WATER AND SANITATION PROGRAM: LEARNING NOTE 56910 Global Scaling Up Handwashing Project Key findings · The project's focus on emergent learning and emphasis on performance monitoring Senegal: A Handwashing allowed for critical mid-term adjustments, correcting the course of the behavior Behavior Change Journey change journey to become more effective in reaching and communicating to families. September 2010 · Men are a critical part of the behavior change journey. Initially the behavior change interventions focused on women, but learnings emerged from the field INTRODUCTION indicating that the project needed to better In 2003, the Public-Private Partnership A second phase of activities was initiated leverage the roles men play in their families for Handwashing with Soap (PPPHW) in early 2008 through WSP's Global (provider, protector, and role model) to was created in Senegal with technical Scaling Up Handwashing Project. This help promote handwashing with soap. project is focused on learning how to assistance from the Water and Sanitation apply innovative promotional approaches · Having a tangible product supports Program (WSP). Housed initially within the to behavior change to generate behavior change intentions. A sample Office Nationale de L'Assainissement, the widespread and sustained improvements handwashing station helps make the government unit overseeing sanitation in handwashing with soap at scale among solution more tangible and concrete, and within the Ministry of Health, the PPPHW's women of reproductive age (ages 15­49) facilitates women's intention and planning main objective was to catalyze and and primary school-aged children (ages to ensure handwashing with soap occurs 5­9). Local and national governments are coordinate multi-sectoral involvement in in the household. implementing the project in Peru, Senegal, the promotion of handwashing with soap.1 Tanzania, and Vietnam with technical · Just-in-time coaching and a performance support from WSP.3 monitoring system are critical in A first phase of activities, initiated in 2004, culminated in a 10-month transforming community outreach workers During this second phase, activities communications campaign launched in Senegal were expanded to eight of (the relays) into valuable community in 2007. Anchored around the theme, the country's then 11 regions, with the resources--beyond conveying information "Water Rinses but Soap Cleans," the objective of reaching over 1.5 million to facilitating mothers' problem-solving campaign focused on conveying "first mothers with children under the age abilities and fortifying their intentions to generation messages" to improve of five through an integrated behavior wash hands with soap. knowledge around the critical times for change approach. The final objective is to washing hands and the importance of improve the handwashing with soap · A simple game can be a powerful tool using soap. Campaign activities included practices of over 500,000 mothers and for engaging men, women, and children. nationally aired television and radio children. In parallel, efforts were directed A handwashing-themed board game spots; entertainment-education events at strengthening the enabling environment designed by an advertising agency in market places and schools; and to ensure that activities and outcomes provides a way for the community-based small-group discussions conducted with would be sustained after the project end. promoter to "break the ice" and introduce women's associations (called m'botayes) the main messages to everyone in the and in the waiting rooms of local health This Learning Note serves to document the household in an engaging and fun way. centers.2 behavior change component of the project 1 For more information on the PPPHW, see www.globalhandwashing.org. 2 Small group discussions were conducted in three regions, Thiès, Diourbel, and Dakar, and in one department, Velingara. 3 For more information on the Global Scaling Up Handwashing Project, see www.wsp.org/ scalinguphandwashing. 2 Senegal: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project in Senegal, including key strategies, results, challenges, and the factors or determinants that influence handwashing with lessons learned. soap. Previous studies undertaken in Senegal focused primarily on knowledge and motivation and did not examine the full spectrum of determinants identified in FOAM. PROBLEM STATEMENT Diarrhea prevalence among children under the age of three in The 2008 "doer/non-doer" study reported the following: Senegal was last estimated at 22 percent and the prevalence of acute respiratory infections within the same age group at · Asked when it is important to wash one's hands, unaided 13 percent.4 A study conducted by the PPPHW5 indicated that, responses were "after going to toilet" (78 percent), "before based on observations, handwashing rates with soap were eating" (32 percent), "before preparing food" (30 percent), relatively low: and "before feeding child" (18 percent). Assisted recall was considerably higher: the percentage of respondents declaring · 23 percent after going to toilet they "always" washed their hands was 95 percent after going · 18 percent after cleaning a child to toilet, 93 percent after touching child's bottom, 86 percent · 18 percent before handling food before eating, 67 percent before preparing food, and 62 percent before feeding child. Although 95 percent of households had some sort of soap available · The importance of soap--the focus of the first phase--seemed for bathing or laundry, previous studies pointed to issues around its to be well understood: 34 percent strongly disagreed and availability and access for handwashing purposes such as: 52 percent disagreed with a statement that "water alone is enough." · Soap is usually far from the toilet or source of water6 · The link between soap and germ removal was also · Soap is controlled by women7 and/or often in the hands of understood: close to 80 percent agreed or strongly agreed someone who doesn't want to share it8 that to remove dirt and invisible germs you need to wash · Most households do not have a specific place for handwashing.9 hands with soap. Almost all (98 percent) agreed or strongly agreed that washing hands with soap protects the health of Early in the second phase, the project team undertook a large your children. quantitative "doer/non-doer" study among 2,040 mothers to identify which behavioral determinants were correlated with The study further revealed that access/availability was statistically handwashing with soap. The project had developed a simple correlated with handwashing. In particular, having a designated behavior change framework called FOAM (Figure 1)10 to analyze place for handwashing with soap in the home, the ability to buy soap without having to ask someone else, and the ability to find Figure 1: FOAM Behavior Change Framework soap each time it was needed were salient characteristics found among mothers classified as handwashers. Focus Opportunity Ability Motivation Based on the findings of the "doer/non-doer" study, the project Access/ Belief and Target attitudes team decided there was no need to continue emphasizing availability Knowledge behavior either the importance of soap for handwashing or the link Outcome between handwashing with soap and disease prevention as Product expectations attributes these knowledge areas seemed well established. Knowledge Target Social Threat around excreta-related critical times (after going to the toilet population Social support and cleaning baby) was also relatively sound, but knowledge norms Intention around the critical importance of handwashing with soap at food-related times (before eating and preparing food) required some improvement. 4 Ndiaye, Salif, and Mohamed Ayad. 2006. Enquête Démographique et de Santé au Sénégal 2005. Calverton, Maryland: Centre de Recherche pour le Développement Humain [Sénégal] and ORC Macro. 5 Aunger, B. 2004. Public-Private Partnership for Handwashing: Senegal: Report on Behavioural Trials. London: Hygiene Center, London School of Hygiene and Tropical Medicine. 6 Ibid. 7 Kane, M. 2009. Rapport étude lavage des mains au savon Sénégal. Unpublished study, Water and Sanitation Program, World Bank. 8 Aunger 2004. 9 Kane 2009. 10 This framework is based on the PERForM framework of Population Services International. For additional information, see Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs, available at www.wsp.org/scalinguphandwashing. www.wsp.org Global Scaling Up Handwashing Project Senegal: A Handwashing Behavior Change Journey 3 Figure 2: Process of Habit Formation · Mental simulation involves thinking through the what, when, where, and how of the intended behavior, making it harder to forget.13 These plans of action are also referred to as "implementation intentions." Based on the results of the "doer/non-doer" study and findings Behavior from the literature review on the sustainability of behavior, Implementation Repetition in relegated to the project team decided to evolve to a "second generation" Intentions stable context cues communications program focused on awakening, fortifying, and (conscious) (automatic) supporting intentions to wash hands with soap. The "second generation" communications program centered on improving availability of soap and water in the household when and where needed, identified in the "doer/non-doer" study as a key behavioral determinant of handwashing with soap. In addition to improving handwashing with soap rates at four critical times The process of habit formation starts with a conscious intention (before eating and preparing food, after going to the toilet and ("I must wash my hands after going to the toilet") and is fortified cleaning a baby), the team identified creating a designated place through repetition in a stable context ("I wash my hands for handwashing with soap as a behavioral objective. at this handwashing station"). As the behavior is practiced repeatedly it becomes more automatic and can be triggered ACTION by an environmental cue or reminder ("seeing the handwashing Communications Strategy: From First to Second station when I exit the latrine reminds me to wash my hands"). Generation Messages The three main communication channels from the first phase have been retained to reach mothers for the following reasons: While the "doer/non-doer" data was being analyzed, the Mass media. Billboards, television, and radio are useful to project team initiated a literature review on the sustainability of convey the overarching concept of a campaign and provide an behavior. This review identified a considerable body of research umbrella slogan or visuals for all other channels. Senegal enjoys around habit formation. In particular, Verplanken and Wood a good coverage of mid-sized billboards even in peri-urban suggest that habit formation begins with a conscious period of areas. For habitual behaviors such as handwashing, TV and implementation intentions,11 similar to the "intention" determinant radio spots also provide reminders or cues to action, particularly in the FOAM framework. Because handwashing requires easy if aired during times when mothers are preparing meals. access to soap and water when and where needed, some Television and radio broadcasting in Senegal have relatively level of planning and intention is required. Once the behavior high coverage. Ownership of radio and TV is respectively is repeatedly practiced in a stable context automaticity can set 87.2 percent and 40.1 percent; however, access is assumed to in (Figure 2). be higher due to sharing among households, particularly in rural areas.14 Listenership among women is particularly large during The literature review further highlighted that: broadcast of South American and Indian soap operas. · Interventions should make people aware of the resources Direct Consumer Contact (DCC). Used by commercial firms in they have to change behavior (skills, or strategies such as brand marketing efforts, DCC provides an opportunity to engage planning).12 and interact with the audience through community events. In · Planning is critical to one's progress from behavioral intention behavior change interventions, DCC uses an entertainment- to actual performance of the behavior. Success scenarios, education approach and invites local authorities to participate. In preparatory strategies, and mental simulation encourage Senegal, market areas allow DCC to reach mothers while they are performance of actual behavior. purchasing food staples and supplies for the day. By including 11 Verplanken, B., and W. Wood. 2006. Interventions to Break and Create Consumer Habits. Journal of Public Policy and Marketing, 25(1):90­103. 12 Schwarzer, R., B. Schüz, J. P. Ziegelmann, S. Lippke, A. Luszczynska, U. Scholz. 2007. Adoption and maintenance of four health behaviors: Theory-guided longitudinal studies on dental flossing, seat belt use, dietary behavior, and physical activity. Annals of Behavioral Medicine, 33(2):156­166. 13 Ibid. 14 Ndiaye 2006. www.wsp.org 4 Senegal: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Figure 3: Fortifying Intentions to Handwash with Soap by specially trained animateurs, the program includes, among others things, presentations of the television spot, handwashing with soap demonstrations, and a question and answer session to engage audience members and refresh basic knowledge. The events also include testimonials from women and government I have a authorities to reinforce commitment and intentions from mothers I have handwashing through the emerging local norms. a plan with soap station and IPC focuses on building skills and self-confidence among I am committed wash my hands mothers to make soap and water available when needed and to create a designated place for handwashing with soap. Research This figure represents the process through which intentions to suggests that generating discussion around how, when, and wash hands with soap are fortified through the intervention. where mothers handwash with soap can contribute to translating intention and commitment (awakened and fortified through the Women commit themselves and formulate a plan to "make mass media) into action.15 Group discussion provides a forum handwashing happen" at home. The intended end-result is to for problem-solving on issues such as how to make soap easily have and use a handwashing station. accessible, how to prevent waste or theft, and how to convince another household member to buy soap. A consultant was recruited to develop a curriculum and testimonials or handwashing demonstrations by local leaders, training materials to help mothers plan the steps they could DCC also allows the program to mirror emerging social norms. take to make soap and water available for handwashing in their home and to set up a dedicated handwashing station. Interpersonal Communication (IPC). Conducted at the IPC is integrated with mass media through the distribution household level, IPC enables mothers to be reached in a real-life of campaign materials such as stickers. In addition, at the setting and allows behavior change interventions to influence conclusion of an IPC session, mothers are asked to repeat the determinants such as beliefs and skills, for which mass media spot's slogan to pledge their commitment. In a limited number is less suited. of cases, a plastic handwashing station has been left behind as a promotional item. Communications Concept: Fortifying Intentions The communications intervention's main concept of fortifying intentions to handwash with soap is illustrated in Figure 3. The Figure 4: "Second Generation" Billboard mass media and DCC efforts focus on securing a commitment from mothers to get their family to wash their hands with soap, and IPC follow-up helps mothers think through a plan for making this happen. A creative brief for the contracted advertising agency called for a warm, engaging, and positive communications concept (i.e., without an emphasis on disease or threat) that could be adapted across all channels. After several iterations and pre-testing with the target audience, the final concept for print communications such as billboards featured a mother declaring, "I commit myself to get my family to wash their hands with soap!" A "second generation" billboard is shown A billboard developed as part of the project's second generation in Figure 4. mass media campaign targeted women's commitment to the DCC events organized in market areas and open spaces such health of their family: "I commit myself to get my family to wash as soccer fields reach 500 to 2,000 people at a time (attendance their hands with soap!" tends to be higher in rural areas than in peri-urban ones). Delivered 15 Schwarzer, R., B. Schüz, J. P. Ziegelmann, S. Lippke, A. Luszczynska, U. Scholz. 2007. Adoption and maintenance of four health behaviors: Theory-guided longitudinal studies on dental flossing, seat belt use, dietary behavior, and physical activity. Annals of Behavioral Medicine, 33(2):156­166. www.wsp.org Global Scaling Up Handwashing Project Senegal: A Handwashing Behavior Change Journey 5 Implementation Arrangements: From The project team set up a robust integrated performance Grass-Roots Organizations to Commercial Firms monitoring system to follow both the quantity of activities (outputs) and the quality of the intervention. The main Mass media. To implement the mass media component, the components include: project completed a competitive bid process to procure two separate firms: one to design the communications concept and produce the materials, another to develop the media plan and Management Information System (MIS). A MIS was purchase radio, television, and billboard space. This same firm designed to generate standard and customized reports, also monitors the airwaves to ensure the media plan is followed enabling the project team to track actual results against by the broadcast stations and oversees the billboards to ensure targets and to analyze the situation along a variety of they are in prime condition (e.g., not knocked down during a dimensions (e.g., region, implementing agency, and others). storm). A first wave of mass media ran from the end of June A consultant was recruited to design the MIS to track outputs to December 2009 and included 92 television and 1,496 radio from the implementing agencies, including key indicators spots. A second wave of mass media, now underway, will from country and global results frameworks. Firms recruited conclude in October 2010. to manage DCC and IPC activities have been trained to use forms to capture standard information for each household visit and event conducted (such as number and profile of DCC. Two firms were procured and contracted to implement participants, materials used, challenges encountered, etc.) DCC in northern and southern regions. The firms conducted and these forms are collected and entered into the MIS on a events more or less simultaneously, totaling 161 events by regular basis. December 2009. A second wave of DCC, now underway, is also scheduled to end in October 2010. Media monitoring. As discussed above, a firm was contracted to monitor airwaves to ensure that the media spots are broadcast IPC. In the first phase, IPC was conducted with small groups according to plan by individual television and radio stations. In of women in public places by commercial firms. In the second the event of discrepancies, the firm negotiates directly with the phase, IPC is implemented at the household level, mostly station to request adjustments. by non-government organizations (NGOs). Few functions in Senegal have devolved to local government agencies and over the years, numerous NGOs have been established to Field supervision. Four individual consultants were hired implement behavior change projects, from family planning and trained to supervise the IPC and DCC firms. Part of their to maternal and child health. As in the case of DCC, the mandate is to confirm that events and activities recorded in IPC intervention is implemented geographically. A non- the MIS have taken place. The field supervisors also shadow profit organization (APAPS), two consulting firms, and two community relays during household visits to provide real-time communications firms were procured. These organizations coaching, attend DCC events, and provide immediate feedback were required to contract, supervise, and monitor community- to the implementing teams. based organizations (CBOs) to deliver basic information and services through outreach workers called community relays. Meetings with implementation agencies. The project team Using these implementation arrangements, the project has holds monthly meetings with the field supervisors and project tapped into a rich network of relays with experience in health- managers of all implementation agencies. In this way, the related IPC. agencies have become part of the behavior change journey. During these meetings, results from the MIS are shared and compared to targets. Challenges and issues are raised and Monitoring and Evaluation: An Integrated cross-agency solutions are proposed. For example, during Performance Monitoring System for Purposive one meeting agencies reported that men had expressed Learning and Program Improvements dissatisfaction and frustration because they were not included in Prior to setting up its monitoring and evaluation strategy, the household visits. The project team organized a special learning project team reached consensus on how indicators from event to probe the role of men.16 A second learning event with the project's results chain would be measured in Senegal the agencies is planned to determine how to further improve and identified additional indicators that need to be tracked, skill building in the areas of handwashing station placement and particularly at input and output levels. soap management. 16 For more information, see Involving Men in Handwashing Interventions in Senegal, available at www.wsp.org/scalinguphandwashing. www.wsp.org 6 Senegal: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Figure 5: "Second Generation" Revised Billboard Mid-Term Adjustments: Correcting the Course of the Journey Based on Emergent Learning As stated earlier, the performance monitoring system flagged a frustration among men at not being involved in handwashing promotion. After the learning event in late 2009, a meeting was held with the advertising agency to iterate the mass media communications to strengthen men's involvement. Both the visuals and the slogan were revised. The modified slogan proclaims, "We commit ourselves more than ever to get our family to wash their hands with soap!" (Figure 5). The IPC curriculum was also updated to further involve men during household visits and community relays were given refresher training. While the initial "second generation" campaign targeted women), program activities and communications materials were KEY CHALLENGES AND LESSONS LEARNED later revised to include men. In the revised billboard, a couple Challenges proclaims, "We commit ourselves more than ever to get our The behavior change journey has not always been an easy one. family to wash their hands with soap!" Key challenges include: Attracting qualified advertising agencies. Though there Specific studies. In response to emerging questions from are several communications agencies in Senegal, the early the performance monitoring process, the project team initiated stages of the procurement process (carried out in accordance specific studies. In early 2010, a survey of approximately 400 with World Bank regulations) attracted mostly consulting firms households was conducted to determine the level of satisfaction from the water and sanitation sector with little experience in with existing handwashing stations. Research findings indicated creative design and media production. Lacking this expertise, the need to conduct spot research among community relays. the lead consulting firm sub-contracted for media production A follow-up learning event to share findings with implementing and considerable negotiations were needed to maximize the agencies is also planned. production budget allocated to the sub-contracted firm. In addition to monitoring activities or outputs, the project team Changing the mind-set of advertising agencies. The initial will monitor outcomes as follows: concepts received from the firm selected used a negative approach focusing on germs, even though the creative brief called "Doer/non-doer" studies. A second "doer/non-doer" study for a positive message. Changing the mind-set of advertising will assess if determinants targeted through the intervention are agencies designing behavior change communications in moving in the "right" direction, particularly access and availability general--and hygiene promotion communications in particular-- to soap and water. Positive changes in targeted determinants requires considerable hand-holding. Monthly meetings with the are assumed to mean that behavior change will follow. agency were held to ensure they were part of the journey. Longitudinal surveys of impact evaluation. As part of the Measuring behavioral determinants. The quantitative project's impact evaluation on health, ten rounds of longitudinal "doer/non-doer" study in Senegal represented the first surveys are planned. Though the main purpose of these surveys time a handwashing study segmented those who practice is to track diarrheal incidence, a limited number of questions will handwashing with soap from those who do not on the basis be added to evaluate the intervention itself. Exposure to various of determinants--though organizations such as Population activities will be measured in mid-2010. Services International have used segmentation for other behaviors, such as condom use. The series of questions Baseline and endline surveys of impact evaluation. Both used to measure each determinant in FOAM were created the baseline and endline surveys of the impact evaluation will from "scratch" and then adapted into French and Wolof, two measure handwashing behavior using the global measurements additional challenging steps. As a result, it was not possible guidelines developed and other indicators such as diarrhea, to measure all of the determinants reliably. For the second nutritional status, and household productivity.17 "doer/non-doer" study, more attention will be paid to piloting 17 For more information on measuring handwashing behavior, see Practical Guidance for Measuring Handwashing Behavior, available under "Publication and Tools" at www.wsp.org/scalinguphandwashing. www.wsp.org Global Scaling Up Handwashing Project Senegal: A Handwashing Behavior Change Journey 7 the questionnaire to ensure more reliable measures of the families (provider, protector, and role model) to help promote determinants. handwashing with soap. Transforming community relays into community Having a tangible product supports behavior change resources. The project has been fortunate to be able to intentions. Community-based promoters report that having a tap into a robust network of community relays that operates sample handwashing station to distribute to women makes the throughout Senegal. However, these relays have been solution more tangible and concrete, and facilitates women's traditionally used to convey information. The second phase planning process to ensure handwashing with soap occurs of the project requires outreach workers to facilitate mothers' in the household. Discussion with mothers can then focus on problem-solving abilities and to fortify their intentions to where to place the handwashing station and how to ensure handwash with soap. Performance monitoring, particularly that the station is always stocked with soap and water. As just-in-time coaching, has proved critical to transforming mentioned above, a handwashing station provides a stable relays into community resources. To reflect their enhanced context in which the behavior can take place and provides role, community relays are now referred to within the project environmental cues. The project team will investigate the as community-based promoters. possibility of scaling up the provision of handwashing stations with other partners, both private and public. Lessons Learned The behavior change journey in Senegal has uncovered several A simple game can be a powerful platform. A handwashing- lessons: themed board game was designed by the advertising agency (Figure 6). The game provides a way for the community- Men need to be part of the behavior change journey. based promoter to "break the ice" during a household visit According to the "doer/non-doer" study, half of the women and introduce the main messages in an engaging and fun surveyed consider their husbands the decision-makers when way. It can be played by up to four people at once and reach it comes to purchasing soap. Though the initial brief prepared potentially more if given to the household as a promotional by the project team for the advertising agency specified item. During the first phase, the game was designed for that men should be portrayed as providing social support (a children (left). However, given the interest expressed by adults, determinant in FOAM), this proved to be insufficient. Through particularly mothers, as well as young adults, the game was its performance monitoring system, the project learned that revised (right) to appeal to a broader age range, as well as it had been under-leveraging the roles men play in their to men, and include specific behaviors such as setting up a Figure 6: Handwashing Board Game A simple board game was initially designed for young children (left). A revised version targets a broader age range, as well as men (right). The content of the game can be modified to prioritize key messages and behaviors. www.wsp.org 8 Senegal: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project handwashing station next to a latrine or through 161 direct consumer contact practicing handwashing with soap after events; and approximately 30,000 Acknowledgements cleaning a baby's bottom. The revised household visits were made by about The authors thank the Global Scaling game has been tested and will be used 150 trained community relays. The Up Handwashing Project team, during the next implementation wave. project has a robust and integrated especially Hnin Hnin Pyne, Nathaniel performance monitoring systems in Paynter, Momar Kane, Bernard Sene, RESULTS place to track both the quantity and quality of interventions. In addition to Alfred Dacosta, Libasse Diagne, As of March 2010, the behavior change reach, data on exposure, movement in Amy Grossman, Mamadou Lamine intervention in Senegal have been scaled up, reaching and in some cases the behavioral determinants, and the Mbengue, and Mamadou Thiam for surpassing, targets. As a result of the behavior change itself are expected in their valuable inputs. "second generation" communications the third quarter of 2010. program, over 92 television and 1,496 --Jacqueline Devine and About the project radio spots have reached an estimated Global Scaling Up Handwashing is a two million people; an estimated Seydou Nourou Koita Water and Sanitation (WSP) project 140,000 people have been reached focused on applying innovative behavior change approaches to improve handwashing with soap behavior among women of reproductive age (ages 15­49) and primary school-age children (ages 5­9). It is being implemented by local and national governments with technical support from WSP in four countries: Peru, Senegal, Tanzania, and Vietnam. For more information, please visit www.wsp.org/ scalinguphandwashing. Contact us For more information, please visit www.wsp.org or email Jacqueline Devine at wsp@worldbank.org and Seydou Nourou Koita at wspaf@worldbank.org The Water and Sanitation Program (WSP) is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP's donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. © 2010 Water and Sanitation Programs (WSP)