WATER AND SANITATION PROGRAM: TECHNICAL PAPER 72093 Integrating Hygiene Promotion into World Bank Projects: Experiences from Colombia and Peru Rocío Florez May 2011 The Water and Sanitation Program is a multidonor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Integrating Hygiene Promotion into World Bank Projects Author Rocío Florez Acknowledgments: to Oscar Castillo, Doris Alfaro, Nathaniel Paynter, and Hnin Hnin Pyne, for their suggestions and contributions and to Tracey O. Miller for the technical edition. Peer review from technical experts We thank the contributions made by Angela Armstrong, Senior Operations Officer of Environment/Natural Resources Management of the World Bank, and Alessandra Marini, Senior Economist of the Human Development Department for Latin America and the Caribbean of the World Bank. Water and Sanitation Program Glenn Pearce-Oroz, Regional Director for Latin America and the Caribbean Yehude Simon, Communications Officer Verónica Valcárcel, Consultant in Communications First edition: May 2011 Print run: 500 copies Lima, Peru © 2011, World Bank, Water and Sanitation Program www.wsp.org wsplac@worldbank.org The findings, interpretations, and conclusions expressed in this study are entirely those of the authors 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 countries they represent. Contents I. Introduction .................................................................................... 4 II. A Multisectoral Approach to Integrating Hygiene Promotion Programs ....................................................... 5 III. Focusing on Behavior Change ...................................................... 7 IV. Lessons learned from experiences in the field ............................. 10 V. Recommendations based on hygiene field projects .................... 13 Conclusion ....................................................................................... 20 Abbreviations ................................................................................... 21 Bibliography ..................................................................................... 22 www.wsp.org 3 Integrating Hygiene Promotion into World Bank Projects Introduction I. Introduction This report is designed to help project leaders from sectors such to serve as a clearinghouse for knowledge in this area. WSP as water and sanitation, environment, health, education, and is learning from previous handwashing initiatives in Ghana, social protection identify effective strategies for integrating Senegal, Peru, India, and other countries and expanding hygiene promotion components that will enhance the results programs into new areas through its partnership with other and long-term impacts of World Bank-financed projects. leaders in hygiene promotion, such as the London School These opportunities for integrating hygiene promotion are of Hygiene and Tropical Medicine, UNICEF, USAID, and based on concrete research and pilot initiatives that have the Academy for Educational Development. provided quantitative and qualitative results indicating a need for increased attention to hygiene behavior change and Support from the Bill & Melinda Gates Foundation— its link to long-term development impacts. amounting to nearly US$ 20 million over the past three years for the Global Scaling Up Handwashing Project carried out In developed countries, diarrhea is seen as little more than in Peru, Senegal, Tanzania, and Senegal—has enhanced WSP’s an inconvenience, but in developing countries, it can be knowledge of evidence-based behavioral change programs life threatening. Significant efforts were made to reduce implemented on a large scale. Over the course of this learning deaths related to diarrheal disease in the 1970s and 1980s, process, knowledge has been generated and methodologies and but mo­ mentum has slowed and today, diarrheal disease tools have been validated in areas such as fostering an enabling continues to be a leading killer of children worldwide, second environment for sustainability; integrating hygiene promotion only to pneumonia.1 Globally, around 2.4 million deaths into private and public programs related to nutrition, water and (4.2 percent of all deaths) could be prevented annually if sanitation, infrastructure, and education; and local capacity everyone practiced appropriate hygiene and had good, reliable building and monitoring and evaluation. sanitation and drinking water.2 WSP has supported World Bank operational teams in the Over the past seven years, the World Bank’s Water and Sanitation Program (WSP) has gained significant experience in the field of design and implementation of project components, either hygiene-related behavioral change, particularly with regard to by sharing documentation or by working closely with them. handwashing with soap and especially in Latin America. This collaboration has resulted in lending operations that have a clear development impact. With varied results, there Research shows that the household is at the core of is now enough experience to provide grounds for a sharper understanding how to change behavior and create effective focus on strategic opportunities for incorporating hygiene hygiene promotion programs that are sustainable and scalable behavior change into lending operations. in order to effect change at the national level. Proper hygiene is closely correlated with the availability of good sources of The following is an experience-based report that aims to water and a proper place to dispose of waste. provide practical information on the collaborative process as well as illustrate how a hygiene component may be tailored WSP hosted the Secretariat for Global Public-Private to project needs and the benefits it can add. Partnership for Handwashing with Soap from 2003–2009 to help compile lessons learned on handwashing promotion and Water and Sanitation Program 1 UNICEF, WHO. Diarrhea: Why Children are Still Dying and What Can Be Done, 2009. 2 Bartram J, Cairncross S (2010) Hygiene, Sanitation and Water: Forgotten Foundations of Health. PLoS Med 7 (11): e1000367. doi: 10.1371/journal.pmed.1000367. 4 Integrating Hygiene Promotion into World Bank Projects A Multisectorial Approach to Integrating Hygiene Promotion Programs II. A Multisectoral Approach to Integrating Hygiene Promotion Programs WSP has directed much of its efforts to supporting hygiene of the level needed, and initiatives to improve household promotion programs that focus on improved behavior with hygiene have been neglected in favor of infrastructure and regard to handwashing with soap, and then supporting public health programs. governments’ efforts to scale these programs up to the national level to increase the overall health impact on targeted Hygiene and Infrastructure populations. Evidence shows that 94 percent of all cases of diarrhea globally are attributable to problems related to water, sanitation, and A major advantage of hygiene promotion is that it is multisectoral. hygiene.6 For infrastructure projects, however, governments Although typically placed within the health sector, it is commonly cus investments on construction works (hardware) typically fo­ considered part of education curricula. It is also a component of rather than on financing to ensure that newly built governments’ environmental and risk management programs; it infrastructure is demand driven or used appropriately by accompanies infrastructure investments in water and sanitation; beneficiaries (software). and, given its impact on diarrhea reduction, it is a fundamental part of current efforts to reduce childhood malnutrition in Experience in the water and sanitation sector in Asia has proven several countries in the world. conclusively that infrastructure alone is not enough to deliver health benefits from water and sanitation interventions, but Hygiene and Health that improved hygiene and sanitation practices (coupled with The World Health Organization (WHO) estimates that safe drinking water) are the most important determinants of “about 2.4 billion people globally live under highly unsanitary improved health resulting from investments. conditions and have such poor hygiene behaviors that their exposure to risks of incidence and spread of infectious diseases In order for the benefits of new infrastructure to be realized, [is] enormous.�3 Globally, hands are washed with soap on less it is important that hygiene and sanitation practices not be than 20 percent of the critical occasions and only 60 percent add-on aspects of infrastructure development, but rather a key of the world’s households have access to sanitation.4 component of a range of people-centered (software) initiatives. Hygiene promotion is not an explicit indicator of the sanitation Considerable efforts have been made to provide infrastructure Millennium Development Goal (MDG) target, nor is it and health services to prevent the occurrence of infectious explicitly identified with a sector code in the Bank investment diseases in developing countries, but the health benefits have system. There is, however, widespread consensus that meeting not been commensurate with the investments. Diarrheal the hardware-related sanitation MDG target without effective disease and acute respiratory infections (ARIs) combined kill behavior change in hygiene promotion will do little to reduce more children under the age of five than any other causes of poverty, the fundamental purpose of the MDGs.7 death5 (almost 3.5 million annually worldwide). Hygiene and Nutrition In addition, although water supply and sanitation services are Diarrheal disease is easily preventable and treatable, but children critical for public health, investment in sanitation falls short with poor health are more susceptible and are at greater risk of 3 WHO: http://www.who.int/water_sanitation_health/hygiene/envsan/en/ 4 UNICEF. Handwashing Training Module 2008. 5 UNICEF. State of the World’s Children 2008. 6 A. Prüss-Üstün and C. Corvalán,WHO, Global Assessment, World Health Organization, 2006. 7 Kolsky et al., 2005. www.wsp.org 5 Integrating Hygiene Promotion into World Bank Projects A Multisectorial Approach to Integrating Hygiene Promotion Programs life-threatening dehydration since water constitutes a greater Hygiene and Education proportion of a child’s body weight.8 Malnourished children School health programs offer a good entry point for hygiene are also at higher risk of suffering more severe, prolonged, behavior modification as teachers can reinforce health and and often more frequent episodes of diarrhea. Furthermore, hygiene messages and set an example for students, who can “when malnourished children are recovering from an episode then be advocates for improved hygiene at home and in their of diarrhea, they are susceptible to pneumonia; this diarrhea- communities. induced susceptibility may be associated with as much as 26 percent of all childhood pneumonia episodes.�9 WHO projects have shown that an approach targeting water, sanitation, and hygiene simultaneously in schools results in Repeated bouts of diarrhea place children at greater risk of (i) a reduced disease burden among children, staff, and their disease due to decreased food intake and reduced nutrient families; (ii) the adoption by school children of lifelong positive absorption. Lack of nutrition and appetite loss also inhibit hygiene behaviors; and (iii) the promotion of safe environments vital growth. Therefore, diarrheal control, particularly in the at home and in the community, among other impacts. first six months of life, may help to reduce the prevalence of stunting among children.10 When all benefits are taken into consideration, investments in hygiene, sanitation, and water yield a net benefit ranging Until recently, the health promotion programs conducted in from US$ 3 to US$ 46 per dollar invested, not counting African countries by the World Bank Human Development the value-added of an increase in school attendance, as data Network (HDN) typically focused on “information, suggests, among families with access to safe water and proper education, and communication� and applied a unidirectional sanitation.13 communication approach without a clear intention of changing behaviors.11 While it is important that information be readily Hygiene and Social Protection available, there are opportunities to go further, combining the Some countries are utilizing conditional cash transfer (CCT) provision of information with complementary activities that programs as a means of incentivizing hygiene-promoting change behavior and reduce diarrheal disease and other diseases behaviors. In Mexico, Oportunidades is the principal anti- associated with poor hygiene. poverty program implemented by the Mexican Government— by providing cash transfers to households based on regular Hygiene and the Environment school attendance and health clinic visits, the program helps An estimated 94 percent of the burden of diarrheal disease fulfill the aim of alleviating poverty. As a result of the program, is attributable to the environment and associated with risk important positive impacts were reported in school enrollment, factors such as unsafe drinking water, lack of sanitation, and health clinic attendance, and nutrition. In Peru, Juntos is at poor hygiene.12 the core of the CRECER strategy, and since 2005, it has sought Although research is increasingly pointing to hygiene to increase demand for health and education services and promotion, specifically handwashing with soap, as the most alleviate income poverty, as well as improve current nutrition, effective method to reduce not only the risk of diarrhea, but health, and education indicators. In both countries, mothers also of ARIs, a clean water supply and appropriate sanitation are required to participate in monthly educational forums and facilities play a major role in preventing the transmission of sessions on health and hygiene as a prerequisite for receiving bacteria and viruses that cause diarrhea. the incentive (see case #2). 8 At birth, children are 75 percent water weight. An average adult is approximately 60 percent water weight. 9 Bartram J, Cairncross S (2010) Hygiene, Sanitation and Water: Forgotten Foundations of Health. PLoS Med 7 (11): e1000367. doi: 10.1371/journal.pmed.1000367. 10 UNICEF, WHO. Diarrhea: Why Children are Still Dying and What Can Be Done, 2009. 11 Elmendorf, E. et al., Behavior Change Communication for Better Health Outcomes in Africa, The World Bank, 2005. 12 Pruss-Ustun, A., and Corvalan, C., The World Health Organization. Preventing Disease Through Healthy Environments: Toward an Estimate of the Environmental Burden of Disease, 2006. 13 Bartram J, Cairncross S (2010) Hygiene, Sanitation and Water: Forgotten Foundations of Health. PLoS Med 7 (11): e1000367. doi: 10.1371/journal.pmed.1000367. 6 Integrating Hygiene Promotion into World Bank Projects Focusing on Behavior Change III. Focusing on Behavior Change Sustained hygiene-related behavioral change comes disease to be transmitted and the motivating factors to change about when it is endorsed by leaders and authorities in a them; (iii) program design and implementation to develop community, when it is integrated into health protocols a hygiene promotion strategy that is responsive to the level and education curricula, and when the impact on health of awareness of behavior and that provides a process for is evident. It is not the result of a sporadic communication measuring behavior change; and (iv) a process for monitoring campaign, but rather of systematic and lasting multi-channel and evaluation, which is critical in order to determine the communication efforts using a varied network of well-trained impact and cost effectiveness of the program. “change agents� and using interpersonal methods as well as direct consumer contact events and mass media. The Power of Handwashing with Soap Qualitative and quantitative research is required to determine Over the years, studies conducted at the global level have effective strategies that will result in the adoption of a certain demonstrated the effectiveness of adequate handwashing with soap at reducing diarrheal diseases and promoting a healthy behavior. Research findings will provide insight into the environment. conditions that could trigger or hinder behavioral change and will therefore guide the design of communication strategies Van Maanen (2010): This literature review about evidences of water, sanitation and hygiene interventions shows that targeted to reach a specific audience. “handwashing can be a critical measure in controlling pandemic outbreaks of respiratory infections. Several studies carried out The approach to behavioral change utilized by WSP has focused during the 2006 outbreak of severe acute respiratory syndrome (SARS) suggest that washing hands more than 10 times a day on multisectoral engagement to involve diverse individuals can cut the spread of the respiratory virus by 55 per cent� (BMJ and institutions in a community: local governments, health 2009). It also finds “that handwashing in institutions such as and education authorities, local leaders and community- primary schools and daycare centers reduce the incidence of diarrhoea by an average of 30 per cent� (Cochrane 2008). based organizations (CBO), and families.14 (see Figure 1). Emphasis is placed on the need to identify opportunities Curtis & Cairncross Study (2003): This study demonstrates the in existing and ongoing projects or programs in order to power of soap and its direct connection to diarrheal diseases. Results show that adequate handwashing with soap can avoid duplication. By focusing on potential points of entry reduce diarrhea by up to 47 percent. The study also indicates within existing initiatives, multi-channel communication that handwashing with soap can save millions of lives, making a strong case for addressing hygiene behavior within national that incrementally includes local and national stakeholders policies in developing countries. It also concludes that changing has rapidly gained legitimacy and helped identify innovative human behavior is not in itself difficult, but that appropriate opportunities for reaching target populations. strategies that motivate target populations are required. Luby Study (2005): This study focused on Karachi, Pakistan, Although hygiene promotion programs vary in scope and and demonstrated that households that were exposed to size, WSP utilizes a general framework or methodology handwashing promotion and free soap over a nine-month period that consists of (i) an assessment to determine the enabling reported a reduction of 53 percent in the incidence of diarrhea. It also showed that two years after the project ended, mothers environment for scaling up a program; (ii) behavioral research participating in the program still maintained a physical place in to identify which specific practices are allowing diarrheal the home for handwashing with soap. 14 School and community component of HWI in Peru. www.wsp.org 7 Integrating Hygiene Promotion into World Bank Projects Focusing on Behavior Change FIGURE 1. IMPACT OF HYGIENE PROMOTION PROGRAMS ON HEALTH IMPACT ON HEALTH Enabling Environment Crosscutting components Assesment Agreements & Commintments Policies Local Media Advocacy Campaigns Research based program design Hygiene Practices Allocation of resources Trained agents of change Social Partnership Mobilization Building Monitoring and Evaluation Capacity Learning and scaling up Building Integrating Behavior Change in Peru Program� so that lessons and tools can be shared with any One behavior change methodology developed in Peru (2007) manager who seeks such information. consists of a process of research-based communication designed and tested to reach specific audiences over time. Cost-Effectiveness of Hygiene Promotion Programs Sustainability is enhanced through securing commitments Strategic communication programs have been shown to and resources from public and private institutions; integrating be among the most cost-effective methods of effecting the approach and methodologies into ongoing programs, hygiene behavior change when compared with other health with the common objective of reducing malnutrition among interventions. However, measuring the cost effectiveness of children; and generating policies in an effort to scale up and hygiene promotion pro­ grams can be difficult as data is hard widen the scope of the process. In Peru, this methodology to obtain. Typically, results are measured through disability- has been incorporated into the environmental education adjusted life years (DALYs), a measure of a life lost due to curricula by the Ministry of Education since 2010. premature death, illness, or injuries and weighted by severity and duration. Cost-effectiveness compares the cost with the The Global Scaling Up Handwashing Project, funded by quality of the process, di­rect results, sustained results, and, the Bill & Melinda Gates Foundation, has provided the sometimes, the impact.15 In this regard, hygiene promotion opportunity to design, evaluate, and validate different is considered to be more cost-effective at US$ 3 DALY than approaches to project design in four countries: Peru, Senegal, other health interventions, including efforts to improve Tanzania, and Vietnam. The global program is launching sanitation (US$ 11 DALY), an increase in the water supply an web based toolkit, to be launched in 2011, called “How (US$ 94 DALY), treatment of diarrhea with oral rehydration to Design and Develop a HWWS Behavior Change therapy (US$ 1,062 DALY), or childhood immuni­zations for cholera or rotavirus (US$ 2,750 DALY) .16 (See Figure 2). 15 Well Resource Center. The Value of Hygiene Promotion: Cost-Effectiveness Analysis of Hygiene Promotion Interventions, 2003. 16 Second Edition of Disease Control Priorities in Developing Countries, World Bank 2006. 8 Integrating Hygiene Promotion into World Bank Projects Focusing on Behavior Change FIGURE 2. COST-EFFECTIVENESS OF HEALTH IMPROVEMENT INTERVENTIONS (COST PER DALY, IN US DOLLARS) Diarrhea: Hygiene Promotion (e.g.: Handwashing) 3 Diarrhea: Sanitation Promotion 11 Malaria: Isecticide-treated nets 17 Diarrhea: Access to water (domestic connection) 47 Diarrhea: Access to water (using manual pump) 94 Acute Respiratory Illinesses: Pneumonia management case (non severe) 208 Diarrhea: Breastfeeding promotion 850 Diarrhea: ORT, each pack costs US$ 0.50 1062 Diarrhea: Immunization for cholera and rotavirus 2750 0 500 1000 1500 2000 2500 3000 Source: Disease Control Priorities in Developing Countries. Second Edition. World Bank (2006). www.wsp.org 9 Integrating Hygiene Promotion into World Bank Projects Lessons learned from experiences in the field IV. Lessons learned from experiences in the field In this report, three case studies are highlighted that show the objective to reduce diarrheal disease. The Handwashing WSP’s contribution to the design of hygiene components in component was geared toward mothers and children under World Bank projects. The case studies provide insight into the age of five. As a first step in developing the program, the process of introducing hygiene promotion in different public-private partnerships were established to help leverage areas of collaboration, the definition of sector roles, the level the private sector’s knowledge of the soap market and of effort required to incorporate hygiene promotion, and the consumer preferences, as well as to define the scope of the approximate costs involved. hygiene intervention. A prior assessment provided insight into the opportunities for and challenges to partnership Even when results obtained from each project vary, successful building. collaboration is mutually beneficial as value is added to project design and implementation of Bank projects, which enhance the sustainability of behavior change among the targeted beneficiaries. Such exchange also provides WSP with A Framework for Handwashing an opportunity to identify new areas to be further assessed In 2007, WSP developed FOAM, a framework to analyze the and studied. These case studies are highlighted because they determinants of behavior related to handwashing with soap. illustrate the diverse possibilities for integrating a hygiene Focus such as access to soap and water, beliefs regarding the practice or the cause of diarrhea among children, or knowledge component into World Bank projects as well as the various about when and how to perform the practice. levels of support WSP can offer. The result or added value may not be perceived necessarily in a specific product or Focus Opportunity Ability Motivation component, but rather the knowledge shared during the Access/ Belief and Target attitudes design phase of the project, may benefit the project as a behavior availability Knowledge Outcome whole. Product expectations attributes Threat Target Social Case Study Summaries population Social norms support Intention 1. Colombia: Improving Public Health Through FOAM stands for (1) Focus: Who is the audience and what Environmental Protection behavior do we want them to adopt? (2) Opportunity: Is the In 2004, WSP was invited to join a technical operations team target audience able to carry out the behavior? (3) Ability: Is to support the development of the Sustainable Development the target audience capable of carrying out the behavior? (4) Motivation: Does the target audience want to adopt the Investment Project in Colombia in response to a study behavior? showing the cost of environmental degradation and the This framework is used to guide behavioral research and severity of the effect of air and water pollution and other monitoring efforts. Based on this evidence, communication environmental challenges on the health of poor children. strategies are designed to better target audiences for the adoption of new behaviors. Monitoring also benefits from This technical team was responsible for assisting the Ministry this approach as the process is measured on the basis of the determinants that trigger behavioral change. of Environment, Housing and Territorial Development (MAVDT) target problems related to inadequate water Source: Global Scaling up Handwashing Project - A Handwashing Behavioral Change Journey, WSP Learning Note: Peru, August 2010. supply and hygiene, and WSP’s role was to provide support in developing the handwashing component designed with 10 Integrating Hygiene Promotion into World Bank Projects Lessons learned from experiences in the field An effort to raise awareness among policy makers and • The approach was based on research-based stakeholders was carried out in the early stages to evaluate communication and capacity building, which was the need for and cost effectiveness of a behavioral change undertaken at a later stage. approach to reducing diarrheal disease. Three studies were implemented: an assessment to evaluate the sustainability 2. Peru: Implementing Hygiene Promotion Programs of the potential partnerships needed to support the project Through Health and Nutrition Services—Support for a and also to commit resources; a market study to learn about Human Development Project consumer preferences regarding various types of soap and Chronic malnutrition is one of Peru’s most serious human purchasing habits; and formative research to determine a development problems and affects nearly half a million baseline for diarrheal disease and behavioral practices in the children. A World Bank Social Protection Project was country. prepared in 2010 with the purpose of strengthening the impact on nutrition of the conditional cash transfer (CCT) A coordinator was selected and support was provided to program Juntos. Like similar programs in the region, Juntos develop an action plan, timetable, and a communications provides financial incentives for poor families to take children strategy based on the research undertaken. Support was to school and to health service centers. It is now considered provided to the coordinator and Ministry team by sharing one of the country’s most effective social programs. The terms of reference (TOR), training and promotional material. World Bank project will support both the strengthening A field trip was organized for the Handwashing Coordinator of the operation of the CCT and the supply of health and to visit Peru and learn firsthand about the process in different nutrition services, as well as enhance the effectiveness of sites in the country. The project allocated a budget of US$ 1 community-based education sessions. million for the handwashing component. WSP provided support and technical assistance from the early Lessons Learned: stages of project design as well as throughout the appraisal and project appraisal document PAD drafting processes. • Timing: there was an explicit decision made by the It also provided support to developing a capacity-building project leader in the early stages of project preparation component and determining responsibility for participation to include a handwashing (HW) component. This in the community-based education sessions, as well as provided an opportunity to ensure that the component sharing field information regarding the Juntos operational would foster efficient use of resources by the client. conditions. • The Public-Private Partnership for Handwashing with Soap (PPPHW) at the global level and in Peru provided Technical assistance was sought from WSP to share lessons a concrete approach and tools that could benefit the and knowledge related to capacity building at the local Colombian Sustainable Development Investment level and monitoring and impact evaluation, as well as Project and which could be applied immediately. These to provide an assessment of the opportunities to develop tools included a Public-Private Partnership (PPP) creative monitoring technologies to better trace the process assessment; TOR for behavioral research, capacity- in distant localities using cellular phone technology. Support building modules and monitoring tools; and TOR for was provided at the national level by working with Juntos an HW coordinator with experience in partnership teams to discuss monitoring design and the contents of building and marketing. the program’s conditionalities. At the regional level, the Handwashing Initiative (HWI) provided feedback on the • Design of the handwashing component was based on activities under way and the results. Juntos promoters were an assessment and market research to determine the trained and delivered messages to audiences. enabling environment for building a national public- private partnership to expand resources and reach, among other objectives. www.wsp.org 11 Integrating Hygiene Promotion into World Bank Projects Lessons learned from experiences in the field Lessons Learned: in branded soap and their purchasing and hygiene-related habits, as well as formative research financed by WSP and • The collaboration between WSP and the World implemented by the Association for rural educative services, Bank was clearly mutually beneficial. Integrated Peruvian NGO (SER by its Spanish abbreviation) to help work opened the door to Juntos at the national level design a Health Education Strategy and an implementation for the teams involved in the HWI, while the HWI plan that included a communication strategy. intervention provided relevant field lessons that helped build the World Bank Social Protection team’s WSP also provided the methodologies and manuals for knowledge base. capacity building at the local level. A workshop was organized to “train the trainers� who were then qualified to • The use of behavioral change methodologies created train citizens in the intervention areas. Trained community as part of the HWI within the Juntos program resulted agents also received the tools to reach and motivate behavioral in the development of spontaneous conditionalities at change among women and their families. The involvement the regional level. Mothers were asked to participate of the beneficiaries during the design and implementation in handwashing training sessions as a condition for phases—through the formation of Water and Sanitation receiving the cash. Field reports were provided to Committees (WSC), as well as through workshops organized the project team to complement or support policy by social promoters—was a key feature in the development design. of this system, which helped to empower the beneficiaries and to sustain adequate operation and maintenance of the 3. Peru: Reducing the Impact of Environmental Damage program. on Health The World Bank Lima Water Rehabilitation and Management Lessons Learned: Project aimed to improve wate r supply and sanitation networks; promote water conservation; expand services to the • By design, this project promoted the condominial urban poor; and strengthen the Lima Water and Sewerage approach to sanitation in which the community role Company’s (SEDAPAL) institutional capacity. was substantial. Hygiene promotion is a top priority, and the methodology and manuals developed by As part of an effort to expand coverage, a hygiene promotion the HWI represented an opportunity for immediate program was included and WSP was asked to assess the action to support the SEDAPAL Coverage Expansion hygiene habits of people who lacked running water or proper Project. Forty facilitators were trained and received sanitation in order to develop educational materials relevant manuals and promotional material to support their to the local culture and conditions. The study applied an efforts. epidemiological approach in order to identify factors that act as barriers to water and food contamination, and a social- • Impact evaluation showed that as a result of the anthropological approach to understand the beliefs of the program, diarrhea incidence among the population population. The study was conducted under the Coverage in two intervention areas was lower (9 percent and Expansion Project (Programa de Ampliación de Cobertura 8 percent) than in two areas of non-intervention (16 or PAC in Spanish) and implemented by SEDAPAL in percent and 15 percent). cooperation with the World Bank, through WSP. • SEDAPAL has since integrated lessons learned from this project within the institution. A “Social Unit� was In order to gather information, the approach involved developed to design and monitor behavioral change/ quantitative, qualitative, descriptive, exploratory, transversal, capacity building components to support investments and representative analysis. It also included data analysis in infrastructure and maintenance. and a market study to learn about consumers’ preferences 12 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects V. Recommendations based on hygiene field projects Field presence and strong relationship with clients provides New approaches have been developed to mainstream hygiene an opportunity for collaboration to leverage the political, promotion within other sectoral programs by looking at scale, institutional, and financial support needed to improve and sustainability, evidence, and systematic strategic learning on scale up hygiene promotion programs. Technical support what works and what does not. The integration of hygiene will add value to the development of the project and assist promotion programs across several sectors helps strengthen project leaders with assessing the enabling environment and each program as they all build upon each other. Some areas conducting pilots in the field, as well as providing creative of cross-cutting support that can be provided by WSP include approaches, evidence, and validated knowledge to guide the following: project design. • Policy design support to national and local During 2010, technical support to integrate hygiene governments; components was provided to 28 different client-led initiatives, • Technical and operational assistance in areas such representing an important part of the WSP portfolio.18 This as program design, capacity building for behavioral support included the coordination of national handwashing change promotion, monitoring and evaluation, and with soap initiatives in eight countries over the past five years. assessment of the enabling environment; These efforts have resulted in a growing body of skills and • Partnership building skills such as mediation, knowledge related to designing, facilitating, implementing, negotiation, joint operational planning, and monitoring monitoring, and evaluating large-scale behavior change of commitments; and programs.19 (See Table 1: Tools and Tips). • Knowledge management and research design and implementation. 18 WSP. Hygiene Strategy 2010. 19 Water and Sanitation Program: Medium-Term Strategic Framework on Hygiene FY 2010-2014 (DRAFT). www.wsp.org 13 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects TABLE 1. TOOLS AND TIPS BASED ON HYGIENE PROJECTS IN THE FIELD (2002-2010) Areas of Technical Purpose Highlights Timing/process Cases/research/learning Support Enabling This assessment All though the • Early stages, best if Colombia: in this case the environment is designed to dimensions of previous to project Handwashing component assessment (EEA) provide information the assessment design. was part of much wider regarding the pre depend greatly environmental program • A thorough national existent factors on the project financed by the World Bank scope enabling that could enable objectives, a well to be housed at the Ministry environment or hinder project’s designed enabling of Environment and Territorial assessment will take sustainability in environment Expansion. As such, the approximately 2 to a given area – assessment can need to explore private 3 months: 2 weeks national or local. provide relevant sector participation was preparation and The information information such as: needed and an assessment coordination; 3 to 4 can be crucial to was implemented to meet - Existing policy weeks field work; and the success of the this specific demand. The about 3 weeks for project and therefore - Additional funding Association of Private analysis and write up. will influence or sources Industries (ANDI) provided guide project design. support and opened the doors It will also provide - Potential partners to all sectors. Representatives parameters for - Local capacities of Private Foundations, Soap monitoring. and Communication firms were interviewed. A map of potential partnerships was developed based on this assessment which guided the scope of the component. Behavior research Behavioral change is FOAM (Focus on • Research design, The Handwashing Scaling Up about knowing the Opportunity, Ability, terms of reference projects in Peru, Vietnam, factors that trigger and Motivation) is a and consultant Senegal and Tanzania, and motivate a framework designed selection needs to be have FOAM in the design of certain audience to by WSP to help in closely guided by a behavioral research and in the adopt a new habit. the development, specialist in the field monitoring of implementation A well designed monitoring, and of behavior change/ since 2008, when it was behavioral research evaluation of social marketing. developed. will provide insight handwashing • Time and cost factors The tool used to monitor the into these influencers behavior change will depend on the process of behavioral change of human behavior programs. FOAM scope of the design. in Peru, was an Intercept Study and how they may was developed for at the market place (2009 and vary according to use in resource- 2010). culture, language, poor settings, geographic but it can also be conditions in a adapted for other particular target socioeconomic group. Findings environments. will guide communication strategy design. 14 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects TABLE 1. TOOLS AND TIPS BASED ON HYGIENE PROJECTS IN THE FIELD (2002-2010) CONTINUED Areas of Technical Purpose Highlights Timing/process Cases/research/learning Support Integration within One of the sources • Experience shows • The process of • A challenge found public programs of sustainability that the link with integration entails when trying to integrate is to integrate the public sector an important level a behavioral change project lessons and institution has to of effort and time component within a Water & tools into ongoing be established allocated to a process Sanitation project/loan is that national programs. from early that may or may not investments in infrastructure The hypothesis stages of project result in a successful have a specific period, rests on the idea implementation achievement that a beginning and an end, that the added to make sure their lies out of the area of while a behavioral change value a project may demand is met. control of a project process doesn’t; it expands provide to a country manager. over a long period of time. • Evidence is program will benefit The sustainability factor relevant source such program after for infrastructure should be of trust that will the program is analyzed further to evaluate result in country’s concluded. the benefits that integrating endorsement a behavioral change of the component would bring to methodologies such an investment. and lessons gathered from the project. Partnership Bringing public, • The public sector • Strengthen the • Hindustan Lever’s brand building private and benefits from the communication among Lifebuoy, funds the single community knowledge and institutions, specially largest private rural health organizations resources of the for those who are and hygiene educational together to private sector in culturally diverse. program in India. Focused strengthen a process the approach to Once the partnership on rural communities, the by adding diverse target audiences is established, is program seeks to educate knowledge and for effective essential to define children and their families. resources to widen communications clearly the roles and • In Peru, agricultural the benefit to the efforts. responsibilities of each and mining companies poorest. institution. • At local level, have integrated hygiene the need to promotion components partner and join into their community efforts is obvious outreach programs as part – institutions of their social responsibility need each other strategies. to improve • In Colombia, Indonesia each other’s and Peru, mass media performance. communication firms have funded air time and widen the scope of audience reach. www.wsp.org 15 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects TABLE 1. TOOLS AND TIPS BASED ON HYGIENE PROJECTS IN THE FIELD (2002-2010) CONTINUED Areas of Technical Purpose Highlights Timing/process Cases/research/learning Support Creating enabling Handwashing and • Tippy-taps and • Once the prototype • Access to a convenient technologies soap devices or similar devices is produced, a handswashing station has stations have been serve the purpose market testing been associated with higher designed in many of providing water period must follow. rates of handwashing, countries to provide and soap to be In Peru this process according to Adams Biram,s an answer to local ready to use and the analysis of “Formative research for demands. It is by the latrine/ observations and hygiene promotion in common knowledge bathroom and in findings took 8 Kyrgyzstan�. (2005) that their presence the kitchen. months. • Recent findings in Peru acts as a reminder to • Homemade liquid indicate that families that use promote adoption of soap (made out HWWS devices at home also the behavior. of a piece of engage in hygiene practices laundry soap throughout the household. bar) provides • Savings (60%) was critical an economic in the general acceptance resource of soap of the liquid soap device in for handwashing. Peru. • In general sense, • Research in Vietnam it provides a found that designing a concrete solution handwashing station must that it is best take user preferences and when kept simple practices into account, thus and accessible a universal model may not be to low income recommended. families. Methodologies One of the main • Methodologies • This is a lengthy • Locally, capacity building developed for local channels of and tools have process that is based workshops and tools are capacity building communication is been developed on research. Once welcomed by authorities and provided by trained with the public the methodology is promoters. They represent an agents that engage sector to ensure designed it should be incentive. in interpersonal that they provide endorsed by the client, communication added value therefore it must be with audiences to community reviewed by technical and support the agents to increase teams of the Ministries behavioral change efficiency and involved to assure process. enhance results. that contents agree Main areas of with current policies. • There is active capacity building Publication should interest in are: communication only happen after their obtaining training for behavioral approval. and tools among change and community monitoring. agents if they will enhance results and recognition. 16 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects Tips for project leaders on Integrating Hygiene data was recorded,� and that for Implementation Promotion Programs into World Bank Projects Completion Reports (ICR) that contained cost data, • Start early in the project cycle to gauge the Government’s average actual expenditure on BCC was US$ 1.82 commitment and current enabling environment for million.20 hygiene promotion. • Make use of the opportunities for a multisectoral • There are many global organizations that support approach to institutional collaboration and hygiene promotion programs such as the Center coordination within a country to help advance and for Disease Control (CDC), UNICEF, USAID, scale up hygiene promotion initiatives. WATERAID, WHO, the Water Supply and Sanitation Collaborative Council (UN), GIZ, and the Swiss • Rely on teams of specialists that can provide technical Development Agency. assistance and existing resources such as World Bank’s Water and Sanitation Program, Unicef, WHO, and Timeline for Integrating a Hygiene Promotion Program other NGOs or Trust Funds. into the World Bank’s Project Cycle • Work with various agencies to have joint planning Each of the key steps in assessing, designing, and implementing sessions to determine how they can complement each a hygiene promotion program requires a series of tasks at other and leverage existing activities. different stages of the project cycle. Although the timing of • Help agencies carve out distinct and complementary tasks will vary, there are key steps that should be taken early domains within the context of the project to help in the project identification stage and continued through to incentivize and build ownership. supervision. • It is difficult to determine the cost of a hygiene The timeline depicted in Table 2 is indicative rather than promotion program that focuses on behavior prescriptive. An assessment of the enabling environment change. The World Bank report Behavior Change will help the project leader determine the level of funding, Communication for Better Health Outcomes in Africa training, and research required, the tasks that may need to be states that “behavior change communication (BCC) outsourced, and the existing capacity for the implementation costs were about eight percent of total costs, where of specific aspects of the hygiene promotion program. 20 Elmendorf, E. et al., Behavior Change Communication for Better Health Outcomes in Africa, The World Bank, 2005. www.wsp.org 17 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects TABLE 2. GUIDELINES FOR INTEGRATING A HYGIENE PROMOTION PROGRAM INTO THE WORLD BANK PROJECT CYCLE World Bank Activity Objectives Notes Project Team Estimated Project Phase Duration Preparation Concept Note Describe and Revision of purpose and Evaluate options and Initial months outline hygiene objectives of the proposal provide available of preparation PAD promotion information, share Discussion of thematic areas component or lessons to clarify of cross-cutting support approach expectations of Awareness of expectations requested support among teams Advocacy Build awareness Relevance of hygiene Design advocacy Throughout the of benefits component may need to strategy–provide project cycle of hygiene be justified with a focus on support and follow- behavior results and cost-effectiveness up in the process of benefits among generating buy-in Authorities may need to be clients and key convinced of benefits stakeholders Impact Provide Depending on the availability Provide support During the evaluation information on of funding, the project may in the design of project and health the incidence of be designed based on an impact evaluation, cycle, before indicators diarrhea among impact evaluation approach monitoring of implementation children and systems, and project starts Baseline, longitudinal, changes over evaluation and end line studies are the course of recommended to measure the project change accurately Behavioral Identify Results will be evaluated Support research Approximately research determinants of according to FOAM design and results three months behavior change framework to guide design of evaluation among target the communication strategy audience Enabling Learn about This research is required in Provide technical Initially in order environment the potential for order to identify potential assistance in the to influence assessment sustainability of opportunities and challenges design of study project design the project as a and guide project design Provide support Occasional whole with a focus on sustainability with: monitoring to Six-month or annual • TOR design evaluate the monitoring of progress is • Consultant process recommended selection The EEA tool known • Monitoring and as “spider� has nine supervision dimensions, but may be • Evaluating adapted results and recommending changes Project design Design project Based on research findings, Provide technical Six months to or component the project will be designed assistance on a year based on or adapted with the research-based research participation of the sector communication conducted involved strategy and a validated approach to behavior change 18 Integrating Hygiene Promotion into World Bank Projects Recommendations based on hygiene field projects TABLE 2. GUIDELINES FOR INTEGRATING A HYGIENE PROMOTION PROGRAM INTO THE WORLD BANK PROJECT CYCLE CONTINUED World Bank Activity Objectives Notes Project Team Estimated Project Phase Duration Implementation Policy building Enhance Once an ad hoc policy is Provide case Throughout the sustainability generated, it implies that the examples, lessons, project cycle and scaling up client has ownership and and technical of the project will assign resources for the assistance in this continuity of the project or process program It is critical to pursue this result and provide support along the way Capacity Enhance client/ Clients and stakeholders at Provide technical Throughout the building stakeholder the national and local levels assistance in the project cycle capacity to most frequently demand design of capacity continue capacity building in the building workshops activities areas of communication for and tool design behavior change, monitoring for trained agents/ methodologies, and impact professionals to evaluation carry out field activities Partnership Align resources EEA provides information Design partnership Throughout the building to ensure that feeds component/ building strategy, project cycle efficiency and project design prioritize potential achieve results partner institutions Potential partners are by their strengths identified; synergies are and areas of synergy studied Provided technical assistance to operator engaged in the process Knowledge Capture Reports and publications Provide support From mid- management lessons and created to share lessons are to design and project cycle share results to documented throughout the technical assistance enhance scaling process in the process of up developing products Supervision Evaluation of Evaluate WSP will join the TTL’s Work with the Bank Throughout the reports the process team to provide support team to monitor project cycle and improve throughout the life of the the process and implementation project evaluate results www.wsp.org 19 Integrating Hygiene Promotion into World Bank Projects Conclusion Conclusion This guide has been created to provide practical tools, tips, and methodologies for project leaders to integrate hygiene components into their projects. It builds on available evidence about the contribution of behavioral change programs to the reduction of diseases, in particular handwashing with soap initiatives, which can benefit health, environment, water, sanitation, and education projects. Project leaders should view hygiene promotion as a behavioral change process rather than a unidirectional media or education campaign. The knowledge generated from the research, enabling environment assessments, and other tools can be utilized in the early stages of project design and throughout the project cycle. It is crucial to understand the local environment to ensure that behavior change is sustainable once the project cycle is complete. Awareness of the importance of hygiene will vary in each region; therefore, every project must start with different assumptions. For example, in most Latin American countries, research has shown that many citizens are aware of the importance of hygiene promotion, nevertheless, they do not adopt hygiene habits, new research will provide insight into the reasons behind it. In some countries in Africa there is less research available, and cultures and habits vary more significantly from region to region and country to country. WSP and other partners continue to generate positive examples and lessons learned and transfer knowledge. For example, the Global Public-Private Partnership for Handwashing with Soap helps countries close the gap as they strive to meet the Millennium Development Goals. The tools and guidelines referenced in this document do not offer a strict formula, however, and should be revised and adapted to the needs of each project. The door remains open for continuous learning and improvement. 20 Integrating Hygiene Promotion into World Bank Projects Abbreviations Abbreviations AND Association of Private Industries (Colombia) ARI Acute respiratory infections BCC Behavior change communication CBO Community-based organization CCT Conditional cash transfer CDC Center for Disease Control DALY Disability-adjusted life year FOAM Focus Opportunity Ability Motivation GIZ German International Cooperation [Deutsche Gesellschaft für Internationale Zusammenarbeit] HDN Human Development Network HW Handwashing HWI Handwashing Initiative HWWS Handwashing with soap ICR Implementation Completion Report MDG UN Summit on the Millennium Development Goals MOU Memorandum of Understanding NGO Non-governmental organization ORT Oral Rehydration Treatment PAC Coverage Expansion Program (PAC by its Spanish abbreviation) PAD Project Appraisal Document PPP Public-private partnership PPPHW Public-Private Partnership for Handwashing with Soap SEDAPAL Lima’s Water and Sewerage Company (Peru) SER Association for rural educative services, Peruvian NGO (SER by its Spanish abbreviation) TAL Technical assistance loan TOR Terms of reference UNICEF United Nations Children’s Fund USAID United States Agency for International Development WSC Water and Sanitation Committee WHO World Health Organization WSP Water and Sanitation Program www.wsp.org 21 Integrating Hygiene Promotion into World Bank Projects Bibliography Bibliography Bartram J, Cairncross, S. (2010) Hygiene, Sanitation, and Prüss-Üstün, A., and C. Corvalán. Preventing Disease Water: Forgotten Foundations of Health. PLoS Med 7(11): Through Healthy Environments: Toward an Estimate of e1000367. doi:10.1371/journal.pmed.1000367. the Environmental Burden of Disease, The World Health Organization 2006. Checkley, William, Epstein Leonardo D., Gilman Robert H., Cabrera, Lilia and Robert E. Black. “Effects of Acute Diarrhea Prüss-Üstün, A., and C. Corvalán. Global Assessment on Linear Growth in Peruvian Children.� American Journal performed by WHO. 2006. of Epidemiology (2003) 157 (2): 166-175. doi: 10.1093/aje/ kwf179. The Lancet, “Maternal and Child Undernutrition: Global and regional exposures and health consequences.� The Lancet Coombes, Y., Devine, J. Introducing FOAM: A Framework (2008) 371(9608): 243-260. to Analyze Handwashing Behaviors to Design Effective UNICEF. Handwashing Training Module 2008. Handwashing Programs. WSP. 2010. UNICEF. State of the World’s Children 2008. Devine, J., Florez, R. Peru: A Handwashing Behavioral Change Journey. WSP. 2010. UNICEF, WHO. Diarrhea: Why Children are Still Dying and What Can Be Done, 2009. Elmendorf, A. Edward, Cabañero-Verzosa, Cecilia, Lioy, Michele and Kathryn LaRusso. Behavior Change Van Maanen, Peter. Evidence base: Water, Sanitation and Communication for Better Health Outcomes in Africa, The Hygiene Interventions Literature Review. September 2010, World Bank, 2005. WASH Section, UNICEF. Esrey, SA. “Water, Waste and Well-being: A Multi-Country WHO. http://www.who.int/water_sanitation_health/ Study.� American Journal of Epidemiology (1996) 143 (6): hygiene/envsan/en/ 608-623. WSP. Hygiene Strategy 2010. Esrey SA., Potash, JB., Roberts, L., Shiff, C. “Effects of Water and Sanitation Program: Medium-Term Strategic improved water supply and sanitation on ascariasis, diarrhea, Framework on Hygiene FY 2010–14 (DRAFT). dracunculiasis, hookworm infection, schistosomiasis, and trachoma.� Bulletin of the World Health Organization 69(5):609-621. Kolsky, P., Perez, E., Vandersypen, W., Jensen, L., Sanitation and Hygiene at the World Bank: An Analysis of Current Activities. 2005. 22