass media Messages crafted to be Low cost per capita, Needs high saturation transmitted through an can be highly (6+contacts) to affect optimized mix of radio, memorable, can raise behavior change TV, billboard, and the political profile of other channels handwashing, easy to Audience cannot interact monitor Difficult to fund Direct Events organized by Good audience High cost per capita consumer professional event interaction, high Uncertainty about contact management agencies, impact, memorable impact and optimal held in schools, public size of audience places, community groups Public Using the ability of Potentially highly Hard to control channels government agencies to sustainable, if Low staff motivation deliver handwashing handwashing Contact with target messages through promotion becomes audiences may be schools and health part of curriculum, infrequent, resulting in centers job description of health low coverage agent, promoted at ante- Low ability to monitor and post-natal contact activities and the approach should be maintained throughout this include television, radio, and billboard advertising. Direct process, which often takes several months. contact with consumers includes activities carried out by First, the results of the research are used to develop a event management organizations and existing number of platforms or concepts. These are developed organizations, such as local government, schools, health and tested by an independent research agency in order to authorities, NGOs, commercial retail outlets, churches, determine which message direction is most likely to drive mosques, etc. The more appropriate the mix of behavior change. The most promising concepts are then communication channels to the local situation, the more further developed into miniature stories for TV and radio effective the campaign will be. ads and into outline poster designs. The advertising stories are illustrated in drawn storyboards, which are also then Mass communications (TV, radio, billboards): When channels testedwithtargetaudiencesforbelievability,attractiveness, such as TV, radio, the Internet, billboards, leaflets, and and potential behavior change power, again by an posters are employed, they can reach large audiences at independent research agency. The processes for testing a low cost per capita. They may thus appear cost- concepts and storyboards are similar, as outlined in box 7. effective. However, the downside is that mass media contacts are thought to be less effective in achieving It is essential that time is allowed in the creative process behavior change than group or individual contact due to for the testing and retesting of concepts; storyboards; the lack of opportunity for audience interaction. and, ideally, draft advertisements, as it is this fine-tuning Direct consumer contact: Public meetings, street theater, that will maximize the campaign's success. mobilecinema,andotherspecialeventsrunbyprofessional direct consumer contact (DCC) organizations, as well as Multiple Strategies for Behavior Change educational sessions in schools and health facilities, can Handwashing programs rely on a variety of communication reach large numbers of people, if enough events are held. channels such as mass media and direct consumer contact The effectiveness of this approach has not been greatly activities. As described in table 7, mass media might studied, and group health education has had uncertain The Handwashing Handbook 37 effects on behavior. However, industry believes that while Public Relations and Advocacy DCC is much more costly per person reached than mass Whilethemassmediaanddirectconsumercontactactivities media, in the longer term its power to change behavior is seek to change handwashing behavior in mothers and greater due to the greater intensity of the communication children, public relations and advocacy aim to create and and opportunity for audience interaction. maintain support for these efforts from the broader stakeholder groups ­ the third target audience mentioned Government and partner agency communication: In an ideal above in `Target Audiences and Segmentation.' If used to world, all government health employees, hygiene staff, its full potential, PR can be a powerful marketing tool that school teachers, and outreach workers would introduce develops and maintains interest, anticipates and deals with handwashing at every contact opportunity with target audiences.However,suchemployeeshaveotherpriorities, negativepublicity,andhelpsmaximizethecampaign'simpact. and special strategies will be needed if handwashing is to Handwashing programs need concerted initial advocacy become their priority. The key to the success of these to bring all key stakeholders on board, but advocacy is communications is the creation of a cadre of motivated, not a one-time activity. During early stages of a program, well-trained agents. This is as difficult to achieve in it may be helpful to have international experts visit to handwashing efforts as in any public health program. raise the profile of handwashing and add credibility: not However, efforts to include handwashing promotion in the everyone may see what a serious issue handwashing is. job descriptions of teachers and health workers may be Advocacy is also needed throughout the life of the program one route to long-term sustainability. A mass media to keep stakeholders on board and to brief new partners campaign may help motivate government employees to experiencing staff turnover. The leading targets for take on the handwashing message. Particular events in advocacy are key decision-makers as identified in the health facilities, such as the distribution of free soap in stakeholder analysis. Often, it makes sense to target the `bounty packs' for new mothers, also enhance health highest possible level: Prime Ministers and Ministers as worker motivation and provide stimuli for mothers to take well as chief executives and country representatives. on new behaviors for the good of their infants. It may also be vital to identify potential dissenters and The use of commitments can increase the likelihood of to keep them well informed and in the loop. behaviorchange.Clinicscanbeencouragedtogivemothers Misunderstandings about the nature of the program can a `certificate' honoring their commitment to wash their lead to bad press, which can seriously damage or even hands with soap at key junctures.These certificates could sink handwashing programs (see box 10). also be distributed to mothers and children at community PR targets stakeholder groups that can leverage publicity, events (see `Direct consumer contact,' above) and to funds, and expertise. Such groups include: children through schools. Rewarding people as they continuetopracticeanewbehavior,evenwithsmalltokens ! The press, which develops news and features that such as stickers or badges, or simple praise, can also be highlight research findings, campaign events, and important in moving people from a one-time trial of accomplishments,andreinforcekeyhandwashingmessages; handwashing with soap to developing the habit. ! Government agents, who lobby officials to support School children could have monthly hygiene prizes, while and promote the program within their institutions and clinics might reward new mothers for continuing to wash budgets and to improve the operating environment; their hands as their baby grows. ! The private sector, which engages the soap industry Product labeling: Ensuring that the handwashing message is and other private sector entities to provide expertise carriedonhandwashing-relatedproductscanprovideagood and financial support for the design and execution of the prompt/reminder to wash hands with soap at key times. handwashing campaign or to carry handwashing messages Foodcompaniescouldbeencouragedtocarrythemessage and logos on their products to remind people to wash orlogoonfooditemstoremindpeopletowashhandsbefore hands at key junctures; and eating or preparing foods, while soap companies could put the message on soap packaging. For example, one soap ! Support agencies, which create interest and company in Ghana intends to introduce a new in packaging commitment in the development community to set that has the same colors as images from handwashing up financial support, networking, technical assistance, campaign. This need not involve additional cost but may and the inclusion of handwashing messages in programs require advocacy and PR (see below). and projects. 38 The Handwashing Handbook The PR Plan handwashing facilities in schools? Like all areas of the The purpose of PR is to create and maintain awareness handwashing initiative, local knowledge of each and support. This is accomplished through various tools, stakeholder group is essential when developing such as press releases, speeches/presentations, and appropriate messages. events. Key points when planning a PR campaign are: Encourage networking among target audiences: Put Know the target audience: What type of stories will the different organizations in touch with each other. media be likely to print? What are the favored media Independent support will leverage the handwashing outlets and venues used by specific stakeholders? What messages, increase credibility, and stimulate are the current `hot' issues with stakeholders that could problem solving. be exploited or could potentially detract from handwashing? Who can address handwashing barriers Start early: PR is the first mass communications step of a raised in the research, such as high import tariffs on raw handwashing initiative. Many of the informal stages of materials that lead to high soap prices or lack of partnership formation will form the basis of the PR plan. Box 10: A Lesson in Public Relations: Handwashing in Kerala, India As part of the Global Handwashing Partnership, a Better media management: The only response handwashing program was started in Kerala, India, to press criticism was an official, lukewarm in early 2001. Facilitated by the World Bank and statement that came six months too late. Regular the Water and Sanitation Program, the government briefings and updates could have helped build of Kerala partnered with the Indian Soap and media support. Toiletries Manufacturers' Association (ISTMA) to develop a handwashing promotion program across Better informed stakeholders: Not all key the state. Hindustan Lever Limited, the largest stakeholders felt included, as the program was privatesoapmanufacturerinIndiaandakeymember designed and business plan developed. of ISTMA, played an active role in developing the public-private partnership. UNICEF, the London Small business involvement: Though local and small School of Hygiene & Tropical Medicine (LSHTM), soap companies were involved and participated, and a number of NGOs were also involved. this was not widely known and led to the perception that multinationals would take over the market. As the handwashing program design and business plan began to receive public attention, Better informed stakeholders: A perception environmental and anti-globalization activists began developed that the campaign was designed to sell criticizing the program through the print media. only one company's soaps and that the whole They were soon joined by other high-profile groups, initiative was being driven by one donor. In reality, including doctors, local newspapers, and opposition the campaign was not promoting any particular firm politicians. The main points of criticism were: or brand, and more than one internationally (a) the choice of Kerala for the program in view of recognized organization was highly involved. its already high human development indicators; (b) unclear linkage between handwashing and health At the same time a politician claimed it would improvement; (c) the potential adverse effect on be better for the government to spend money the indigenous and local soap industry by increasing on providing safe water and sanitation the market share of multinational soap companies; infrastructure rather than handwashing. This and (d) the suggestion that the state government argument was buttressed by the assertion that was capitulating to World Bank pressure. In the safe water and sanitation initiatives are "tangible face of mounting media attacks and after a long and based on hardware," while a communication- period of inaction, the state cabinet decided to based initiative like handwashing is "largely abandon the program in August 2003. ephemeral, intangible, and therefore prone to Could the problems in Kerala have been avoided wastage and misuse." Even doctors were skeptical or handled better? The ideal combination of an about the health benefits of handwashing with soap. interested donor, an interested soap company, and Information of the benefits of handwashing and the initial demand from the government for a monitoring and evaluation frameworks could have handwashing program evaporated under been regularly disseminated to policy makers, widespread media criticism. A PR plan could have constituents, and health professionals with forums contributed to: encouraging the exchange of views. The Handwashing Handbook 39 Initially, PR can convey the importance of handwashing Monitoring and Evaluation with soap. With research results in hand, PR can highlight The object of monitoring and evaluation (M&E) is to country-specific handwashing needs. ascertain the extent and effectiveness of the program. Monitoring serves to diagnose and help fix problems during Align the PR plan with broader communications efforts: As the communications strategy is developed, PR activities program execution. Evaluation is the process of will need to align with the mass media and direct measuring outcomes both during and after the consumer contact campaigns. This will improve impact intervention, to determine how successful the program through message clarity, timing, and campaign identity is, or was. M&E involves three broad steps: a baseline (logos, colors, etc.). In short, PR should fit with the survey, ongoing monitoring of program activities, and a communications brief, whether or not professional PR post-intervention survey. expertise is engaged. In industry it is standard to run a communications program in six-month phases, with three-month gaps between The Media Mix each phase to review and adapt content. This enables Modeling the impact of different communications routes evaluation of the reach of the message, its content, and on target audiences is the next step. With finite the target audience's understanding and interpretation resources it is essential to work out which mix of of it. The media mix is revised to give better coverage of communications channels will be most cost-effective. This target audiences, to reflect what channels reach people, is a science well understood by industry. Models of media and which channels are most influential. Interim consumption and contact patterns in the target evaluations can gauge the degree of saturation of the populations are built by professionals. The capacity of message and provide the information for minor or TV, radio, and other channels to reach the whole target complete revision, if needed. However, in early stages audience is calculated. Assumptions are then made about one cannot expect to detect significant behavior change the costs and effectiveness of different channels, and must rely more on qualitative assessment of people's and finally a mix of channels is selected to maximize understanding and appreciation of the messages and cost-effectiveness. indicators of the propensity to change behavior. When designing the communications strategy and Baseline Survey apportioning budgets to various different Initially, the team needs to understand local handwashing communications channels, it is essential to ensure that practices and local determinants of regular handwashing all are utilizing the same promotional messages and with soap. A single baseline survey, which can be carried materials as used in the mass media channels. Hence, out along with the consumer research, can provide both, before designing the direct consumer contact and with advanced planning by the initiation team. Marketing district-level programs, it is essential that mass media companies tend to choose convenient populations to messages are finalized. explore attitudes and motivation. A baseline survey to assess the impact of a program, however, requires a This does not, however, mean that the same company carefully drawn representative sample. Having the people should be used for every communications approach. conducting the baseline evaluation and the handwashing Agencies that specialize in both advertising and direct determinants investigation work in a single team or at consumer contact will have to be recruited. least closely enough together is economical, as they would Finally, there are many activities that could promote identify and work with the same population. In addition, handwashing in any country. However, since resources their results would have more explanatory force, because and management time are limited, each activity must be a sophisticated understanding of people's motivations can justified in terms of the time and resources it would take be directly linked with their handwashing behavior. away from other efforts. Many small agencies may wish The handwashing baseline survey should be conducted to be involved, for example, but may take far more time among a random sample of people who are the target of to bring on board and convince of strategies than their the handwashing promotion program. Thus, when the likely impact would warrant. Strategic planning is essential: baseline survey is commissioned, the handwashing for each activity, managers have to decide how much promotion team needs to be clear on who comprises they can expect in terms of impact and concentrate on the campaign's target audience. For example, is the those with expected high returns. campaign a national campaign striving to reach all 40 The Handwashing Handbook households or is it focused primarily on urban, rural, or the link between health and handwashing or demand low-income households? Once the campaign target has direct measurement of health impact. been identified, a strategy is developed to identify a random sample of persons within the target audience. A Monitoring cluster-randomized design, similar to an immunization The second requirement for evaluating a handwashing coverage survey, where communities are randomly promotion program is an ongoing process to monitor the selected with the probability of selection proportional to implementation of planned activities and ensure that the population, is generally the most efficient and practical messages are reaching their target audiences. approach. The survey team visits 30 randomly selected communities and evaluates 10-30 households in each. Information from a well-designed monitoring system can serve to reorient programs and make them effective. As The primary indicators for the baseline survey include: with any large-scale program, managers need to set up ! The presence of soap in the home, presence of hand soap in the home; systems to follow the progress of activities and gather data on achievements. Such information can be ! The presence of a handwashing station (that is, supplemented with periodic random sample surveys to a place where water and soap are readily available document the reach of the program via the different for handwashing); channels of communication. In essence, a simple survey, representative of the target audiences, documents how ! Structured observations of handwashing behavior much contact each actor has had with the program. at key times, specifically recording the proportion of Audiences report their recall of contact and content and family members who wash their hands with soap before preparing, eating, or giving food; after defecation; and indicate if this has led to any changes in belief or behavior. after cleaning up a feces-soiled infant; and (As mentioned, this does not prove behavior change, but is a general indicator of progress in the right direction.) ! Diarrhea occurrence among each family member Qualitative work concerning how well the audience is in the last 24 hours, which may need to be measured in reacting to the media presented can provide insight to countries where key stakeholders are unconvinced of reorient programs. Table 8: The Ghana National Handwashing Initiative: Phase 1 Evaluation Results (in Percentages) Women Handwashing with Reporting HW Reporting HW Change in Soap Juncture before Campaign since Campaign Reporting After defecation 76 89 +13 Before eating 14 55 +41 Before feeding a baby 6 25 +19 Before preparing food 11 26 +15 After eating 53 31 -22 Children After defecation 76 89 +13 Before eating 14 76 +62 After eating 61 41 -20 The Handwashing Handbook 41 Figure 6: Monitoring and Evaluation: Program Activities and Impact Resources mobilized Resources and Program management deployed Input: and effective activity costs Program actors deployed and effective Promotional Products/ activities take components place sourced Facilitating environment created Delivery Target audiences Products in Output: receive messages place benefits change Behavior Target audiences Products used act on messages effectively Health impact Health accrued improves Evaluation requires special epidemiological expertise. The Final evaluation compares handwashing behavior with the prevalence of diarrhea is highly variable, so two one- baseline in order to determine the outcomes and impact of day measurements years apart in two populations of the program. During evaluation, a new random sample is 300-900 households is insufficient to demonstrate a drawnfromthetargetpopulation.Thirtynewcommunities direct effect attributable to the handwashing promotion are identified, and 10-30 households approached in each. program. However, these data can be used to model The same instrument that was used to collect the baseline the prevalence of diarrhea and its association with data is administered to collect the post-intervention data. observed handwashing practices. This can then be used The in-depth determinants of handwashing behavior to model the impact of the improved handwashing on investigation do not need to be repeated. The data from diarrhea. However, since the impact on improved thefinalsurveyareanalyzedandcomparedtothefirstsurvey to assess changes in behavior (see table 8). handwashing behaviors on disease is known, it usually suffices to look for impact on behavior as proof that Detailed program evaluation, including the final the program is achieving its objectives. Health impact outcome, health impact, is expensive to do well and can then be extrapolated. 42 The Handwashing Handbook SECTION 4 Program Organization The Handwashing Handbook 43 SECTION 4 Program Organization The Partnership Mix produce public health campaigns that rival, or surpass, Putting together a country team with the commitment, industrial marketing efforts. resources, and skills to set up, support, and run a national handwashing program takes time and effort. When A General Partnership Model partners from different backgrounds are not accustomed The experience of previous handwashing campaigns in to working together, it takes time to build common aims Central America, Ghana, Nepal, and Senegal suggests and mutual trust. that a coordinator-committee model for PPPs is Public-private partnerships (PPPs) provide an effective an effective way of managing a program with a diverse model for handwashing programs because they combine group of partners. the health objectives of the public sector with the The coordinator: The coordinator manages day-to-day marketing expertise of the private sector. As noted, the operations, keeps stakeholders engaged and informed, private sector stands to gain from joining such a and ensures that the whole initiative is moving towards partnership primarily through market expansion, by being its objectives. The coordinator is responsible for seen as contributing to social goals, and by networking developing and fulfilling the project business plan through with development partners and international experts. The public sector gains from the marketing expertise the engagement of partners and resources. A sample and resources of industry. They are thereby able to TOR, contained in the annex, outlines a coordinator's duties, qualifications, and skills. The steering committee: The key stakeholders that provide resources ­ technical, financial, and management support ­ make up the steering committee. They communicate with each other and the coordinator regularly and take the lead on specific business plan components. The benefits of having many members must be weighed against the transaction costs, which rise geometrically with every additional member. The consultative committee: The consultative committee comprises stakeholders who have a specific interest in the program but do not expect to be engaged on a daily basis. Its members might be asked for occasional feedback and approval on specific issues. This committee may include government officials, members of the press, community groups, the wider scientific community, and senior institutional managers. They may also represent organizations, such as regional or nongovernmental organizations, that will be extending the campaign to specific geographical areas. Meeting formally or informally, the consultative committee helps the coordinator organize stakeholders at the appropriate level of inter-action and helps keep stakeholders engaged and enthused. Subgroups oncommunications,consumerresearch,andthepressmay be useful. 44 The Handwashing Handbook Box 11: Handwashing in Action: The Handwashing Partnership in Peru Identifying the right partners, building a relationship with new members joining from the private sector: of trust, and then maintaining their involvement Radio Programas del Perú, a national radio and willingness to compromise at high levels, are broadcaster engaged in social responsibility, and the probably the most challenging, frustrating, and at international NGO CARE with experience in the same time rewarding tasks the coordinator must handwashing promotion in rural areas. Their achieve and sustain during the initiative. Once the professionals participated in and followed closely the PPP is believed to be solid, a coordinator must planning process and activities that concluded in a never rest on his/her success, because there is business plan at the end of the first year. always the risk that a pending threat may affect or interrupt the consolidated equilibrium Other private partners, such as Colgate-Palmolive among partners. and Alicorp (the leading national producer of laundry soap), members of a broader body, and Peru's initiative started on the right footing. the consultative committee were key members A mission of the Global Committee visited Peru in the communication task force, organized to at the end of 2003 to identify opportunities for draw the communication program structure of the the implementation of a handwashing initiative business plan. there. Public and private institutions were invited to evaluate the project and showed interest from Slowing pace: The beginning of the implementation the beginning. phase was marked by uncertainty. Financial sources previously identified as strong possibilities fell The mission planted a seed, and a few months later, through, forcing the initiative to move more slowly, the Ministry of Health, the Swiss Development and momentum was lost. Cooperation, the Water and Sanitation Program of the World Bank, and USAID, joined the Changes took place within almost every handwashing steering committee with a institutional member of the executive committee. well-defined agenda for the first year Partners' roles were not fully understood by of operations. incoming members: Should the initiative be made public? What responsibilities should executive Steering committee meetings were held regularly, committee members assume once funding and building a strong partnership became a priority. was received? Close to 20 institutions were identified and visited with two objectives in mind: to provide A window of opportunity opened when USAID handwashing information by way of a motivated decided to fund the first activity of the and persuasive speech and to gather quality implementation phase: the creative process, which information about the partner-to-be: its profile; brought with it the opportunity to rebuild the its institutional objectives; the assets it would bring executive committee around a well-defined action to the partnership; and its potential for providing plan. The process had to start again. professional advise and clout, for bringing along new partners, and for becoming financial partners The ability to communicate and build trust among at some point. a wide variety of institutions; the capacity to promote partners' participation and commitment, Steering committee members in Peru participate in a global strengthening their ownership rights over the technical workshop initiative; to know when to push and when to stop; to be alert for changes and able to discover The first year: The steering committee evolved opportunities and manage risk as they appear, are into a sound, well-defined executive committee, all necessary tools for a coordinator. The Handwashing Handbook 45 Box 12: Private Sector Handwashing Activities The private sector engages worldwide in handwashing among children. Handwashing has handwashing promotion and educational activities been demonstrated to have a significant that can link and coordinate with country impact in helping to reduce diarrhea and handwashing initiatives to leverage program scope infectious diseases. The program operates as and help to ensure sustainability by tying a partnership, with Safeguard providing handwashing messages to expanding soap brands. expertise and materials while counting on its These excerpts from the promotional material of media, government institutions, and education three large soap producers illustrate private sector partners to reach people. Nationally known approaches to handwashing activities. newscaster Lolita Ayala, who has a foundation Colgate-Palmolive: Clean Hands, Good Health for underprivileged children, endorses the overall campaign. Health experts recommend handwashing as a key tool in protecting the public health. It's a Safeguard donates a portion of sales to the mainstay in infection control. Yet surprisingly, Solo por Ayudar Fund. The campaign employs promotion of handwashing to the general public these partners: is not always visible. Research on habits of the general public reveals a gap between practice ! Mexico's Institute of Social Security, which is and the ideal. This is true in industrialized and using its infrastructure to distribute materials on developing nations as well. To address the need handwashing. The goal of this segment is to reach for handwashing promotion and education, more than two million rural residents during the Colgate-Palmolive launched a global education first 12 months. If Safeguard can reach this goal initiative, Clean Hands, Good HealthSM. The with good results, it plans to expand the program initiative began in 1998 with a poster campaign to reach 11 million people. entitled Lather Up for Good HealthTM, designed to promote and raise awareness of proper ! More than 2,000 Mexican radio stations, which handwashing through outreach to U.S. public have been running information on handwashing. health professionals and the community at large. In 2000 the program was expanded with the ! Mexico City's Children's Museum is featuring introduction of a school education program an interactive computer game about bacteria that designed to help educators teach school-age children can use at its main site and also in its children in an engaging way. Since its U.S. launch, traveling show. millions of children have been reached in the ! A puppet show promoting good hygiene to U.S., Asia, Latin America, and Africa. The more than 80 percent of first-grade students program consists of both a structured school in three cities, as well as in Merida's most curriculum as well as community programs. popular plaza. Children, parents, educators, and health professionals work together to make Unilever: Lifebuoy Swasthya Chetna handwashing an important component of hygiene (Awakening to One's Health) education and practice. Studies show that young children exposed to the curriculum can easily This program was borne out of a need for grasp the how and why to wash, making it a great personal hygiene practices like using soap companion in teaching self-protection. everyday for handwashing as well as bathing in India. It's a campaign in multiple phases and Procter & Gamble: touches every member of the community ­ Mexico Handwashing Program children, parents, influencers, and young mothers Mexico's Safeguard bar soap has been running ­ at all possible places of interaction, with every a multi-element campaign to promote possible media. 46 The Handwashing Handbook Lifebuoy Partnership The program uses an innovative tool, the `Glow The campaign is now in its third year, and the Germ demo,' to demolish the myth, `Visible clean response has been very encouraging. Villagers speak is safe clean' and demonstrate `Water is not very highly of it and consider it to be their campaign. enough.' Apart from this, stories, skits, quizzes, Lifebuoy Swasthya Chetna is currently covering rallies, health checkup camps, posters, close to 18,000 villages across eight states, in newsletters, and stencils are used to deliver keeping with the vision of contacting the message. 100 million people by the end of 2005. The Business Plan The first draft outlines the vision for the Setting up a handwashing partnership is an iterative and, partnership. Updated versions will reflect the in many cases, entrepreneurial process. While a general participation of new partners and the completion vision can be set out early on, objectives become more of components, such as consumer research and the detailed and activities crystallize as the project progresses. communications strategy. Holding this process together is the business plan (box 13), which provides potential stakeholders with the Business plans are usually limited to about 15 pages justification for contributing and shows them where with a one-or two-page executive summary. resources are needed. Interested parties can be invited to review more detailed documents, such as consumer research The business plan evolves with the initiative. As results or the communications strategy. The business the partnership grows, the business plan will help plan should be drafted in a simple attractive format participants consolidate ideas and reach consensus. that is easily disseminated. The Handwashing Handbook 47 Box 13: Elements of the Business Plan This outline provides a starting point for a The communications strategy summarizes the business plan that captures and promotes a communications strategy, setting out precise, handwashing program. measurable objectives, for example: "Double the rates of handwashing with soap among mothers of Executive summary: A one- to two-page summary children under five after using the toilet or cleaning of the business plan, usually written last. up a child" or "Fifty percent of new mothers in Vision, needs statement, and brief initiative the country will receive a free bar of soap and description: These brief documents answer such instruction on the importance of handwashing." It questions as: What will the project achieve? What sets out strategy, approaches, and the main needs will it fulfill? Who are the partners? elements of the communications plan. Sector summary: This document summarizes current The communications campaign describes and projected development flows into the country mass media, direct consumer contact, govern- that could be used for handwashing campaigns: ment programs, public relations, and any MDGs and Poverty Reduction Strategies ­ other components. sanitation and child mortality, etc. ­ show numbers Monitoring and evaluation describes the M&E and trends. Is this a growing area? It also describes strategy:Whatdatawillbecollected,how,andwhen? the country's soap market: Who are the players by sales revenue and volume? What are the trends? Management structure of the PPP: This is a record of existing and desired committees and their Analysis of health burden and cost of disease responsibilities, who will coordinate and what the What handwashing with soap can do: This document coordination tasks will be, and a justification of the is a summary of the scientific evidence for the choice of participants. importance of handwashing, its feasibility, and effectiveness. It forecasts the likely impact of the Timing and milestones indicates the amount to be partnership on health and the economy. funded and accomplishments to be completed by stipulated dates. Financial position and funding Handwashing in country X provides consumer needs show operating costs by component and research results and a summary of needed activity and includes sources of financing. It also behavior change. provides secured and needed support. Component Description Time Line Estimated Cost or `in Source of Kind' if Support is Funds (if Secured and Amount Secured) 1. Situation assessment and initial consensus 2. Program establishment 3. Consumer research 4. Strategy development 5. Materials development and testing 6. Campaign implementation 7. Monitoring and Evaluation 48 The Handwashing Handbook Conclusion -SA STUBBS/WSP GUY The Handwashing Handbook 49 Conclusion This handbook outlines an approach to the promotion of sector. However, for handwashing to be widely accepted handwashing with soap, an approach that will continue and sustained, such programs also need ownership in to develop. Ministries of Health and of Education. Many issues remain to be resolved. More work, for Greater evidence on the importance of handwashing to example, is needed to demonstrate cost-effectiveness. public health will also help improve acceptance. In In addition, public-private partnerships can be slow to particular, rigorous trials of the impact of handwashing build and be even slower to show results. This is not on infectious disease are needed. The evidence for the surprising, since communication between groups with impact on acute respiratory infections, specifically, is still different traditions, aims, and ways of doing business are weak and needs more investigation. In addition more difficult. Furthermore, personnel changes frequently research on comparing the effectiveness of different require that bridge building be repeated, as the Peru approaches to generating behavior change will help example shows. Nevertheless, as handwashing with soap optimize implementation. programs demonstrate their effectiveness, and documentation of experiences is applied, momentum and Available evidence is sufficient to enable public health to efficiencies will grow and stimulating partnerships act on issues that, on balances of probability, look the should become easier. most promising. From this perspective, making handwashing with soap ubiquitous is a key challenge for Anther key issue PPPs face is that hygiene does not have public health in the 21st century. Government, industry, a single institutional home. In the many programs, such support agencies, and academia all have important as Ghana, funding came from the water and sanitation roles to play. 50 The Handwashing Handbook References AMERICA TIN -LA WSP The Handwashing Handbook 51 References and Resources Burros A, D. Ross, W. Fonscea, L. Williams, and D. Moreira- Favin, M. 2004.ActivityReport143: PromotingHygieneBehaviorChange Filho. 1999. Preventing acute respiratory infections and diarrhoea in within C-IMCI: The Peru and Nicaragua Experience. Washington, D.C.: child day care centres. Acta Paediatrica 88(10): 1113­18. EnvironmentalHealthProject OHIDN/BGH/USAID.www.ehproject.org. Bateman, M., Bendehmane, D., and Saade, C. 2001. The Story of a Favin M., Naimoli G., and Sherburne L. 2004. Joint Publication 7: Successful Public-Private Partnership in Central America, Handwashing for Improving Health Through Behavior Change: A Process Guide on Hygiene Diarrheal Disease Prevention. Arlington, VA.: BASICS II, UNICEF, World Promotion. Washington, D.C.: PAHO, PLAN and EHP OHIDN/BGH/ Bank and EHP OHIDN/BGH/USAID. www.ehproject.org. USAID. www.ehproject.org. Bateman M., Jahan R., Brahman S., Zeitlyn S., and Laston S. Joint Gilman R.H., G.S. Marquis, G. Ventura et al. 1993. Water cost and Publication 4: Prevention of Diarrhea through Improving Hygiene Behaviors: availability: Key determinants of family hygiene in a Peruvian shantytown. The Sanitation and Family Education (SAFE) Pilot Project Experience. CARE, American Journal of Public Health 83 (1): 1554-58. ICDDR,B and EHP (OHIDN/BGH/USAID). Reprinted in 2002. www.ehproject.org. Hoque, B.A. 2003. Handwashing Practices and Challenges in Bangladesh. International Journal of Environmental Health Research, 13 Biran, A. 1999. What form could a DFID-funded Hygiene Promotion Supplement 1: 81-87. ProgrammeTakeinOrdertoSupportandHelpEnsureMaximumHealth Benefits from Proposed Improvements to Water Supply Systems in Jones,G.,Steketee,R.W.,Black,R.E.,Bhutta,Z.A.,Morris,S.S.and Northern Kyrgystan? MSc Thesis for LSHTM. theBellagioChildSurvivalStudyGroup.2003.HowManyChildDeaths Can We Prevent This Year?" Lancet, 362: 65-71. BuchholzandWordemann.2001.WhatMakesWinningBrandsDifferent: The Hidden Method behind the World's Most Successful Brands. Wiley & Kolesor, R., Kleinau, E., Torres, M.P., Gil, C., de la Cruz, V. and Sons, Chichester. Post, M. Combining Hygiene Behavior Change with Water and Sanitation: Monitoring Progress in Hato Mayor, Dominican Republic. Washington, D.C.: Cairncross, S. and Shordt, K. "It Does Last! Some Findings from the Environmental Health Project OHIDN/BGH/USAID, 2003. Multi-City Study of Hygiene Sustainability." Waterlines 22 (3): 4-7. www.ehproject.org. Cercone, James A. et al. 2004. Handwashing as a cost-effective approach to improving health: A framework for the economic analysis Luby, S. P., M. Agboatwalla, J. Painter, A. Altaf, W.L. Billhimer, and of handwashing projects: Case study of Central America and Peru. R.M. Hoekstra. 2004. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: A randomized Curtis V., B. Kanki, S. Cousens et al. 2001. Evidence for behaviour controlled trial. Journal of the American Medical Association 291: 2547-54. changefollowingahygienepromotionprogrammeinWestAfrica.Bulletin of the World Health Organization 79 (6): 518-26. McGahey, C. and Rosensweig, F. 2002. Hygiene Improvement Framework. Washington, D.C.: Water Supply and Sanitation Collaborative Curtis V., A. Biran, Deverell K., C. Hughes, K. Bellamy, and Council (WSSCC) and EHP OHIDN/BGH/USAID. www.ehproject.org. B. Drasar. 2003. Hygiene in the home: Relating bugs and behaviour. Social Science and Medicine 57 (4): 657-72. Omotade, O.O., C.M. Kayode, A.A. Adeyemo, and O. Oladepo. 1995. Observations on handwashing practices of mothers and Curtis V. and Cairncross. 2003.Water, Sanitation & Hygiene at Kyoto. environmental conditions in Ona-Ara Local Government Area of Oyo British Medical Journal 327: 3-4 State, Nigeria. Journal of Diarrhoeal Disease Research 13 (4): 224-28. Curtis V. and Cairncross. 2003. Effect of washing hands with soap on PRISM and EHP. 2004. Joint Publication 11E: Behavioral Study of diarrhoeariskinthecommunity:asystematicreviewTheLancet Infectious Handwashing with Soap in Peri-urban and Rural Areas of Peru. Washington, Diseases 2003; 3: 275-81 D.C.: EHP OHIDN/BGH/USAID. www.ehproject.org Delafield, S. 2004. Activity Report 128: Planning Tools for the Nepal Public-Private Partnership for Handwashing Initiative. Environmental Health Rai, R., Khanal, S., and Wicken, P. 2004. Hygiene Behavior Can Be Project OHIDN/BGH/USAID. www.ehproject.org. Sustained, A Report on the Nepal Country Findings of a Multi-Country Study on Sustaining Changes in Hygiene Behavior. NEWAH. EHP. 2004.StrategicReport8:AssessingHygieneImprovement:Guidelines for Household and Community Levels. Environmental Health Project Simpson,Mayling,Sawyer,Ron,andClarke,Lucy.1997. Participatory OHIDN/BGH/USAID, 2004. www.ehproject.org. Hygiene and Sanitation Transformation (PHAST): A New Approach to Working with Communities. WHO, EOS/96.11; reprinted 2002. www.WHO.org. EHP,UNICEF,WB/WSP,WSSCC,andUSAID.2004.JointPublication 8: The Hygiene Improvement Framework: A Comprehensive Approach to Sircar B.K., P.G. Sengupta, S.K. Mondal et al. 1996. Effect of Preventing Childhood Diarrhea. Washington, D.C.: UNICEF, WB/WSP, handwashing on the incidence of diarrhoea in a Calcutta slum. In Journal WSSCC, and EHP OHIDN/BGH/USAID. www.ehproject.org. of Diarrhoeal Diseases Research 5 (20): 114. EHP, UNICEF, WSSCC and USAID. 2004. Joint Publication 13 UNICEF/WES, USAID, World Bank/WSP, WSSCC. 2004. Joint (Adapted from EHP Joint Publication 8): Preventing Childhood Diarrhea Publication8,TheHygieneImprovementFramework:AComprehensive Through Hygiene Improvement. Washington, D.C.: EHP OHIDN/BGH/ Approach for Preventing Childhood Diarrhea. USAID. www.ehproject.org. Wood S., Sawyer R., Simpson-Hebert M. 2002. PHAST step-by- EHP. Behavior Change Lessons Learned. Washington, D.C.: EHP Office step guide: a participatory approach for the control of diarrhoeal disease. of Health, Infections Diseases and Nutrition, Bureau for Global Health, Geneva,WorldHealthOrganization(unpublisheddocumentWHO/EOS/ U.S.AgencyforInternationalDevelopment(OHIDN/BGH/USAID),1999. 98.3). www.WHO.org. www.ehproject.org. Esrey S.A., J.B. Potash, L. Roberts, and C. Shiff. 1991. Effects of Zaltman, J. 2003. How Customers Think: Essential Insights into the Mind improved water supply and sanitation on ascariasis, diarrhoea, of the Market. Harvard Business School Press. dracunculiasis, hookworm infection, schistosomiasis, and trachoma. World Bank, EHP, WSP: Handwashing Consumer Research Reports: Bulletin of the World Health Organization 69 (5): 609-21 Ghana, Peru, Senegal. 52 The Handwashing Handbook Tools and Terms of Reference AMERICA TIN -LA WSP The Handwashing Handbook 53 Tools and Terms of Reference Tool 1: Behavioral Trials and In-depth In the course of the interview you are to probe into the Interviewing reasons, likes, and dislikes for each separate handwashing Information and Instructions for Fieldworkers occasion, noting whether soap is used or not and why. It is just as important to learn from those women who did What Is a Behavioral Trial? not use the soap given to them as those who experienced A behavioral trial introduces a behavior to individuals and positive experiences. Often informants will refer to assesses their experiences with trying to carry out that subjective concepts such as cleanliness and dirtiness. It is behavior over a period of seven to 14 days. It gives insight important that you probe into what people mean by such into how easily that new behavior is adopted, things that terms and how they are indicated, noting especially what facilitated its practice, and those that hindered it. In this sensory cues (touch, sight, smell, etc.) are involved. case a soap is given to each participant, who is asked to The Post-Experience Interview use this soap ONLY for handwashing with soap, focusing particularly on handwashing after contact with feces (after ! Last week I left a soap with you and asked you to use defecation, after wiping a child's behind, and after it specifically for handwashing, did you use it? disposing of stools), and before feeding a child. After a period of time an interviewer visits each woman and ! ASK TO SEE THE SOAP AND NOTE HOW MUCH carries out an in-depth interview with her to learn about THE PRODUCT APPEARS TO BE USED AND WHERE her experiences between the two visits. IT WAS KEPT: RECORD ITS CONDITION: _________________________________________________________________________ The key practice we are interested is handwashing with _________________________________________________________________________ soap, what motivates women to carry out this behavior, WHERE SOAP WAS KEPT:_____________________ and what hinders them. In particular, we are interested in handwashing WITH SOAP after defecation, after _________________________________________________________________________ wiping a child's behind, after disposing of a child's stools, ! Before we begin, may I get some basic and before feeding a child. sociodemographic information from you? How old are you? Under 24 = 1 25-30 = 2 31-35 = 3 36-40 = 4 41+ = 5 Where do you live? Place Name: ______________________ Place Type: Urban = 1 Peri-urban = 2 Rural = 3 What is the highest level of education you have attained? What is your occupation? What is your husband's occupation? Does your husband work at home or away? Home = 1 Away = 2 How many children do you have? One = 1 Two = 2 Three = 3, etc. How many of these are under five years? One = 1 Two = 2 Three = 3 etc. IF NO CHILD IS UNDER FIVE YEARS, TERMINATE INTERVIEW. 54 The Handwashing Handbook How old is your youngest child? 0-6 months = 1 7-12 months = 2 1-2 years = 3 3-5 years = 4 Have you moved to work or live in another town/city in the past 12 months? Yes = 1 No = 2 Place:_____________________________ Where do you defecate? WC = 1 Private ordinary pit = 2 Private VIP = 3 Private pour-flush = 4 Public = 5 Bush = 6 Other = 7 _______________________ Where do your children defecate? Pottie = 1 Wrapper = 2 Floor = 3 As above = 4 Now conduct the interview covering the topics below: General Soap Before being given this soap, for what did you use the soap and why? Experiences Usual handwash occasions and reasons. IF THEY MENTION DIRT OR CLEANLINESS, ASK THEM WHAT THEY MEAN (Each time a AND HOW THEY CAN TELL IF SOMETHING IS CLEAN OR DIRTY (I.E., handwashing is CAN YOU BE DIRTY EVEN IF YOU CANNOT SEE, SMELL OR TOUCH mentioned, clarify THE DIRT?). whether soap is used Water source for handwashing. or not and why hands Any shortages in water supply? are washed with or Does this affect handwash practice? without soap.) Is soap ever used for handwashing? If so, when and why? What cues drive the use of soap? If not, then why is soap not used? Type of soap: Toilet or multipurpose. REASONS. Soap source and storage. Availability of soap. What happens when soap is unavailable? How do women feel when soap is not available, how do they get over this? Key benefits to using soap for handwashing AT EACH JUNCTURE. Key dislikes/problems associated with handwashing with soap. Most important times to wash hands with AND without soap. Reasons. Other uses of soap and reasons. Soap Usage Was the soap given to the woman used? What was it used for and where was it kept? (Get woman to show you, if she hasn't already. Note soap condition and place of storage.) Non-Soap Users/ Why was the soap not used? Little Use Are these reasons general or specific to the brand given? What would have aided/encouraged soap use? Was a different soap used for handwashing? IF ANSWER IS YES, CARRY ON AS BELOW, IF NOT TERMINATE INTERVIEW. The Handwashing Handbook 55 Soap Users If not already answered, for what purpose was the soap used for and why? PAY PARTICULAR ATTENTION TO HANDWASHING WITH SOAP. BE SURE TO NOTE THE REASONS FOR EACH SEPARATE HANDWASH INCIDENCE (THE REASONS ARE LIKELY TO BE DIFFERENT). Did other people in the household use the soap, if so which members, for what purpose and why? Soap Use Experiences Likes and dislikes about the soap given. Feeling after handwashing with soap ­ at each juncture. Differences between using soap and water alone ­ at each juncture. Difficulties associated with handwashing with soap. How difficulties were overcome. Was handwashing with soap ever forgotten, if so why and what was done to remember. Best things about handwashing with soap. Worst things about handwashing with soap. Benefits of handwashing with soap, both absolutely and as compared to using water alone. Soap Attributes If a person has not been asked about likes and dislikes of soap in above section ask now. Was soap given a good one, or is there one on the market that is better. If so, which one and why? Most important attributes of a soap for handwashing. (Probes: cost, smell, color, multipurpose, skin care, size, lather, etc.) Reasons. FINAL Having experienced handwashing with soap does the participant think it is good? Will she continue to handwashing with soap once this bar has finished? Will she continue to buy soap? From where, which one? What will she use it for? How would she persuade someone else to take up the habit of handwashing with soap? Ask "If I returned in a month, or a year, would I still find you washing your hands with soap?" And "At what junctures would you be washing your hands with soap?" THANK YOU VERY MUCH FOR TAKING THE TIME TO TALK TO ME, I HAVE LEARNED A LOT FROM YOU. OUR CHAT HAS BEEN VERY INTERESTING. DO YOU HAVE ANY FINAL COMMENTS? Tool 2: Structured Observations Instructions Format to be Adapted for Behavior Study and Baseline for M&E Arrive five minutes before start of observation time (05.55). Objectives: to Determine: ! The proportion of times mothers wash hands with Greet politely and ask for a seat in the yard. Place the soap (WHWS) after using the toilet. seat where you can observe domestic activity. ! The proportion of times mothers WHWS after cleaning up a child. Sit quietly and keep conversation to the absolute ! The proportion of times mothers WHWS before minimum. feeding a child. When an event of interest occurs, watch closely what ! The proportion of times school-age children WHWS happens, then fill in the relevant section of the form. after the toilet at home. ! The proportion of times school-age children WHWS After completing the observation period, move on to before eating at home. the survey form (questionnaire). 56 The Handwashing Handbook Before leaving, check that an answer has been filled in to every question. This will prevent your having to come back again. Always use a blue biro. Any other colors or writing instruments will be refused. Put a ring round the correct response. If you make a mistake, cross it through once and ring the correct response. Only one response is allowed for each question. Only supervisors can fill in 9 or 99. Notes Format designed for analysis with EPIINFO: 5-letter codes are unique identifiers. Structured Observation of Childcare Practices Section 1. Identification 1.1 Identification number of mother IDMOT |__|__|__|__| 1.2 Identification number of observer IDOBS |__|__|__|__| 1.3 Name NMEMO 1.4 Address ADDMO 1.5 Name of the index child <5 NMECH 1.6 Sex of the child M=1 F=2 9. SEXCH 1.7 Date of visit DAVIS |__|__|.|__|__|.|__|__| 1.8 Arrival time ARRTI |__|__|.|__|__| 1.9 Observation start time STATI |__|__|.|__|__| 1.10 Observation complete time FINTI |__|__|.|__|__| The Handwashing Handbook 57 Section 2. Index Child Defecation 2.1 Did the index child defecate while you were present? Yes, I saw = 1 Yes, I'm sure s/he did = 2 No s/he didn't = 3 9 ICDEF ONLY FILL IN THE NEXT SECTION IF THE INDEX CHILD DEFECATED 2.2 What time did the child defecate? TIDEF |__|__|.|__|__| 2.3 Where did the child defecate (first time)? In a nappy/pants/wrapper = 1 On the ground/floor in the yard/house = 2 In a potty = 3 On the ground outside the compound = 4 On a paper = 5 In the toilet = 6 Other (write in) = 7....................................................... 9 WHDEF 2.4 Did someone clean the child's bottom? Nobody = 1 Mother = 2 Sister = 3 Grandmother = 4 Other = 5 9 CLBOT 2.5 Did someone clear up the child's stools straightaway? No = 1 Mother = 2 Sister = 3 Grandmother = 4 Other = 5 9 CLST1 2.6 Immediately after completing stool contact, did the person . . . Carry on as before = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 ICWH1 If 2.4 and 2.5 were different, for the second person fill in: 2.7 Immediately after completing stool contact did the second person . . . Carry on as before = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath =7 No second person/Unable to see = 8 9 ICWH2 2.8 Did someone clear up the child's stools later on? No = 1 Mother = 2 Sister = 3 Grandmother = 4 Other = 5 9 CLST2 2.9 Immediately after clearing up stools did the person . . . Carry on as before = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 ICWH3 2.10 Where did water for handwashing (first person) come from? Hands not washed = 1 From a container in the compound = 2 Laundry water = 3 A tap = 4 Unable to see = 5 9 ICWAT 2.11 Where did soap for handwashing come from? Soap not used =1 Soap kept near water source = 2 Soap distant from water source = 3 Unable to see = 4 9 ICSOA 58 The Handwashing Handbook 2.12 What brand of soap was used? Soap not used = 01 Duck = 02 Imperial Leather = 03 Sunlight = 04 Canoe = 05 Rexona = 06 Lifebuoy = 07 Key = 08 Medimix = 09 Geisha = 10 Sweetie = 11 Johnson's Baby = 12 Ayu = 13 Safeguard = 14 Sa = 15 CB = 16 Guardian = 17 Harmony= 18 Village Fresh liquid = 19 Tempo = 20 Fa = 21 Premier =2 2 Lux = 23 ..... List Soap powder = 64 Unidentified liquid soap = 65 Unidentified brown soap = 66 Unidentified colored soap = 67 Unidentified local soap = 68 9 ICBRD Other = 77 Specify___________________ Unable to see = 88 Section 3. Feeding Index Child 3.1 Did a carer feed the index child during the observation period? Yes, I'm sure = 1 Yes, I think so = 2 No = 3 9 ICFED ONLY FILL IN THE QUESTIONS BELOW IF THE INDEX CHILD WAS FED 3.2 For the first item of food or meal, who fed the child? Mother = 1 Sister = 2 Grandmother = 3 Other = 4........................................... 9 ICWFD 3.3 What was the food and how was it served? `Meal' food served with an implement = 1 `Meal' food served with hands = 2 Liquid food served with an implement = 3 Liquid food served with hands = 4 Snack food served with an implement = 5 Snack food served with hands = 6 9 ICFOO 3.3 Immediately before feeding did the person . . . Not wash hands = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 ICFWH The Handwashing Handbook 59 Section 4. Mother's Defecation 4.1 Did mother go for defecation/toilet during the observation period? Yes, I'm sure = 1 Yes, I think so = 2 No = 3 9 MODEF ONLY FILL IN THESE QUESTIONS IF THE MOTHER WENT FOR DEFECATION 4.2 Where did mother go for toilet? To a public toilet = 1 To a toilet outside the compound = 2 To a toilet in the compound = 3 To a toilet inside her house = 4 To the bush = 5 Used a paper = 6 Not sure = 7 9 MOWHE 4.3 Immediately after completion, did she . . . Carry on as before = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 MOWHS 4.4 Where did water for handwashing come from? Hands not washed = 1 From a container in the compound = 2 A tap = 3 Unable to see = 4 9 MOWAT 4.5 Where did soap for handwashing come from? Soap not used = 1 Soap kept near water source = 2 Soap distant from water source = 3 Unable to see = 4 9 MOSOA 4.6 What make of soap was used? Soap not used = 01 Duck = 02 Imperial Leather = 03 Sunlight = 04 Canoe = 05 Rexona = 06 Lifebuoy = 07 Key = 08 Medimix = 09 Geisha = 10 Sweetie = 11 Johnson's Baby = 12 Ayu = 13 Safeguard = 14 Sa = 15 CB = 16 Guardian = 17 Harmony = 18 Village fresh liquid = 19 99 Tempo = 20 Fa = 21 Premier = 22 Lux = 23 ..... List Soap Powder = 64 Unidentified liquid soap = 65 Unidentified brown soap = 66 Unidentified coloured soap =67 Unidentified local soap = 68 Other = 77 Specify MOBRD ________________________________________________ Unable to see = 88 60 The Handwashing Handbook Section 5. School-Age Child Defecation RECORD FIRST SCHOOL-AGE CHILD SEEN 5.1 Did you see a school-age child going for defecation during the observation period? Yes, I'm sure = 1 Yes, I think so = 2 No = 3 9 SCDEF ONLY FILL IN THESE QUESTIONS IF YOU SEE A SCHOOL-AGE CHILD GO FOR DEFECATION 5.2 Where did the child go for defecation? To a public toilet = 1 To a toilet outside the compound = 2 To a toilet in the compound = 3 To a toilet inside his/her house = 4 To the bush = 5 Used a paper = 6 Not sure = 7 SCWHE 5.3 Immediately after completion, did the child Carry on as before = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 SCWHS 5.4 Where did water for handwashing come from? Hands not washed = 1 From a container in the compound = 2 Under a tap = 3 Unable to see = 4 9 SCWAT 5.5 Where did soap for handwashing come from? Soap not used = 1 Soap kept near water source = 2 Soap distant from water source = 3 Unable to see = 4 9 SCSOA 5.6 What make of soap was used? Key = 01 Duck = 02 Imperial leather = 03....List brands Unidentified brown soap = 66 Unidentified colored soap = 67 Unidentified local soap = 68 Unable to see = 88 99 SCBRD Section 6. School-age Child Seen Eating NOTE: RECORD FIRST SCHOOL-AGE CHILD SEEN EATING, MAY BE DIFFERENT FROM SECTION 5 6.1 Did you see a school-age child eating during the observation period? Yes = 1 No = 2 9 SCEAT ONLY FILL IN THESE QUESTIONS IF YOU SEE A SCHOOL-AGE CHILD EATING 6.2 Immediately before eating did the person Not wash hands = 1 Rinse one hand with water = 2 Rinse both hands with water = 3 Wash one hand with soap = 4 Wash both hands with soap = 5 Rinse hands in soapy water = 6 Take a bath = 7 Unable to see = 8 9 SCEWH 6.3 What was the food and how was it eaten? `Meal' food eaten with an implement = 1 `Meal' food eaten with hands = 2 Liquid food eaten with an implement = 3 Liquid food eaten with hands = 4 Snack food eaten with an implement = 5 Snack food eaten with hands = 6 9 SCFOO The Handwashing Handbook 61 Structured Observation Instructions at Public Toilet Arrive at 05.55. Objective 1: Record total number of users and total number of users who wash hands with soap. Sit in a place where you can see people entering and leaving and where you can see handwashing, if any. Objective 2: Record conditions in public toilets. Carry out the observations. At 09.00 use the toilet and then fill out section 3. Section 1. Identification 1.1 Identification number of toilet IDTOI |__|__|__|__| 1.2 Identification number of observer IDOBS |__|__|__|__| 1.3 Name of toilet NMEMO 1.4 Address ADDMO 1.5 Date of visit DAVIS |__|__|.|__|__|.|__|__| 1.6 Arrival time ARRTI |__|__|.|__|__| 1.7 Observation start time STATI |__|__|.|__|__| 1.8 Observation complete time FINTI |__|__|.|__|__| Section 2. Public Toilet Conditions Note: After completing observation, ask to use the toilet Questions refer to the main part of the toilets used by and fill in this section. the general public. 2.1 How many male cubicles does the toilet have? TCUBM 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 99 2.2 How many female cubicles does the toilet have? TCUBF 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 (If no M&F, fill in just 2.1) 99 Is there a separate facility for VIPs? Yes = 1 No = 2 2.3 What is the price of using the toilet for an adult? |__|__|__|__| Cedis 62 The Handwashing Handbook 2.3 What is the price of using the toilet for an adult? |__|__|__|__| Cedis 2.4 What is the price of using the toilet for a child? |__|__|__|__| Cedis 2.5 What is the additional cost of toilet paper? |__|__|__|__| Cedis 2.6 What is the additional cost of washing hands? ||__|__|__|__| Cedis 2.7 What is the condition of the superstructure? Overall, well maintained, roofed, recently painted = 1 Reasonable, some cracks, painted but not recently = 2 Tatty, dilapidated = 3 9 2.8 What is the condition of the floors? Solid and very clean = 1 Cracking, unswept = 2 Dilapidated and dirty = 3 9 2.9 What is the condition of the cubicles? Solid and very clean = 1 Cracking, unswept = 2 Dilapidated and dirty = 3 9 2.10 What is the condition below ground? Sewer connection/septic tank (WCs) = 1 Pit, not full = 2 Pit, visibly nearly full = 3 Pit full = 4 Pit overflowing = 5 9 2.11 Subjectively, how did you find using the toilet? Extremely smelly and disgusting = 1 Smelly and disgusting = 2 Reasonable = 3 Very clean and free of smell = 4 9 2.12 Any other remarks (insects, flies, dangerous structure, feces on ground, etc.) 2.13 Is there some means of washing hands inside the toilet building? Yes = 1 No = 2 2.14 Is there some means of washing hands immediately on exit from the toilet building? Yes = 1 No = 2 If no to 2.13 and 2.14 skip to Q 2.15 Source of water for handwashing None = 1 Basin with tap water (functioning) = 2 Handwashing stand with water = 3 Bowl or container to put hands in = 4 Container of water, water given to clients = 5 Other.... Describe = 6................................................................. 9 The Handwashing Handbook 63 2.16 Is soap available for handwashing? Yes = 1 No = 2 2.17 What sort of soap is available? What make of soap was used? Soap not used = 01 Duck = 02 Imperial Leather = 03 Sunlight = 04 Canoe = 05 Rexona = 06 Lifebuoy = 07 Key = 08 Medimix = 09 Geisha = 10 Sweetie = 11 Johnson's Baby = 12 Ayu = 13 Safeguard = 14 Sa = 15 CB = 16 Guardian = 17 Harmony = 18 Village fresh liquid = 19 Tempo = 20 Fa = 21 Premier = 22 Lux = 23 ..... List Soap Powder = 64 Unidentified liquid soap = 65 Unidentified brown soap = 66 Unidentified coloured soap = 67 Unidentified local soap = 68 Other = 77 Specify.................................................................... Unable to see = 88 64 The Handwashing Handbook Section 2. Observation Of Clients Leaving Facility It is very important that you record all people leaving. Instructions: Complete for all people leaving. If you miss (WH = washed hands; WHWW = washed hands with whether they washed their hands, indicate "didn't see." water; WHWS = washed hands with soap). Person Tick One Office Use Exit time Didn't WH WHWW WHWS Didn't see 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 The Handwashing Handbook 65 Tool 3: Focus Groups Begin with a round of introductions. Each woman should introduce herself (she may use an alias), what her Handwash Behavior Study Instruments occupation is, what her husband's occupation is, how many Focus Group Discussion Guide children she has, and how old they are. Instructions for Fieldworkers: We are going to focus the discussion on a series of The key practice we are interested is handwashing exercises to encourage group interactions: the basic with soap, what motivates women to carry out this content of each exercise is described below. behavior and what hinders them. In particular we are interested in handwashing with soap after The Exercises defecation, after wiping a child's behind, after 1. Daily Activities/Life Values disposing of a child's stools, and before feeding a child. ! Ask each woman to outline what they do each day, In the course of the focus group, you are to probe into noting the key activities on separate pieces of paper. reasons, likes, and dislikes for each separate handwashing ! Wheneachwomanhassummarizedherday,askthem occasion, noting whether soap is used or not and why. It to rank these activities in order of their importance and can be difficult in transcripts to distinguish whether people the satisfaction and enjoyment each activity provides. are talking about bathing, handwashing with water alone, They may shuffle the pieces of paper around, as this or handwashing with soap. It is therefore important that helps the thought processes and discussion. you are make clear which of these the participant is talking about on each occasion. While women's bathing ! Askthewomentoexplainthereasonsfortheranking behaviors can be interesting and inform us about they have chosen. motivations for more general hygiene behaviors, the focus of interviews should always be handwashing with soap. 2. Soap Use Ranking ! Ask each woman to note what she uses soap for, Often informants will refer to subjective concepts such noting each use on a separate piece of paper. as cleanliness and dirtiness. It is important that you probe into what people mean by such terms and how ! When each woman has summarized the main uses of they are indicated, noting especially what sensory cues soap, ask them to rank these in order of importance, (touch, sight, smell, etc.) are involved. Often habit will discussing while they do this and the reasons for the order be mentioned, or women will not be sure as to why they are choosing. they hand wash with soap: try to probe into when they 3. Handwash Junctures Ranking started the practice, who taught them, why and when. ! Ask the women when they wash their hands, noting Whenever someone gives a reason for a behavior, each handwashing occasion on a separate piece of paper. especially handwashing with soap try to probe as deeply For each juncture ask whether soap is used and note this as possible, often the original answer is a means to on the appropriate piece of paper. achieving a higher goal, and we want to know what this final goal is. What are the most important benefits of ! Lay the pieces of paper out in two categories: with hand washing with soap? and without soap. In focus group discussions it is common that certain ! For each category ask women which junctures are participants dominate, while others keep quiet. We want most important for handwashing and why handwashing to hear everyone's views, so try to encourage everyone to is practiced. contribute. It is also important to allow women to guide ! In the case of water only, ask why soap is not used. the shape of exercises and discussion themselves. While youareafacilitator,youmustnottakeovertoomuch:Women ! In the case of with soap, ask why soap is used. should feel in control of what they are doing/discussing. ! Note ­ in discussion of reasons for handwashing (both with and without soap), deep probing is necessary to The Discussion understand what cues are most important. Terms such as Before beginning, explain to women that there are no cleanliness and dirtiness are not reasons in themselves: How right or wrong answers and that you just want to learn is the reason to wash hands perceived? Sensory cues, feelings from them and hear what they think. of contamination, other people watching, protect child, etc. 66 The Handwashing Handbook 4. Personification Exercise ! Which ads have they seen/heard and liked lately? ! Ask women to describe the profile of the following Why did they like them? Do they make them want to two people: buy the products? 1. A person who washes their hands with soap regularly. 2. A person who never washes their hands with soap. Tool 4: Tips on Researching School-Aged Children Probes: Appearance, hobbies, music preference, School toilets are not just used for practical issues of educational level, position in society, condition of hygiene. Adolescent girls may meet to apply make up, compound, what people think of them, etc. discuss boys, and make plans for after school, and boys may smoke a cigarette. Children may have different ! What do women feel about the two people they motivators for using the toilets, mainly to gossip and to have described? have some private time with their friends, far from the 5. Concepts Ranking watchful eye of the teachers. Children may be reluctant ! Read out each concept (social acceptance, status, to wash their hands in school, because being a good health, nurture/children, cleaniliness/contamination, student is associated with having chalk all over your hands. thrift) to the group one at a time. Another very important feature of schools is the fact that children do not want to lose one minute of play ! After each concept ask the women to discuss how with their friends. These aspects need to be kept in they feel about that concept and its importance to them. mind when researching kids. ! Wheneachconcepthasbeendiscussed,presenteach one on a separate piece of paper and ask the women to Tips: rank them in order of: 1. Segmentation: Think like a Child. Children have their own agendas that are important to them. While ! Importance the onset of puberty for a 12-year-old, adolescent girl ! Relevance may be a motivation towards hygiene, a six-year-old boy's ! Interest playful nature may need a different appeal. If segmentation ! Disgust of different age groups is not appropriately done, promotion is unlikely to be effective. ! Ask them to explain their reasons for each ranking. 2. Be creative. The conventional methods of focus ! Finallyaskthemwhichconceptaffectsthemthemost groups and questionnaires may never find the truth. For and which concept they think would be most useful in children under the age of 10, interviews should if possible trying to persuade someone to adopt a new habit such be based on observation and play. Research methods that as handwashing with soap before `Name a Juncture.' include stimuli (video clips, drawing, photography, local 6. Communication Channels games) generate more insight. Knowing all the local songs ! Ask women what their main sources of information and games that are in fashion is very helpful. are for: 3. Children evolve in groups. Children love being in ! Local groups and do not like time away from their playmates. Research methods that include play groups and friendship ! National pairs (interviewing two friends at the same time) can ! International news facilitate finding useful insights. Questions can be redirected so that the children talk to each other. ! Health issues 4. Separate adults and children. In schools there are ! How often do they have contact with each of risk practices carried out by adults (teachers and head these channels? teachers) that children know and may be scared to report ! Which of these channels do they like the most? Why? during research carried out in the school settings (for example, teachers may systematically take the soap ! Which of these channels are most credible/do they home). Different research methods will be needed to believe or trust the most? gather insights from different groups. The school The Handwashing Handbook 67 watchman in certain contexts is highly respected and is Terms of Reference 1: Consumer Research an important figure amongst children. 1. Background Diarrhea kills about two million children every year. 5. Children can be the lead researchers. Children Human excreta is the source of most diarrheal pathogens can play a role as the senior researchers carrying out the and probably the most important moments at which hands research on their peer groups. They are likely to should be washed with soap are after contact with human distinguish the differences between the truth and fantasy. excreta and before handling food. A recent review of all The spirit of competition often motivates children to the available evidence suggests that handwashing with express themselves. Organizing a competition to get soap could reduce diarrhea incidence by 42-46 percent children to express their frustrations about the poor and save at least one million lives worldwide. hygiene in their schools and then identify some of the key features that keep reappearing. Try asking children The World Bank and the Water and Sanitation the same thing in different ways in order to find the Program (WSP), the London School of Hygiene & truth; for example, ask them to draw, write, come up Tropical Medicine (LSHTM), the Academy for with words, and create comics and collages. Educational Development, and the private sector, in collaboration with USAID, UNICEF, and the Bank- 6. Start with the head teacher. The head teacher Netherlands Water Partnership are implementing a sets the tone for his or her school and decides if hygiene global initiative aimed at promoting the use of is going to be an important subject. Interviewing the head handwashing with soap in developing countries. teacher and then providing him or her with the study Partnerships were established in two pilot locations in report will ensure that you have the educational 2001: Ghana and Kerala, India. During FY03, the authorities' blessing. initiative will expand in at least two additional countries. 7. Identify `Leaders of the Pack.' Leaders of the pack In [country], the [country lead agency], the Water and or opinion leaders are key in school settings. Children model themselves after a few leaders in the school. To Sanitation Program (WSP), and the World Bank in know what is cool, what is in, and how best to address collaboration with other public and private partners, the other kids, identifying these opinion leaders is crucial. proposes to develop a Public-Private Partnership Teachers may know who they are. Consider training Handwashing Initiative (PPPHW) with the overall identified leaders to run your focus groups. objective of improving the health of populations at risk of diarrhea through a public-private partnership promoting handwashing with soap. Things to avoid: 1. Taking up recess time with questionnaires. Note: this document concerns formative research only. Children love their recess time. If you take it, their Separate monitoring and evaluation (M&E) studies will answers will not be much use, as kids will rush though so be executed for the purposes of documenting the impact as to get out and meet their friends. If you plan to carry of the program. out research during that time, make sure it is a group activity and that the children enjoy it. 2. Rationale for handwashing in [country] The rationale for proposing such an initiative in the 2. Making children feel younger than they are. If country is: there is one thing that children dislike, it is being made to feel younger than they are. Children hate to be Diarrheal diseases are one of the most important causes babied. Knowing what is acceptable to each age group of morbidity and morbidity in [country] in children under is crucial. five years old (source). 3. Breaking the confidence vow. Researching children Reliable data on handwashing with soap after using a toilet is no different from adults in respect to keeping or after cleaning up a child are [not available] in [country]. information in confidence. Children expect it. However,... 4. Taking what children say for granted. The key Informal discussions with community women and men to research with children is to investigate what they would revealed that... not say. Children have a clear idea of what they think a It is now recognized that handwashing is a much more cost- researcher wants to hear. effective means of lowering diarrheal incidence than the more 68 The Handwashing Handbook costly infrastructure building programs (that is, water and A methodology for formative research techniques is explained sanitation). Nevertheless, hygiene promotion initiatives in in the booklets `Happy, Healthy and Hygienic' (UNICEF/ the country have in the past focused on the provision of LSHTM 1998). water and sanitation facilities, good storage methods, and water treatment but not on handwashing. Little is therefore 5. Responsibilities of the contracted agency known about the availability, affordability, and desirability of The agency will be responsible for the following: soap, especially for use after contact with excreta in rural Detailed study design in collaboration with [lead agency] and semi-urban areas. There is a need to make a connection (that is, the client) and their technical advisors. between hygiene promotion/provision of water and sanitation facilities on one hand and the production and distribution of Set up and manage the study. affordable soap on the other. Industry stands to gain by selling more soap through an expansion of their market into Logistics arrangements, that is, travel, accommodation, more households and by better market penetration towards allowances, communications, and stationery. poorer households. Public agencies stand to gain by involving Quality Assurance. soap manufacturers in their programs aimed at improving the quality of life by reducing morbidity related to improper Analysis of the results. hygiene practices. [to update/drop as required] Production of a final report in 10 copies 3. Objectives of the assignment This formative research will enable the partners to It is the responsibility of the agency to recruit, train, and design an appropriate handwashing campaign. supervise a suitable team of field workers. Therefore, the main objective of this research is to The Global Partnership will provide technical support to develop the insights needed to design an effective the agency at key stages of the assignment, which may communication program to promote handwashing include: the appraisal of technical submissions; review of with soap. proposed detailed study designs and guidance from prior experience; assistance with the training of field workers The specific objectives of the assignment are: during piloting of instruments, fine tuning and finalizing of proposal;monitoringofthequalitycontrolsystemtoevaluate to record current handwashing practices and their progressandrefocusifnecessary;reviewoffirstdraftreport context; and recommendations for production of the final report. to understand what drives and facilitates handwashing in 6. Qualifications and selection of the contracted communities; agency The contracted agency will be a professional consumer to identify target audiences; and or market research organization with track record of at least five years of consumer studies in [country and/or to document current channels of communication. region].The team will need to demonstrate their members' experience both in quantitative and qualitative 4. Methods research techniques. Commercial/industry sector The study requires the employment of both experience is essential. quantitative and qualitative research techniques and may include focus group discussions, behavior trials, The qualifications of the proposed study team will make up structured interviews, and structured observations for a part of the submission and should be as follows: data collection (as set out in the table in section B of One statistician and one social scientist or anthropologist the annex), as well as the compilation of available with: routine data. Track record on qualitative and quantitative surveys; Detailed study designs will be proposed by the contracted agency and finalized in collaboration with the technical Familiarity with industry; advisor (that is, the lead agency's consultant recruited for Experience in cleaning products; and the program) and with the technical support of the partnership. Knowledge of the local language. The Handwashing Handbook 69 Field workers should: summary document suitable for posting on websites. have at least one year of experience of field work; A presentation of results at stakeholder workshop. be female; and The main report will include the following chapters: be fluent in local languages (as appropriate). I. Approach The firm will provide a detailed plan for the management II. Methods and quality assurance of the study and justify the proposed staffing. III. Implementation schedule 7. Final products IV. Results set out using the framework of table in The final products include: section A of the annex Cleaned and fully referenced electronic data sets in an V. Conclusion and recommendations agreed format with copies of the original data The report will contain graphics when needed. collection forms. Annexes will contain all relevant background Full transcripts of all in-depth interviews and focus group information for the study that is not necessary in the discussions in an electronic format. body of the report. A 50-page document in 10 copies with detailed findings. 8. Time schedule It is expected that the work will last about 13 weeks An eight-page illustrated summary document suitable for from appointment to final report. The schedule for each general consumption and an electronic version of the phase is set out in the table below: Activity When Set up and training Week 1 Inception report with refined methodology and pretested materials Week 2 Field survey Week 3 to 10 Analysis Week 10 Draft report and stakeholder workshop Week 11 Final report Week 14 70 The Handwashing Handbook Section A: Framework of variables and data collection techniques The following sets out the framework for the formative research on handwashing and is intended as guidance for the agency in designing and conducting the research. Issues Data Source/Method Notes 1. What are current handwashing practices? 1.1 What are the handwashing practices of Quantitative representative Note 1: Refer to M&E child caregivers (at key junctures)? sample on handwashing framework. 1.2 What are handwashing practices of practices using Note 2: The specific occasions other family members (at key junctures)? Structured Observation for handwashing to be recorded 1.3 What soap (laundry versus beauty soap) depend on the exact objectives or other agent is being used? of the handwashing program. 1.4 What is the source of water? Note 3: Structured observation 1.5 What is the immediate placing of soap? needs to be designed to capture all handwashing events at key 1.6 How do people dry their hands after junctures. washing? 2. What drives and facilitates handwashing? 2.1 Drivers Behavior trials Note 4: A driver is a psycho-social What motivate domestic hygiene, bathing motivator or inhibitor for and handwashing with soap? In-depth interviews including with school kids (about 12 hygiene behaviors and can be After what is handwashing practiced? ­ years old) either positive or negative. With/without soap? Focus group discussions Note 5: When noting drivers for Specific cues and occasions for people to (FGDs) hygiene behaviors it is necessary wash their hands. to note motivators for ­ general Reasons for not using soap at key hygiene, bathing, handwashing handwashing junctures? that is, psycho- (without soap) and handwashing social inhibitors to soap use ­ cost, smell, with soap separately, paying drying of skin... particular attention to How and when was handwashing learnt? handwashing with soap. Who taught it? Note 6: Probe meaning of `clean' What are the attributes of a good and `dirty' ­ are these defined handwashing soap? visually, by feel, smell, or Brand ranking of both soaps and their concepts of moral purity? attributes for handwashing (ask why ranked The environment refers to the like this) and of handwashing practices. external conditions that facilitate Ranking of hypothesized drivers/concepts or hinder handwashing with (status, nurture, disgust, aesthetics, soap. See the annexed note on attractiveness). Handwashing Motivation Images/beliefs concerning cleanliness/ (Annex 3). dirtiness, healthy/non-healthy person, Training on handwashing hygienic/non-hygienic... motivation and concept Rules for soap use within the household. ranking needed. The Handwashing Handbook 71 2.2 Environment Household survey Water supply: Where, Type, Access (cost, Structured observations distance, who), Storage. In-depth interviews Sanitation facilities: Where, Type and FGDs Access (including for children), Presence of fecal material in the yard? Handwashing facilities: What is it? (probe) Where is it?/availability ­ Distance from toilet, Storage place of soap, State, Access. 3. Who are the target audiences? 3.1 Who buys the soap? FGDs 3.2 Who decides about soap buying? In-depth interviews 3.3 Who influences the buyers and Household survey decision makers? 4. How do target audiences communicate? Exposure and reach of all channels of communication including modern and traditional. 4.1 Time spent and media consumption Household survey Note 7: Allow costs of moments (quantitative data). FGDs/In-depth interviews consulting commercial databases. (IDIs) Commercially available media data 4.2 Reach of all traditional channels of Households surveys Note 8. Traditional channels may information? FGDs/IDIs include churches, social 4.3 Reach of government channels of organizations, women's groups, communication? markets, local events, etc. Government channels include 4.4 What programs do they like and why? contact with health services What do they remember? (qualitative data) (e.g., vaccination coverage, 4.5 Which adverts do they know and like, maternity and post-natal care), and why? schools, agricultural extension, 4.6 Which communication channels do they local authorities, etc. find the most credible? 72 The Handwashing Handbook Section B: Definitions of Research Tools Disgust: An instinct to avoid and remove anything disgusting, which includes sensory cues (olfactory, Household Survey: Designed for a representative tactile, visual: such as the sight of stains, feeling of sample of mothers/care givers and children under five. stickiness on hands, bad smells, or a feeling of In-depth Interview: Qualitative one-to-one interview contamination, both actual or imagined). It is important with fully recorded transcript using a discussion guide. to know which of these cues plays the greatest role in the disgust instinct in order to direct handwashing Behavior Trials: Volunteers asked to adopt handwashing promotional messages. There appears to be a strong with soap over a two-week period and then interviewed. correlation between the objects of disgust and the sources of infection and disease faced by our ancestors, Structured Observation: Systematic technique for thus the disgust instinct may be closely linked, observing and recording particular practices in order to according to Curtis (2001) to: quantify them directly and monitor the impact of the program. It requires careful planning, detailed piloting, Health: Consumers often explain handwashing as a desire training, follow-up and quality control. to avoid germs and disease. However, the usefulness of this explanation in behavior change programs is not clear Checklist Observation: A list of all behaviors putting (see note). Often concepts of good health are linked to children at risk of diarrhea. The list should note behaviors the nurture instinct and the desire to protect one's (who, what, when, where) observed in the household. children from disease. Results are used to design study instruments. Note that the underlying motivator may be more to Focus Group Discussions: Interviews with small create an ordered, balanced life that leads to success groups of relatively homogeneous people asked to reflect and well-being, rather than behavior calculated from an on the interviewers' questions, provide their own intellectual understanding of the mechanisms by which comments, listen to what the rest of the group has to particular microbes cause specific diseases. Germs are say and react to their observations. It requires a skillful also thought of as invisible beasties that are disgusting facilitator guiding the discussion, cross-checking each and so need removal. participant's comments, and ensuring an even participation from all members. Negative drivers include laziness, a desire to do something else that conflicts with handwashing, a wish to avoid soap Note: All instruments should be translated, back because of the perfume, beliefs surrounding links between translated, piloted, and tested. sensory cues, and the presence of `germs' and disease- Reference: `Happy, Healthy and Hygienic' (UNICEF/LSHTM carrying agents. 1998). Habits are behavioral routines that are laid down often Section C: Note on Handwashing Motivation early in life and are semi-automatic. The external environment can facilitate or hinder handwashing. For Previous research suggests that handwashing behavior is example, where soap and water are readily available, motivated by psychological drivers, habits, and the handwashing with soap is more likely, whereas if the toilet environment (Curtis 2001). Drives can be both positive is situated far from the house and handwashing facilities, and negative. handwashing after the toilet may be less likely. Positive drivers usually include: 1. Curtis, V.A., S. Cairncross, and R. Yonli. 2000. Nurture: The desire to care for children. This is often Domestic hygiene and diarrhea, pinpointing the problem. related to health, as outlined below. Tropical Medicine and International Health 5(1): 22-32. Status: A wish to appear clean for the sake of social 2. Curtis, V. 200l. Hygiene: how myths monsters and status and dignity. mothers-in-law can promote behavior change. Journal of Aesthetics: A desire to look and smell good, to be Infection 43: 75-79. attractive to others, and please oneself. 3. Curtis, V., and A. Biran. 2001. Dirt, disgust and (Note: These last two drivers in particular can be disease-Is hygiene in our genes? Perspectives in Biology & considered as linked.) Medicine v.1: 17-31. The Handwashing Handbook 73 4. Luby, S.P., M. Agboatwalla, J. Painter et al. 2004. of soap, especially for use after contact with excreta, in Effect of intensive handwashing promotion on childhood rural and semi-urban areas. There is a need to make a diarrhea in high-risk communities in Pakistan, a connection between hygiene education/provision of water randomized controlled trial. Journal of the American Medical and sanitation facilities on one hand and the production Association 291(21): 2547-54. and distribution of affordable soap on the other. Industry stands to gain by selling more soap through an expansion Terms of Reference 2: of their market into more households and by better Handwashing Coordinator market penetration towards poorer households. Public Public-Private Partnership Handwashing agencies stand to gain by involving soap manufacturers in Coordinator in Peru their programs aimed at improving the quality of life by reducing morbidity related to improper hygiene practices. Terms of Reference 2. Objectives of the Consultancy 1. Background To assist DIGESA, WSP, and the partners in establishing The Government of Peru, with support from the Water an effective public-private partnership for a successful and Sanitation Program (WSP) and others, is initiating a handwashing initiative. The coordinator will be expected new intervention to promote handwashing with soap to co-ordinate all activities of the partnership and manage under a public-private partnership (PPP) with the the planning and implementation of agreed activities objective of reducing diarrhea morbidity among children during the initial phase of the process. The end result of below age five. A documented PPP experience in Central this first phase is the submission of an approved business America has demonstrated the positive impact on plan and communications strategy. handwashing behavior and on the incidence of diarrhea. The World Bank, WSP, UNICEF, and USAID at the global 3. Scope of Services level have formed with the three major soap producers The consultant will perform the following services: a Global Initiative for PPP in Handwashing. Two pilots in Kerala, India, and Ghana are implementing a local PPP. ! Promote effective partnership relations between the Peru is another candidate for expanding this PPP private, public, NGOs, and external agencies on the handwashing initiative. A local coordinator for this new, handwashing initiative, with a special focus on establishing promising activity is needed. credibility and mobilizing technical input from the private sector. Rationale for a Handwashing Initiative: ! Liaise with the global team to obtain information and ! Diarrheal diseases kill two to three million children expertise of the global and other country initiatives. globally every year, are the third most important cause of morbidity and morbidity in Peru and account for ! Conduct a background study on existing hygiene 35 percent morbidity in children under five years old. studies and reports on hygiene promotion (particularly handwashing practices) programs in Peru. ! Most diarrheal diseases are caused by fecal-oral contamination. ! Collectadditionalinformationonthemarketsituation, with particular reference to the poorer segments of ! Diarrhea can be prevented by stopping excreta from the population. reaching the environment through proper sanitation and handwashing. ! Identify potential research firms and co-ordinate the planning, consultant recruitment, and implementation of ! Handwashing with soap alone could reduce reported the consumer study. cases of diarrhea by 35 percent. ! Complement the situation analysis by integrating Reliable data on handwashing with soap after using a toilet the results of the three studies (background, market, or after cleaning up a child is not available in Peru. Hygiene and business). promotion initiatives have focused on the provision of water and sanitation facilities, good storage methods and ! Develop a draft business plan and communications water treatment but not on handwashing, so little is strategy as an iterative process, seeking input from known about the availability, affordability, and desirability the partners. 74 The Handwashing Handbook ! Raise funds to cover activities of the business plan. to the relevant network of contacts and provide continuous backstopping to strengthen inter-agency ! Solicit comments and submit final approved plan relationship building. and budget. 7. Reporting 4. Approach The consultant shall report to the WSP Country Program The consultant will work closely with key WSP and Coordinator and work closely with the Director of DIGESA staff and other partners to build consensus on DIGESA and his staff. All reports should be copied to the direction and scope of the PPPH Initiative through DIGESA. The consultant will submit brief monthly participatory arrangements. Initially the consultant will progress reports and the following month's workplan. build trust with the stakeholders by embarking on one to one contacts. Appropriate strategies have to be 8. Level of Effort and Duration of Assignment adopted to generate and sustain the interests of all stakeholders in the PPH Initiative. The consultant shall initially be engaged for six months of work over a 10-month to completed the first phase of 5. Output the PPP process. The assignment could be extended to the next phase of work based on performance and The consultant is expected to: funding availability. ! Deliver a situation report on the soap market and 9. Qualification hygiene promotion programs targed to the poor, conducted by private, NGO, and public sectors in Peru; The consultant shall have a solid experience working in the private sector in the area of marketing and /or business ! Organize meetings and coordinate PPPH Steering developmentpreferablywithfast-movingconsumergoods. Committee (formation will be the responsibility of WSP The consultant should have proven expertise in developing and DIGESA); marketing plans and communication strategies aimed at ! Provide oversight to ensure the quality of the behavioral change. Familiarity in dealing with market consumer study; research and communication agencies is a must. Additionally, the consultant should have excellent inter- ! Deliver a draft business plan; and personal skills and ability to work with all partners in order to act as an effective catalyst. It would be extremely ! Deliver a final business plan that considers partner advantageousfortheconsultanttobeconversantinEnglish. comments and commitments. 10. Selection process 6. Client Input Short-listed consultants who meet the qualifications WSP will provide the consultant with office space and criteria will be invited to an interview with WSP and the necessary communication tools to perform the job. DIGESA staff. The final selection will be based on the The consultant is expected to provide their own consultant's qualifications, the proposed approach to the computer. WSP and DIGESA will introduce the consultant work, and the financial proposal. The Handwashing Handbook 75 ABBREVIATIONS BASICS Basic Support for Child Survival Project CI Consumer interviews DALY Disability Adjusted Life Year DANIDA Danish International Development Agency DCC Direct consumer contact DFID United Kingdom Department for International Development DHS Demographic and Health Surveys EHP Environmental Health Project FGD Focus group discussion IRR Internal rate of return ISTMA Indian Soap and Toiletries Manufacturers' Association LSHTM London School of Hygiene & Tropical Medicine MDG Millennium Development Goals M&E Monitoring and evaluation NGO Non-governmental organizations NPV Net present value PPP Public-private partnership PPPHW Public-Private Partnership Handwashing Initiative PR Public relations SDC Swiss Development Cooperation SO Structured observations TOR Terms of reference UNICEF United Nations Children's Fund UNICEF/WES United Nations Children's Fund/Water and Environmental Sanitation USAID United States Agency for International Development WES Water, environment and sanitation WSP Water and Sanitation Program WSSCC Water Supply & Sanitation Collaborative Council 76 The Handwashing Handbook © The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433, USA www.worldbank.org All rights reserved The findings, interpretations, and conclusions in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this document and accepts no responsibility for any consequences of their use. The World Bank Group 1818 H Street, NW Washington DC, 20433 USA Ph: +1 202 473-1000 email: feedback@worldbank.org www.worldbank.org Task Team Leaders Parameswaran Iyer, Jennifer Sara Chief Contributors Valerie Curtis, Beth Scott, Jason Cardosi The Global Public Private Partnership for Handwashing www.globalhandwashing.org Production Vandana Mehra Created by Write Media and printed at PS Press Services Pvt. Ltd.