WATER AND SANITATION PROGRAM: Research Brief 74162 Global Scaling Up Handwashing Project Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru September 2012 Key findings INTRODUCTION • Respondents exposed to mass media and Preventable diseases exact a high cost among the world’s direct consumer contact activities only (radio, poor. Diarrhea and acute respiratory infections account print and public events like parades) did not for two thirds of deaths among children under five. recall handwashing messages. Handwashing with soap can prevent these diseases by minimizing the transmission of harmful pathogens found in • In contrast, intensive activities in community fecal matter into the home. Hygiene programs can become and school settings translated in higher recall a potentially effective way to improve public health, and the of handwashing messages, showed positive health of children in particular. Despite potential benefits, effects on handwashing knowledge, and resulted in greater availability of water and however, handwashing with soap remains uncommon: soap. • Program effects were most consistently observed in households with children in target schools. These improved self-reported and directly observed handwashing behavior in two of four critical times. However, these improvements in handwashing behavior did not translate into significant impacts on environmental conditions or child health. • Yet, observed rates of handwashing behavior, still under 35%, indicate there is significant room for improvement of this practice in Peru. www.wsp.org 2 Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru rates of handwashing after defecation are below 35% in at the provincial level and consisted of mass media and many developing countries. direct consumer contact (DCC) activities, while the second intervention operated at the district level with additional In Peru, a baseline survey conducted during 2008 found activities delivered in communities and schools. that only 46% of caregivers reported washing hands after defecation. Evaluation results from The Handwashing The mass media-DCC intervention, comprised of radio Initiative (HWI) in Peru show that a behavior change advertisements, posters, comic books, brochures and campaign consisting of radio, print and public events alone public marketing events, emphasized the need to wash was not successfully recalled by target audiences and did hands with soap at critical times (after defecation, after not prove to stimulate any behavior change. However, cleaning a child’s bottom, before preparing food, and when this strategy was coupled with more intensive before feeding children). activities in community and school settings, the program positively affected the handwashing practices of caretakers The community and school intervention supplemented the of young children, although not to an extent that showed mass media and DCC activities with training to community- improved child health. based agents of change such as teachers, medical professionals and community leaders. This included THE HANDWASHING INITIATIVE (HWI) handwashing with soap demonstrations and educational The Handwashing Initiative consisted of marketing and sessions to highlight the link between soap use and child strategic communication activities at multiple levels, health. Finally, a handwashing curriculum was implemented aimed at reaching large populations. HWI delivered two in a certain number of schools, and classrooms were levels of behavior change interventions between September outfitted with a designated place for handwashing with 2009 and December 2010. The first intervention operated water and soap. www.wsp.org Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru 3 A rigorous evaluation design ensured the validity of program surveys to the same households were completed the study’s findings. The methodology used (randomized from March through June 2011. controlled trial) enabled to identify causal linkages between program activities and outcomes of interest. Provinces The evaluation assessed efforts to influence the and districts throughout Peru were randomly selected behavioral determinants, practice and effects of for participation in the study and randomly assigned to handwashing. The specific aspects evaluated included receive the behavior change intervention (treatment) or not (i) self-reported recollection of exposure to handwashing (control). This process ensured that the households across messages; (ii) knowledge about the best way to wash groups differed only in respect to whether they received hands; (iii) availability of soap and water in the home at HWI activities. a place convenient for handwashing at critical times; (iv) self-reported handwashing with soap; (v) observed One group of 40 districts received the mass media-DCC handwashing with soap; (vi) environmental contamination; behavior change intervention only. A second intervention and (vii) child health. group received both mass media activities as well as the community and school activities (44 districts). Within Survey respondents from the community and school this second intervention group, certain households were intervention recalled exposure to handwashing tracked to isolate the impacts of activities at target schools. messages while respondents from the mass media- A third group of 41 districts served as control. Baseline DCC activities alone did not. When asked whether they household surveys were conducted among approximately had encountered promotional handwashing messages 3,500 households from May through August 2008; post- during the past year, caregivers in the mass media- www.wsp.org 4 Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru Figure 1. Respondents Exposed to Mass Media and DCC activities group did not recall additional exposure Direct Consumer Contact Activities Only (Radio, Print to any messages (Fig.1). Because the theory of this and Public Events) Did Not Show More Recognition of intervention relies on effective exposure to behavior change Handwashing Messages or Higher Knowledge communication messages, no other causal effect on relevant outcomes can be attributed to the mass media- 65.4% 58.9% DCC intervention alone. In contrast, community and school activities were considerably more successful in reaching target audiences. The proportion of mothers or caregivers 22.5% 24.5% exposed to the community and school interventions who recalled having received handwashing messages through at least one of the communication channels was 19.4% Recall of handwashing Events that require higher than the recall of the control group (78.1% vs. messages(at least one handwashing 65.4%). The proportion of caregivers from households with communication channel) (summary index) children in a school with the handwashing curriculum who reported exposure to handwashing messages through at 94% 93.4% least one channel increased by 10.6% relative to similar families in the control group (77.6% vs. 70.1%). 87.9% 87.6% Community and school activities increased not only the exposure to handwashing messages, but also Best method to wash Not washing hands the knowledge of mothers and caregivers regarding hands is using water with water and soap handwashing. Respondents in the community and school and soap causes diarrhea component answered that the best method to wash hands Control Treatment is using water and soap at around a 5% higher rate than www.wsp.org Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru 5 the control group. In addition, 3.3% more households in However, only the households with children in schools the community knew that the main cause of diarrhea is with handwashing curriculum showed improvements inadequate handwashing. in handwashing practices. Despite increases in knowledge of proper handwashing techniques, community Given the high level of knowledge at the baseline for both and school intervention respondents without children these indicators (over 85%), the increased rates represent attending the target schools did not report increases significant progress in closing existing knowledge gaps. in handwashing during any of the four critical times. Also, the availability of soap and water anywhere in In contrast, households with children attending target households with students in target schools was 8.4% higher schools showed a consistent increase in self-reported than for similar households whose children attended other handwashing behavior for two of the four critical schools (83.3% vs. 76.8%). In contrast, the mass media handwashing times: 23.6% more respondents reported and DCC intervention was ineffective both in improving they washed their hands with soap before eating and knowledge of participants and in increasing availability of 27.8% more reported they washed with soap before soap and water in the household, as expected. feeding a child, relative to the control group. No effects www.wsp.org 6 Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru Figure 2. Households with Children in Target Schools were detected for self-reported or observed handwashing Showed Positive Effects on Behavior Change with soap after fecal contact (Fig. 2). Finally, direct observations, conducted only among Self-reported handwashing behavior improved in two households with children in target schools and a control of four critical times: group, showed substantial effects in two of the four critical times: 61% more households with students in target 23.6% 65.6% 67.5% 69.4% 65.2% schools washed hands with soap before eating than those 27.8% 49.7% in the control groups. Similarly, households with children in 40.2% target schools were 69% more likely to wash hands before 24.8% 19.4% food preparation than households in the control group. Still, directly observed rates of handwashing behavior Before After fecal Before food Previous were consistently lower than self-reported rates and did feeding contact preparation to eat not exceed 35% in any of the critical times studied (Fig. 2). child Program effects were most consistently observed in households with children in target schools. Households with older siblings who attended schools where behavior Directly observed handwashing behavior improved in two of four critical times: change activities took place showed the most consistent shift in handwashing behavior, supporting the hypothesis 60.8% that siblings can serve as agents of change. 34.2% 68.6% 32.0% 30.4% With respect to the control group, these households reported higher recollection of program activities, more 18.9% 16.7% availability of water and soap in the house, higher rates 11.6% 9.9% of self-reported handwashing with soap behavior in two 7.6% of the critical times (prior to eating and prior to feeding a child) and better observed behavior at two of the four Before After fecal Before food Previous critical times (prior to eating and prior to preparing food). feeding contact preparation to eat child However, no impacts were found on diarrhea, acute lower respiratory infection or anemia: 27.8% 25.6% 6.9% 6.4% 5.6% 3.5% Diarrhea 7- ALRI 7- Anemia day prevalence day prevalence (Hb < 110 g/L) Control Treatment www.wsp.org Promoting Handwashing Behavior: The Effect of Mass Media and Community Level Interventions in Peru 7 Finally, the improvements in handwashing practices measurement or anemia levels are observed, and the did not produce significant impacts on environmental prevalence of parasites and parasite count obtained from conditions or child health. Analysis of drinking water the stool samples was not significantly different among samples showed that the prevalence of E. Coli was lower intervention and control groups. in the treated households than those in the control group, but not at a statistically significant level. Child health and LOOKING FORWARD WITH LESSONS wellbeing were measured in the program using a number LEARNED of variables, none of which was significantly affected by Despite known health benefits, handwashing with soap program activities. has proven to be a complex behavioral phenomenon resistant to change. In this large-scale intervention in Peru, There are no statistically significant differences in the the mass media - DCC component when implemented prevalence of diarrhea or acute respiratory illness among alone failed to ensure greater awareness of messages, children in treated households in any of the components. which prevented further behavioral change. In contrast, Similarly, no improvements in child anthropometric the intensive activities delivered at the district level www.wsp.org 8 Promoting Promoting Handwashing Handwashing Behavior: Behavior: The Effect The of of Effect Mass Mass Media and Media Community and Community Level Level Interventions Interventions in Peru in Peru Related reading For the full report, please see: Galiani, Sebastian, Paul Gertler, and Alexandra Orsola-Vidal (2012). Promoting Handwashing Behavior: The Effect of Mass- Media and Community Level Interventions. Water and Sanitation Program; forthcoming in World Bank Policy Research Working Paper Series. Acknowledgments This research brief was prepared by Bertha Briceno, senior evaluation specialist for WSP, with valuable contributions by Rocio Florez, Glenn Pearce-Oroz, and Eduardo Perez. About the program Global Scaling Up Handwashing is a Water and Sanitation (WSP) project successfully reached the target Finally, although the behavior changes focused on applying innovative behavior change approaches audience with the handwashing mentioned did not translate into to improve handwashing with promotion messages, generated improved health outcomes for children soap behavior among women of learning about best handwashing under five, the results provide evidence reproductive age (ages 15–49) and practices, increased availability of in support of supplementing mass primary school-age children (ages 5–9). It is being implemented by water and soap in the house and media and DCC events with intensive local and national governments with improved handwashing practices activities at the school level. Future technical support from WSP in four in two of the critical times. Yet, efforts should focus on identifying countries: Peru, Senegal, Tanzania, observed levels of handwashing other complementary interventions and Vietnam. behavior indicate that there is and removing environmental barriers More information about the considerable room for improvement to ensure significant and sustainable project at: www.wsp.org/ scalinguphandwashing of handwashing practices in Peru. improvements in child health. Contact us WSP is a multi-donor partnership created in 1978 and administered by the World Bank to Visit www.wsp.org or contact support poor people in obtaining affordable, safe, and sustainable access to water and Bertha Briceno at wsp@worldbank.org 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. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. © 2012 Water and Sanitation Program www.wsp.org