WATER AND SANITATION PROGRAM: WORKING PAPER 59934 Global Scaling Up Handwashing Project Enabling Technologies for Handwashing with Soap: A Case Study on the Tippy-Tap in Uganda Adam Biran February 2011 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Global Scaling Up Handwashing Project Enabling Technologies for Handwashing with Soap: A Case Study on the Tippy-Tap in Uganda Adam Biran February 2011 Executive Summary Background The purpose of this study Handwashing with soap at key times is believed to be an effective and highly cost- effective means of reducing diarrhea incidence.1 However, global rates of hand- was to document the washing with soap are frequently low, particularly among the poor, who also face the greatest threat from infectious diseases.2 Access to a convenient handwashing process through which station has been found to be associated with higher rates of handwashing3 and tippy-taps were promoted decreased fingertip contamination.4 to qualitatively explore One such handwashing station is the "tippy-tap," which consists of a small (3 or 5 liter) jerry can filled with water and suspended from a wooden frame. A string the results and to draw attached to the neck of the jerry can is tied to a piece of wood at ground level. Pressing on the wood with the foot tips the jerry can, releasing a stream of water out lessons for future through a small hole. Soap is suspended from the frame beside the jerry can. A interventions. tippy-tap located close to a latrine provides a cheap and potentially convenient means of washing hands after latrine use. A qualitative case study was carried out May 11­18, 2010 in Uganda to learn about two projects, described below, in which health workers and village-level volunteers promoted the tippy-tap, provided health education and carried out household inspections. The purpose of this study was to document the process through which tippy-taps were promoted to qualitatively explore the results and to draw out lessons for future interventions. Data were collected through nine key informant interviews, forty-seven interviews with householders from model and non-model villages, and twenty-two spot-check observations of handwashing facilities. The first project studied, an Agency for Cooperation and Research in Develop- ment (ACORD) water and sanitation project, started in 2008 and is scheduled to run for a total of three years. The second project studied, a Government of Uganda initiative implemented by District Health Authority staff members, started in 2007 and is ongoing. This project established model villages in which households were encouraged to take up a variety of behavior changes including: washing hands with soap at key times; construction of tippy-taps; making and using drying racks for kitchen utensils; building bathing shelters; building or improving latrines; making and using garbage pits; and growing vegetables. 1 Curtis, V., and S. Cairncross. 2003. "Effect of washing hands with soap on diarrhoea risk in the community: a systematic review." The Lancet Infectious Diseases, 3, 275­281, May; and Laxminarayan, R., J. Chow, and S. A. Shahid-Salles. 2006. "Intervention cost effectiveness: Overview of main messages" in Jamison, et al. eds. Disease Control Priorities in Developing Countries. Second edition, 35­86. The World Bank, Washington DC. 2 Scott, B., V. Curtis, and T. Rabie. 2003. "Protecting Children from Diarrhoea and Acute Respiratory Infections: The role of Hand Washing Promotion in Water and Sanitation Programmes." Regional Health Forum, WHO South- East Asia Region, Vol. 7, Number 1. 3 Biran, A., A. Tabyshalieva, and Z. Salmorbekova. 2005. "Formative research for hygiene promotion in Kyrgyzstan." Health Policy and Planning 20 (4) 213­221. 4 Pinfold, J. V. 1990. "Fecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water-supply and sanitation activities on fecooral disease transmission. A case-study in rural North-East Thailand." Epidemiology and Infection 105 (2) 363­375. www.wsp.org iii A Case Study on the Tippy-Tap in Uganda Executive Summary Changes were promoted through village meetings and the tippy-tap is the need to replace components annually. It is house-to-house visits carried out by Health Assistants--vis- possible that over time the need to replace and repair tippy- iting health workers employed by the District Health Au- taps will lead to a decrease in the number of users if house- thorities--and by village-level volunteers. Households were holds lack the motivation to carry this out after visits by health also inspected periodically to see if recommendations are workers and village health committee members cease. being followed. Dissemination of information about the tippy-tap be- The ACORD project differed from the District Health Au- tween villages and even between households within vil- thority project in that rainwater-harvesting systems, im- lages is limited. In non-model villages most respondents proved cooking stoves, tippy-taps and materials for are unaware of the tippy-tap. upgrading latrines were subsidized. The project worked with women's savings groups to provide members with While quantitative data on handwashing rates were not credit on a rotating basis, enabling them to access the tech- collected, households with tippy-taps believed that their nologies being promoted. post-latrine handwashing rates had increased as a result of the taps. It seems likely that tippy-taps provide both Quantitative data (e.g., rates of handwashing with soap or convenient water and soap and a salient cue to wash hands. prevalence of tippy-taps in villages) were not collected in Householders also report that children like using the tippy- this study. taps. They may therefore play a useful role in nurturing the handwashing habit in children. Findings Tippy-taps are common, though not universal in model Respondents in non-model villages were largely unaware villages. Their acquisition seems largely driven by the com- of the tippy-tap. Scaling up the approach is likely to be bination of educational messages and instructions from the challenging, since it would need to rely heavily on the in- Health Assistants and the possibility of inspection. puts of village-level volunteers. Awareness of the tippy-tap does not necessarily translate Conclusions into immediate action to obtain one. Households that Tippy-taps were an acceptable means of providing a low- were aware of the tippy-tap but had never owned one did cost enabling technology for handwashing in this popula- not report any barriers to acquisition other than that they tion. Anecdotally they have increased rates of handwashing either had not lived at their current house for long or that after latrine use. However, uptake appeared driven by the they were waiting for a package of home improvements to `push' of the intervention rather than the `pull' of the tech- be funded (through the ACORD project). nology and the extent to which spontaneous uptake and sustained use can be achieved in the absence of intensive Tippy-taps are acceptable to householders and are thought intervention activities is not known. Respondents in non- to have a number of advantages over using a jerry can. The model villages had little contact with model villages and most salient of these is that the foot pedal prevents contami- were largely unaware of the tippy-tap. The interventions nation of the jerry can alone. The main reported drawback of were labor intensive and probably difficult to scale-up. iv Global Scaling Up Handwashing Contents Executive Summary...................................................................iii I. Introduction ............................................................................... 1 1.1 Background .................................................................... 1 1.2 The Tippy-Tap ................................................................. 1 II. Conducting a Qualitative Case Study in Uganda..................... 3 2.1 Study Objectives ............................................................ 3 2.2 Interventions Studied ..................................................... 3 2.3 Methods.......................................................................... 3 2.4 Study Limitations ............................................................ 5 III. Findings and Discussion ........................................................... 6 3.1 Handwashing Facilities in Households .......................... 6 3.2 Uptake of the Tippy-Tap ................................................. 6 3.3 Advantages and Disadvantages of the Tippy-Tap.......... 8 3.4 Effect of the Tippy-Tap on Handwashing Rates ........... 10 3.5 Implications for Scaling Up .......................................... 11 3.6 Conclusions .................................................................. 12 Tables 1: Distribution of Household Interviews .................................. 4 2: Distribution of Spot-Check Observations ........................... 4 Appendices 1: ACORD Project ................................................................. 14 2: Government of Uganda Intervention ................................. 16 3: Terms of Reference ........................................................... 17 4: Schedule of Activities ........................................................ 19 www.wsp.org I. Introduction 1.1 Background The Water and Sanitation Program's (WSP) Global Scaling Up Handwashing Project is testing whether innovative pro- motional approaches to behavior change can generate wide- spread and sustained improvements in household hygiene and sanitation practices in Peru, Senegal, Tanzania, and Vietnam. Among other learnings, the project is seeking to ascertain the key factors that influence handwashing behav- ior change (also known as behavioral determinants). Enabling products and technologies are some of the "ex- ternal factors" that influence individuals' likelihood to perform a behavior, regardless of their ability and moti- vation to take action.5 Availability of enabling products and technologies is often overlooked in the design of A tippy-tap is easy to use and commonly constructed near handwashing initiatives, although it has been well docu- latrines. mented that behavior change is most successful if the behavior is not only intentional, but also feasible for the target population to adopt.6 These "external factors" have tippy-tap provides a controlled quantity of flowing water been shown to facilitate handwashing behavior, in com- for washing hands and is made from locally available ma- bination with other behavioral determinants such as at- terials such as gourds or old plastic cooking oil bottles. titudes and beliefs about handwashing and knowledge Variants include a design that can be operated by foot, about the positive consequences of handwashing, among thereby avoiding contamination of the tap itself. Usual others.7 methods for promoting and disseminating the tippy-tap technology within hygiene promotion interventions are In the case of handwashing, the tippy-tap is perhaps the through volunteer outreach workers or community re- best-known enabling technology. It is a low-cost, do-it- source persons as well as health club activities in schools. yourself technology that has been widely promoted for over a decade, notably in Uganda and Madagascar. The While guidelines and "how-to" instructions are available about tippy-taps and other enabling products, very few evaluations or assessments inform the design of hygiene 5 As part of its Global Scaling Up Handwashing Project, WSP developed a behavior promotion programs through the documentation of lessons change framework to explain handwashing behaviour. The FOAM framework learned, promising practices (including implementation identifies the key factors or determinants that influence Handwashing, organized into four categories--Focus, Opportunity, Ability, Motivation. Enabling products models), or successes and challenges (particularly with re- and technologies fall under the Opportunity category of determinants. See spect to changing behavior at large scale). Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs, available at www.wsp.org/scalinguphandwashing 6 For more information on tippy-taps and other enabling technologies for 1.2 The Tippy-Tap handwashing with soap, see WSP's Enabling Technologies for Handwashing Database at www.wsp.org/scalinguphandwashing/enablingtechnologies. The tippy-tap was initially developed in Zimbabwe by Jim 7 Biran, Adam, Anara Tabyshalieva, and Zumrat Salmorbekova, "Formative Research Watt and Jackson Masawi. It consisted of a small gourd sus- for Hygiene Promotion in Kyrgyzstan," Health and Policy Planning 20, no. 4 (2005): 213­21. pended on a string. The gourd was filled with water that www.wsp.org 1 A Case Study on the Tippy-Tap in Uganda Introduction could be dispensed in small quantities if the gourd was 0.5-liter drinking water bottle. A shallow depression filled tipped by means of a string tied to its neck. Soap could be with gravel or stones acts as a soak-away and prevents a suspended on a string beside the gourd. pool of water from forming below the tap. Subsequently, the gourd was replaced with a small (3 or Research shows that a person washing hands under a tippy- 5 liter) plastic jerry can with a hole punched in the side. A tap uses 40-50ml of water as compared with 600ml when more recent addition is a piece of wood at the bottom of water is accessed by other means.8 string tied to the neck of the jerry can. This allows the tap to be operated by foot, avoiding the need for any hand contact with the jerry can. This variant of the tippy-tap 8 Hurtardo E (1993) Dialogue on Diarrhoea Online (54) September­November, was in use at the study site in Uganda. Soap can be pro- pp 6­7. tected from rain by covering it with the base of an old 2 Global Scaling Up Handwashing II. Conducting a Qualitative Case Study in Uganda 2.1 Study Objectives In March 2010, WSP conducted a qualitative case study in Uganda to learn about the promotion of specific handwash- ing enabling technology (the tippy-tap) through a particu- lar approach (the use of visiting health workers and village-level volunteers to provide health education and carry out household inspections in model villages) in Uganda. A schedule of activities is included in Appendix 4. WSP's overall aim is that these findings will inform both WSP's Global Scaling Up Handwashing Project and the wider water, sanitation, hygiene promotion, and health communities on the potential role, value, and limitations of enabling products and provide insights into promising practices to maximize scale and sustainability. Key objectives included: Tippy-taps consist of a jerry can filled with water hung by a · Look for evidence of sustained use of tippy-taps be- rope next to a container of soap. The stones below the tippy- yond the period of an intervention tap act as a soak-away. · Look for evidence of dissemination of tippy-taps be- yond intervention areas Health Authority staff members also worked in non-model · Look for evidence of the reach of the intervention villages where the same behavior changes were promoted or promotion but at a lower intensity. Each project is described in greater · Understand reasons behind adoption or detail in Annexes 2 and 3. non-adoption · Draw out features of the technology and/or the dis- 2.3 Methods semination model that may have contributed signifi- Data were collected from May 11­May 18, 2010 using cantly to the levels of uptake and sustained use three qualitative approaches: (1) semi-structured interviews · Consider how these features might help or hinder with householders, (2) semi-structured interviews with key future attempts to promote the technology at a informants, and 3) spot-check observations of hand wash- greater scale ing facilities: 2.2 Interventions Studied Semi-structured interviews with householders: The au- The case study research focused on two distinct projects: thor worked through either a District Health Inspec- one, a project implemented by the Agency for Cooperation tor or a Health Assistant who acted as a translator and Research in Development (ACORD), a non-govern- for the interviews. A total of forty-seven interviews mental organization; the other, a Government of Uganda were conducted, including in model villages where initiative implemented by District Health Authority staff the projects had been implemented and in neigh- members. Both projects established model villages in which boring non-intervention villages from the same sub- households were encouraged to take up a variety of behav- county.9 Of these interviews, thirty-four were with ior changes. The intention was that model villages would serve as examples of good practices thereby inspiring and 9 Sub-county is the administrative level below district. Below sub-county are parish encouraging changes in neighboring villages. District and village levels. www.wsp.org 3 A Case Study on the Tippy-Tap in Uganda Conducting a Qualitative Case Study in Uganda TABLE 1: DISTRIBUTION OF HOUSEHOLD INTERVIEWS TABLE 2: DISTRIBUTION OF SPOT-CHECK OBSERVATIONS (N = 47) (N = 22) Village Interviews Village Spot-checks ACORD Intervention ACORD Intervention Model village, Mwizi sub-county 8* Model village, Mwizi sub-county 10 Non-model village 1, Mwizi sub-county 8 Non-model village 1, Mwizi sub-county 10 Non-model village 2, Mwizi sub-county 8 Non-model village 2, Mwizi sub-county 0 District Health Authority Intervention District Health Authority Intervention Model village, Mbarara District 8 Model village, Mbarara District 0 Model village, Ibanda District 9 Model village, Ibanda District 0 Non-model village, Ibanda District 6 Non-model village, Ibanda District 2 Total 47 Total 22 *Six respondents were members of savings groups directly involved in the ACORD project; two were non-members. female heads of household, eight with male heads of from a list of villages in the same sub-county. Households household, and five with male and female heads of for interview were selected randomly from a list of all household together (Table 1). households in the villages because there was insufficient in- formation available to allow purposive sampling. Semi-structured interviews with key informants: The author worked through either a District Health In- Data collection from the District Health Authority inter- spector or a Health Assistant who acted as a transla- vention took place in two model villages located in Mbarara tor for the interviews. A total of nine interviews were District and Ibanda District respectively and in one non- conducted to learn about the content and nature of model village from a neighboring village in Ibanda District. the interventions. Interviews were conducted with: The District Health Authority proposed the model villages. one Project Director and Social Worker (ACORD); The neighboring non-model village in Ibanda District was two District Health Inspectors; one Volunteer Proj- selected randomly from a list of villages within the same ect Coordinator (from the ACORD model village); sub-county as the model village. In Ibanda District house- two Village Chairmen from model villages; one holds to be interviewed were chosen randomly from a list of Chairman, Village Water and Sanitation Committee all households in each of the two villages (model and non- (from a model village); one Deputy District Health model). In Mbarara District households to be interviewed Officer; one Health Assistant. were chosen randomly from a list of twenty households provided by the village chairman. Spot-check observations. A total of twenty-two spot- check observations of handwashing facilities were The average size of the villages studied was estimated to be carried out in a small, convenience sample House- one hundred households. In each village, the village chair- holds were not informed in advance that they would man or a representative visited selected households in the be visited. The spot checks observations were used to late afternoon or early evening of the day before the inter- look for the presence handwashing facilities, soap, view with a request that an adult from the household be and water beside household latrines (Table 2). available for an interview on the following day. This prepa- ration was necessary as the study took place during a busy Data collection from the ACORD project took place in one agricultural season and few people were likely to be home model village and two non-model villages from the same during daylight hours. Householders were told that the in- sub-county. The model village visited was proposed by terview would be about daily domestic life including water ACORD. Two non-model villages were selected randomly and sanitation. 4 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Conducting a Qualitative Case Study in Uganda During the Interviews: 2.4 Study Limitations This study had a number of limitations that should be Householders were asked about where they washed their borne in mind when interpreting the results: hands and what they used for handwashing. 1. Despite efforts to focus the fieldwork in areas where promotion of the tippy-tap had ceased, interven- Householders with a tippy-tap were interviewed about when tions were still active in the villages studied. Thus, it and why they acquired the tippy-tap, how they learned was not possible to assess the extent to which tippy- about it and their opinions of it (including ease of con- tap use is sustained in the absence of active promo- struction and use, appearance, maintenance, main advan- tion efforts. tages and problems, and how it compared with their 2. Introduction to villages and interpretation during in- previous practice). terviews was done through District Health Inspectors. The inspectors appeared to have excellent rapport with householders but were probably perceived by Householders without a tippy-tap were asked whether they householders as associated with the interventions, po- knew about tippy-taps, how they knew about them, what tentially increasing the possibility of respondent bias. they thought of them, and whether they were happy with 3. In order to ensure that respondents were present for their current handwashing practice. interviews it was necessary to make arrangements on the day prior to interview. Householders were aware Households in model villages were asked about their aware- that the interview would cover different household ness of and contact with the intervention. They were also technologies including water and sanitation. It is asked about whether they talked about or promoted the therefore possible that householders made efforts to tippy-tap to friends and neighbors. ensure the presence of soap and water at tippy-taps. 4. A quantitative assessment of handwashing rates or Households in non-model villages were asked about their con- prevalence of tippy-taps was not included as part of tact with the model village in their sub-county. this study. www.wsp.org 5 III. Findings and Discussion 3.1 Handwashing Facilities in Households was a blue laundry bar either placed on a rack or soap dish All households that owned tippy-taps had constructed them on the frame of the tippy-tap or suspended on a cord tied to close to their latrine on the route between the latrine and the frame and covered with a cut-off plastic drinking water the house. They reported that they used it exclusively for bottle. washing hands after latrine use. When washing hands at other times, such as before eating, before preparing food, or Very few respondents from non-model villages had tippy- on returning from the fields hands were washed beside the taps. In households without tippy-taps, householders re- house or in the kitchen using a jerry can of water and some- ported washing their hands using soap and a jerry can of times a bowl. water. Practices varied between individuals and between households. Not all tippy-taps had water in them at the time of the vis- its. This does not necessarily imply that they were not in use Sometimes water was poured from the jerry can into a bowl since it may be that they had been emptied through use in for washing and sometimes it was used directly from the the course of the day (observations took place in the late jerry can. Some households used a small (3 liter) jerry can mornings and afternoons). for handwashing rather than pouring directly from a 20-liter jerry can. Common practice was to keep the jerry Almost all tippy-taps had soap beside them or contained cans and water inside the house and to bring them out for small pieces of soap within the water. The type of soap used handwashing when needed. However, some households kept a small jerry can with water beside the latrine that was reported to be specifically for handwashing after latrine use. 3.2 Uptake of the Tippy-Tap Householders acquired tippy-taps as the result of hygiene promotion and inspection efforts or because they came as part of a package of home improvements (offered in the ACORD model village only). That is to say they acquired them because they were told that they should, because they were told about the need to avoid contamination of the jerry can and because they knew that there were household inspections to check on hygiene and sanitation arrangements. That is not to suggest that households were coerced into acquiring tippy-taps, however there was no suggestion that tippy-taps are seen as a `must have' technology, nor was it clear that the benefits of tippy-taps reported by owners were sufficient to drive adoption without the social pressure re- sulting from household visits and inspections. This qualitative study was not able to assess the true extent of diffusion of tippy-taps. The impression gained from in- terviews was that diffusion of tippy-taps to households out- Many households reported increased rates of handwashing side of the model villages did occur but was very limited. with soap after constructing tippy-taps. Only one individual interviewed said that she had seen the 6 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Findings and Discussion REASONS TO GET A TIPPY-TAP `I was told to get [a tippy-tap] and there are inspections.' --Woman, Mbarara District model village `I was told to get one because the village is competing.' --Man, Mbarara District model village `We got [the tippy-tap] with the water tank, stove and latrine.' --Woman, ACORD model village `I built [the tippy-tap] yesterday because I knew visitors (i.e. the interview team) were coming.' --Woman volunteer, Village Health Team, Ibanda District non-model village `We were made aware of the advantage [of avoiding contamination of the jerry can].' Tippy-taps are low-cost and can be easily constructed ­Woman, Ibanda District model village using available materials. tippy-tap and decided to construct one for herself (rather than being told she Within model villages, respondents should have one). The reason given for construction was that she thought it had acquired tippy-taps as the result of direct promotion by health looked modern and would be attractive for visitors to use. Two other households workers rather than diffusion through with tippy-taps were among respondents in non-model villages. One had con- neighboring tippy-tap users. structed a tippy-tap four or five years previously, following health education pro- vided by the District Health Authority as part of a cholera prevention campaign. The other was a volunteer in the Village Health Team (VHT) who had been taught about tippy-taps by the Health Assistant a month earlier but had built the tippy-tap the previous day on hearing that she was going to be visited and inter- viewed. Within model villages, respondents had acquired tippy-taps as the result of direct promotion by health workers rather than diffusion through neighboring tippy-tap users. Two householders were lapsed users. One from a non-model village said his wife had found the tippy-tap more difficult to use than a jerry can and therefore they no longer have a tippy-tap. He taught adult education classes and had taught a class about the tippy-tap. He learned about the tippy-tap when being trained for the teaching. He believed that only one of his students had constructed a tippy- tap following the lesson and that this was an elderly woman who in his words had `enough time and money not to be concerned with other things.' The other www.wsp.org 7 A Case Study on the Tippy-Tap in Uganda Findings and Discussion `Is it common? I have not respondent, also male and from a non-model village, had promoted tippy-taps as a volunteer with the Child Health Uganda campaign in 2006 and was now a heard.' VHT volunteer. He said that parts of his tippy-tap had been stolen and that he ­Man, Mbarara District, could see no advantage over simply having a jerry can. In his view people con- non-model village struct tippy-taps during campaigns because there are inspections and they fear fines but subsequently drop them. Another male respondent from a non-model village had a tippy-tap at his other home in Mbarara town. He had it constructed after an inspection from the health department. Although he said he liked the tippy-tap he did not see the need to construct one at his home in the village. Respondents from households without tippy-taps in non-model villages had not heard of tippy-taps. In model villages respondents without tippy-taps offered explanations as to why they did not have one. These responses suggest that respondents believed that the interviewers expected them to have tippy-taps but that constructing them was not a high priority for households: Two respondents from the ACORD model village reported that their tippy-taps had been stolen (although inspection beside the latrine found no evidence of their having been constructed). Other respon- dents who had heard of tippy-taps said that they did not have them because they had only recently moved in (several months ago), were waiting to get the home improvement package (in the ACORD model village), were waiting until they construct a new latrine, or were waiting to hear more about them from the VHT. 3.3 Advantages and Disadvantages of the Tippy-Tap The most important advantage Householders with a tippy-tap reported that it has advantages over using a jerry was considered to be that it avoids can in that it avoids contamination of the jerry can, uses less water, and is easier contamination. to use. The most important advantage was considered to be that it avoids contamination. The possibility of contaminating the jerry can used for handwashing is something that householders were told about by Health Assistants and VHT volunteers dur- ing health education sessions (either in group meetings or during household vis- its). Through health education sessions householders hear that washing hands after using the latrine is important in preventing disease, that provision should be made for handwashing by the latrine, and that the tippy-tap prevents contamina- tion by avoiding contact between hands and the jerry can. They also are informed that the tippy-tap uses less water. Householders who have not been exposed to these health education messages do not mention the need for a solution to avoid contamination of the jerry can. It is not clear whether householders with tippy- taps now felt a genuine need to avoid contamination of their jerry cans as a result of the hygiene education or whether they were simply repeating an explanation given to them by the health workers. 8 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Findings and Discussion Perhaps unsurprisingly all respondents who had a tippy-tap disagreed with the `Perhaps it is not modern to interviewer's suggestion that some people thought it did not look very modern. you but for us it is.' However, one male respondent (a lapsed tippy-tap user in a non-model village) -- Woman from said he thought the tippy-taps did not look attractive and that this was a problem model village in promoting them. Households without a tippy-tap generally had no experience of them and were unable Households without a tippy-tap to comment on them. Those that were aware of them said that they believed they are generally had no experience of them better than a jerry can and that they planned to get one soon. One elderly woman and were unable to comment on them. however, reported that she considered the tippy-tap to be childish and unnecessary and suggested that people used to live longer before tippy-taps were invented. Most tippy-tap users interviewed said that they found the tippy-taps easy to refill. Refilling rates varied according to the size of the household. Reported rates ranged from twice daily to once per week. However, respondents did not want larger reservoirs of water in their tippy-taps as it was thought that these would become stagnant and would allow algae to grow in them. Most tippy-tap users interviewed also reported having to replace the jerry can, string and wooden frame every year as they wear out and degrade in sunlight. The fact that respondents report making these replacements suggests that they were motivated to continue using them. It is not known if this is because of the ongo- ing hygiene promotion and inspections or because they have adopted the habit of handwashing with the tippy-tap. All respondents with tippy-taps reported that they found them easier to use than a plain jerry can. However, all of these respondents continued to use a jerry can REPORTED DISADVANTAGES OF TIPPY-TAPS Most tippy-tap users interviewed reported having to replace the jerry can, string, and wooden frame every year as they wear out and degrade in sunlight. One respondent suggested that a frame made of metal would be a useful improvement. Other problems associated with tippy-taps were chil- dren playing with them and using all the water and the problem of jerry cans, water, or soap being stolen or used without permission. These problems were par- ticularly acute in villages with severe water shortages and varied depending on the location of the house and the latrine. www.wsp.org 9 A Case Study on the Tippy-Tap in Uganda Findings and Discussion `It is more difficult to dodge for handwashing at times other than after latrine use. When asked why, if they genuinely found the tippy-tap easier to use and a means of saving water they had handwashing.' not constructed an additional tippy-tap beside the house, all respondents reacted --Woman, ACORD with embarrassed laughter followed by an explanation such as `We have not been model village told,' `We were not aware of the need,' and `If you tell us to we will construct one tomorrow.' The responses again suggest that This suggests two possibilities: 1) despite what respondents reported, there are tippy-taps are seen as something features of the tippy-tap that make it less convenient to use than a jerry can or that is done to comply with the 2) that other household handwashing takes place at various locations--meaning recommendations of the Health that a fixed tap in general or a tippy-tap in particular would not be convenient. Assistants and VHTs. The responses again suggest that tippy-taps are seen as something that is done to comply with the recommendations of the Health Assistants and VHTs. 3.4 Effect of the Tippy-Tap on Handwashing Rates Collecting data on handwashing rates is a challenge and such data are likely to be prone to bias. No data were collected in this study to quantify handwashing. It is likely that the presence of the tippy-tap close to the latrine on the route to the house acts as a salient reminder to wash hands and also facilitates handwashing by providing a convenient source of soap and water. Some households already kept a jerry can beside the latrine to facilitate handwashing but for others the tippy-tap is the first time a handwashing facility has been provided close to the latrine. Access to a convenient handwashing station has been found to be associated with higher rates of handwashing10 and decreased fingertip contamination11. However, it is also worth noting findings from rural Bangladesh where the distance from the latrine to the handwashing place was not associated with a decrease in hand- washing rates12 and findings from urban Bangladesh where availability of soap at the handwashing place was found to decrease with increasing distance from the house13. Thus, it may be worth exploring with households the optimal site for a tippy-tap and accepting that this may not be beside the latrine. Respondents with tippy-taps reported that handwashing after latrine use had in- creased in their households as a result of having the device. Respondents with tippy-taps also reported that children enjoyed using them be- cause of the novelty of the foot pedal. The tippy-tap may thus play a useful role in nurturing the handwashing habit among children. 10 Biran, A., A. Tabyshalieva, and Z Salmorbekova. 2005. "Formative research for hygiene promotion in Kyrgyzstan." Health Policy and Planning 20 (4) 213­221. 11 Pinfold, J. V. 1990. "Fecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water-supply and sanitation activities on fecooral disease transmission. A case-study in rural North-East Thailand." Epidemiology and Infection 105 (2) 363­375. 12 Luby, S. P., et al. 2008. "Associations among handwashing indicators, wealth and symptoms of childhood respiratory illness in urban Bangladesh." Trop Med Int Hlth 16 (6) 835­844. 13 Luby, S. P., et al, 2009. "Household Characteristics Associated With Handwashing With Soap in Rural Bangladesh." Am J Trop Med Hyg 81 (5) 882­887. 10 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Findings and Discussion Where homesteads are close together the visibility of tippy- taps may also help to encourage handwashing as a social FIVE ATTRIBUTES THAT CONTRIBUTE TO THE norm if they become sufficiently common, used, and DIFFUSION OF INNOVATION maintained. Five attributes of innovations seem to be strongly 3.5 Implications for Scaling Up related to the speed with which they diffuse in Five attributes of innovations seem to be strongly related to populations: the speed with which they diffuse in populations. These are 1. The ease with which an innovation can be not objective attributes of an innovation but rather percep- understood and used; tions that the target group holds about it. Additionally up- 2. The opportunity to experiment with it on a take of innovations is frequently associated with status limited basis; seeking.14 3. The relative advantage of the innovation over existing practice; Interviews with householders suggest that the tippy-tap is 4. The ease with which the innovation can be easy to understand and use; its low cost should make it easy observed before adoption; and to try out on a limited basis; and users of the tippy-tap iden- 5. Compatibility with existing values and tified advantages over previous practices. It should also be needs. reasonably easy to observe the tippy-tap prior to uptake. The tippy-tap does not seem to conflict with existing values; however, the extent to which it addresses a salient perceived need is questionable. Promotion of the tippy-tap aims to use of face-to-face communication and the provision of re- create a need amongst householders to avoid contamina- wards and sanctions are all factors that have been associated tion of the jerry can when washing hands, and may be suc- with behavior change and indeed this approach seems rea- cessful in this. However, it may be more effective to start sonably effective, at least in the short term. However there with a sound understanding of the existing needs of the are likely to be problems associated with using this ap- target group and to think about how best to address these proach at scale because it is very labor intensive, requiring needs through a facilitating technology. The extent to which multiple visits to households over an extended period. the tippy-tap is able to deliver status benefits is also not Sub-counties vary in size and Health Assistants do not work clear. on a standard schedule. However, typically a sub-county The social networks into which innovations are released in- might comprise around fifty villages and a Health Assistant fluenced the speed of diffusion. In the Ugandan context might aim to visit a village two or three times during a year. there was little contact between model and non-model vil- A village may comprise eighty to one hundred households. lages and, even within villages, homesteads could be fairly In a single day, if households are close together and house- isolated from each other. As a result dissemination of holders are at home, a Health Assistant might manage to knowledge of the tippy-tap was slow and even within model visit thirty households. However, households are often scat- villages not all households were even aware of the tered and people are often away from home meaning that tippy-tap. the actual number of households reached is likely to be much lower. Radio achieves wider coverage than Health As- The projects rely on health education and instruction by sistants and VHTs. Most householders in model and non- Health Assistants or VHT volunteers to create demand for model villages had some exposure to health and hygiene tippy-taps and to give people the skills to make them, and education through the radio. However, promoting a new on inspections to encourage and enforce continued mainte- technology such as the tippy-tap through a non-visual com- nance of tippy-taps. The authority of health workers, the munication channel is likely to be difficult. This means that the task of promoting the tippy-tap currently falls largely to 14 Rogers, E. M. 2003. Diffusion of Innovations. 5th edition. Free Press, New York. the volunteer VHTs. www.wsp.org 11 A Case Study on the Tippy-Tap in Uganda Findings and Discussion VHTs are probably reasonably effective at delivering simple tippy-tap that looked more attractive and did not wear out health education messages over limited time periods. They so rapidly. are probably less suitable for delivering motivational or so- cial marketing messages and would probably be unwilling This is not to imply that a commercial handwashing technol- to invest large amounts of time over long periods in pro- ogy is a necessity. Social (not for profit) marketing of the moting handwashing and tippy-taps. tippy-tap might also succeed. However, attempts to market a handwashing technology, whether commercially or as part of Another issue related to scale is the sustainability of the in- a social marketing or behavior change communication ap- tervention. As tippy-taps were still being actively promoted proach are most likely to succeed if the product promoted is in the model villages at the time of this study, it is not pos- based on a sound understanding of the needs and preferences sible to comment on the long-term sustainability of their of the intended consumers. The promotion of the technology use. However, inspections and the possibility of sanctions must also be based on drivers (such as status) or other behav- appeared to play an important role in promoting and rein- ioral determinants identified through research. Respondents forcing the use of tippy-taps. It is not clear if tippy-taps are only able to judge the usefulness and performance of the alone will deliver sufficient benefits for households to sus- tippy-tap relative to other facilitating technologies. In this tain their use once the possibility of inspections subsides. study neither households with tippy-taps nor those without This problem may be exacerbated by the need to replace had experience of using an alternative technology besides the worn-out components annually since in the absence of in- jerry can and they could not tell whether the tippy-tap is the spections householders may lack the motivation to main- technology that best addresses their needs. tain tippy-taps in working order. On the other hand, it is possible that inspections over a limited period of time will 3.6 Conclusions prove sufficient to allow a handwashing habit to develop Tippy-taps are a cheap and acceptable enabling technology through repetitions of the behavior, with the presence of for handwashing after latrine use in this rural Ugandan the tippy-tap acting as a cue, and that this habit will be suf- population. ficiently powerful to motivate maintenance and continued use of tippy-taps. Research on sustainability of hygiene be- The tippy-taps probably increased handwashing after la- havior change in schools has found this to be positively cor- trine use by providing convenient soap and water, and by related with the duration of the intervention.15 It is not acting as a salient cue to wash hands. The tippy-taps were known whether there is an optimal duration for tippy-tap also attractive and easy for children to use and may help enforcement after which maintenance of the practice be- foster the habit of handwashing among children. comes stable. Tippy-tap users perceived benefits of the tippy-tap but it is A commercially marketed enabling technology might be not clear if these perceptions motivated adoption of the able to achieve more widespread coverage in the long run technology or if they came about as a result of becoming a avoiding the need to rely on volunteers for promotion and tippy-tap user. Perception of the tippy-tap among non- distribution. In view of the low cost and ease with which users is unknown as they generally had no knowledge of the households are able to make tippy-taps it is unlikely that technology. Some consumer research might be useful to un- they could be commercially marketed in their current form. derstand the needs of householders in relation to hand- There might be a market for an improved version of the washing and whether the tippy-tap is the technology that best meets these needs or whether a different technology, 15 Cairncross, S. and K. Shordt. 2003. "It Does Last. Some Findings from a Multi- either homemade or commercially produced, might be Country Study of Hygiene Sustainability." Waterlines 22: 3 4­7. more desirable. Research of this sort carried out recently in 12 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Findings and Discussion Vietnam was useful in revealing consumer needs such as a because it relies on labor-intensive, repeated visits to villages preference for squatting while washing hands and a desire and households. An alternative might be to use radio as a to control the flow of water.16 means of stimulating interest and promoting demand for a handwashing technology, and then to use a short, intensive Although this study did not collect quantitative data on the intervention over two or three days in a village in an effort prevalence of tippy-taps, diffusion of the tippy-tap beyond to get uptake in a majority of households, hoping that visi- the model villages in which it was promoted seemed very ble uptake by the majority would create a social norm that limited. This may be because the social networks connect- would drive uptake in remaining households and help sus- ing villages are relatively few and weak and because addi- tainability. This could be supported by efforts such as dis- tional means of promotion are not currently used (radio trict level direct consumer contact events and low-literacy may not be a suitable medium for this). comic strips such as these being used or planned for hygiene promotion in Tanzania.17 Radio could again be used to re- The `model village' approach in its current form would be inforce the belief that having and using a handwashing difficult to scale up to cover an entire district and beyond technology is a social norm. 16 17 Devine, J. 2010. Insights from Designing a Handwashing Station for Rural Vietnamese Devine, J and Y. Coombes. 2010. Personal communication. WSP. June. Households. WSP Learning Note, February. www.wsp.org 13 A Case Study on the Tippy-Tap in Uganda Appendix 1: The ACORD Project Appendix 1: ACORD Project The ACORD water and sanitation project began in 2008 fortnightly slots on a private radio station. This is funded and is scheduled to run for three years. The project is work- 50 percent by ACORD (as part of a different project) and ing in eight model villages, each in a different sub-county. 50 percent from the radio station's corporate social respon- These villages were selected by ACORD in collaboration sibility budget. The talk show slots last for one hour and with the district Department of Health as ones in which the cover a variety of health topics including water and sanita- project is thought likely to have a reasonable chance of suc- tion and hygiene issues. cess (i.e., they are not the poorest and they have reasonably well functioning and supportive leadership structures and a In each model village the project works with three or more need for improvements to water supply). selected women's savings groups. These groups operate as credit groups and allocate funds to households on a rotating Scope of the Intervention basis to enable them to purchase the promoted technolo- The project is not only promoting hand hygiene but a pack- gies. Local materials and labor are provided through the age of home improvements including rainwater harvesting, savings groups. Non-local materials are sourced through the improved pit latrines, improved domestic hygiene (through project at a 50-percent subsidy through which ACORD use of dish racks, garbage disposal pits, urinals, and bathing matches each household package of technologies funded by shelters) and fuel efficient stoves. the savings groups. A household package comprises a rain- water-harvesting tank, an improved latrine (with cement The project uses a combination of community mobilization, slab, vent pipe, and iron roof ), a fuel-saving stove, and a health education, and social pressure and enforcement along tippy-tap. with a subsidy for the purchase of materials and technical support for construction. The approach followed by the proj- The project is working in a water-scarce area in which ect is to establish model villages at the sub-county level in women report journey time of an hour or more to collect which the interventions are promoted through a process of water. The experience of ACORD has been that rainwater community mobilization, construction of demonstration harvesting systems are a priority for households and that units (latrines, stoves, water tanks, and tippy-taps), technical provision of these systems serves as an entry point for the training of selected individuals and group meetings, house- project allowing the opportunity for promotion of hand- hold visits, and community events to promote uptake and washing and other household hygiene practices. behavior change. Meetings and community events are open to group members as well as non-group members. Hygiene The project works with the district Department of Health promotion focuses on education and raising awareness about at the sub-county level. In each sub-county one Health diarrhea transmission routes, the importance of handwash- Assistant from the Department of Health is active in the ing with soap after latrine use and before handling food, and model village. In the village the Health Assistant is sup- the use of the tippy-tap to avoid contamination of the jerry ported by a volunteer coordinator who acts as a point of can while handwashing. As described by one ACORD staff contact between the project and the savings groups and member this amounts to `telling people the do's and don'ts and households and who coordinates and facilitates meetings explaining the key times for washing hands.' and household visits. The Health Assistants work with the savings groups to agree on action plans and to arrange for Additional promotion of technologies and health messages follow-up support visits as needed. Sensitization visits comes from the use of radio by the district health authori- raise awareness of the project aims and way of working. ties and by ACORD. Since 2009 there have been Subsequent visits to households focus on priorities with 14 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Appendix 1: The ACORD Project respect to hygiene and water and sanitation as identified · Construction of forty-four household ventilated im- by the Health Assistant or village coordinator in discus- proved pit (VIP) latrines sion with householders. Health Assistants facilitate group · Construction of forty-four fuel saving stoves meetings with support from ACORD staff as needed. · Construction of 300 tippy-taps These meetings center on members of the savings groups · Household visits to carry out hygiene promotion in but are open to all villagers. Progress and plans for imple- 300 households18 menting changes in households are reviewed, and also an opportunity is provided for the Health Assistant to pro- There had been no evaluation of the project at the time of mote or highlight appropriate health messages. The proj- the study. Anecdotally, villages vary in how much uptake is ect employs two social workers and three technical staff achieved. It is reported that most success seems to be (two civil engineers and one plumber) to provide support achieved when the village chairman is actively involved and in the villages as needed. when the volunteer coordinator at village level is a woman. Success also depends on the social and political interactions Selection of Handwashing Technology that take place at village level. There was no formative research to inform design of the handwashing technology promoted in the project. The The ACORD Project in Mwizi Sub-County tippy-tap technology was copied from a UNICEF project Model Village in Uganda and was regarded by the ACORD project team The model village in Mwizi sub-county was visited during as being the only suitable handwashing enabling technol- this study. The village had a population of 108 households. ogy available, mostly due to its low cost. The project worked with five women's savings groups in this village (the group members are predominantly but not ex- Schools clusively women and predominantly but not exclusively The project is not working in schools. ACORD would like from the model village). There were fifty-seven households to include a schools element in subsequent projects if suffi- that were members of at least one of the savings groups in- cient funding is available. volved in the project. The savings groups were selected by ACORD for involvement in the project on the basis of Planning for Sustainability their apparent capacity to collect and distribute funds ef- Sustainability is planned for by using existing structures at fectively among their members. The opportunity for group the sub-county and village levels (Health Assistants and sav- members to obtain rainwater-harvesting systems (water ings groups respectively), and by training masons at the vil- tanks and pipes) was the primary motivation for groups to lage level. Health Assistants are already trained in technologies join the project. and basic promotion techniques. The intention is that Health Assistants will be able to continue the work, spreading to A village water and sanitation committee had been formed neighboring villages once the project ends. from members of the five groups. The committee carried out home visits to inspect hygiene and sanitation facilities Baseline and can reportedly impose sanctions on households that fail A baseline survey of water coverage was conducted at the start to comply with their recommendations. Sanctions are said of the project in 2008. At the time of the visit the consultant to include the possibility of a fine for not constructing a was unable to obtain the report of the baseline survey. latrine and the social sanction of the transgressing house- hold not being used as a meeting place during the rotating Monitoring and Evaluation cycle of savings group meetings. Households are reportedly The 2008 and 2009 annual reports include the following visited approximately every two months. among the activities completed per year: 18 The project is working in eight model villages. Assuming that these villages are of · Construction of forty-four domestic rainwater har- similar size to those visited during the study, this would equate to a population of vesting tanks around 800 households. www.wsp.org 15 A Case Study on the Tippy-Tap in Uganda Appendix 2: Government of Uganda Intervention Appendix 2: Government of Uganda Intervention The Government of Uganda intervention started in 2007 daylight into houses, constructing and maintaining sanitary and is ongoing. This intervention uses essentially the same latrines, and construction of bathing shelters. There was no approach as the ACORD intervention, that is, dissemina- indication of any strict hierarchy as to the relative importance tion of a variety of health messages through Health Assis- of these different messages but rather that Health Assistants tants working with village level volunteers. The main were free to use their own judgment as to what was appropri- differences are that materials are not provided and the inter- ate in order to achieve a suite of changes. vention does not work with savings groups. Each village has a Village Health Team (VHT) comprising Each sub-county has a Health Assistant appointed by the volunteers trained by the District Health Authority and District Health Authority. Health Assistants visit the vil- used to disseminate health messages and carry out inspec- lages within their sub-counties and work with village level tions to help encourage and enforce changes at household volunteers to disseminate health messages. In each sub- level. These include messages on sanitation and hygiene. county there is a model village in which the work of the Prior to the establishment of VHTs the Child Health Health Assistants is concentrated. However, Health Assis- Uganda project (a Ugandan Government initiative) oper- tants also carry out similar work to a lesser extent in the ated in a similar way, promoting health messages through other villages of the sub-county. village level volunteers and carrying out inspections of sani- tary conditions in households. Messages include but are not restricted to the need to wash hands at key times, the need to have a handwashing facility A limited number of rainwater-harvesting systems is avail- by the latrine, and the construction and use of tippy-taps. able annually through the sub-county municipal authorities Other messages include construction of drying racks for at a 50 percent subsidy. In 2010, forty systems were allo- kitchen utensils, growing vegetable gardens, digging garbage cated to Mwizi sub-county in Mbarara district by the dis- pits, boiling water for drinking, safe water storage, allowing trict authorities. 16 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Appendix 3: Terms of Reference Appendix 3: Terms of Reference 1. Objective and Purpose of Consultancy only intentional, but also feasible for the target popula- The objective of this consultancy is to conduct a case study, tion to adopt. These "external factors" noted above have delving into the innovation process and framework. been shown to facilitate handwashing behavior, in com- bination with other behavioral determinants such as at- The purpose of the case study is to investigate the process in titudes and beliefs about handwashing and knowledge which some of the enabling products have been developed, about the positive consequences of handwashing, among what results were obtained, and what lessons can be learned. others. The results will inform WSP's Global Scaling Up Hand- washing Project and the wider water, sanitation, hygiene In the case of handwashing, tippy-taps are perhaps the best- promotion, and health communities on the potential role, known enabling product. However, there are many others value, and limitations of enabling products and provide in- including handwashing stations, soap nets, and soap fea- sights into promising practices to maximize scale and tures themselves. A quick online search reveals several sustainability. guidelines and instructions on how to construct tippy-taps or other enabling products. However, very few evaluations 2. Background or assessments, if any, can be found which would document The Water and Sanitation Program (WSP) is implementing lessons learned, promising practices (including implemen- the Global Scaling Up Handwashing Project with support tation models), successes, and challenges, particularly with from the Bill & Melinda Gates Foundation. The project will respect to changing behavior at large scale, and that might test whether innovative promotional approaches to behavior inform the design of hygiene promotion programs. This change can generate widespread and sustained improvements consultancy aims to fill this void and push the learning en- in household hygiene and sanitation practices in Peru, Sene- velope forward in this area. gal, Tanzania, and Vietnam. The project also has a significant learning objective, an important component of which is to For the purposes of this consultancy, the spectrum of en- ascertain the key factors that influence handwashing behavior abling products and technologies to be included is limited change (also known as behavioral determinants). to those whose primary purpose is to enable handwashing.20 In this light, technologies that increase water availability, Enabling products and technologies are some of the "exter- such as rain water harvesting, would be excluded. nal factors" that influence individuals' chance to perform a behavior, regardless of their ability and motivation to Further examples are provided by products and technolo- take action.19 Availability of enabling products and tech- gies that allow or provide the following: nologies is often overlooked in the design of handwash- · Access to water in sufficient quantity to facilitate ing initiatives, although it has been well documented that handwashing, such as use of a tippy-tap. Tippy-taps behavior change is most successful if the behavior is not are simple and economical handwashing stations made with commonly available materials (e.g., a gourd, jerry can, and so forth) that allow for release 19 As part of its Global Scaling Up Handwashing Project, WSP developed a behavior change framework to explain handwashing behavior. Called FOAM (Focus on Opportunity, Ability and Motivation), the framework identifies the key factors or 20 determinants that influence handwashing. Enabling products and technologies fall Both informal and commercially branded products will be considered in the under the Opportunity category of determinants. compilation of the resource guide. www.wsp.org 17 A Case Study on the Tippy-Tap in Uganda Appendix 3: Terms of Reference of small quantities of water for handwashing, thereby d. How was/were design(s) of enabling product(s) avoiding wasting water. developed? What field/pre-testing was con- · Management of soap within a household or institu- ducted? Did design(s) evolve over time? tion (e.g., school, workplace). The end purpose is to e. What was the process of innovation and what can present waste, theft, or spoilage or to facilitate access. be said about its diffusion within the community? Soap nets and dishes are examples. f. What communication strategy and tools were used · Availability of a handwashing station: a designated to support the rollout or diffusion of the product? or mobile space bringing together water and soap to g. What, other "marketing mix" strategies, if any, wash hands in the household or an institution that, used (e.g., distribution of the product)? ideally, is in close proximity to the sanitation facility h. How is/was sustainability planned for? or the food preparation area. 2. Results and Outcomes22 a. What coverage and use were obtained? Were 3. Scope of Work these results maintained or have they evolved over Conduct a case study on enabling products for handwashing: time? Why? b. What effect on handwashing rates and behavior The consultant will execute the following tasks: did they have? 1. Develop protocol/framework for a case study based c. What monitoring supported the diffusion efforts on initial research questions to be provided by WSP and what did it consist of? (see attached for partial list), including rationale and d. Was any formative or evaluative research con- justification for country selection, objectives, meth- ducted and if so, what are key findings? ods (including use of knowledge management tools e. Were spillover effects reported/observed (e.g., on such as emerging learning maps), discussion guides, neighboring communities)? timeline and budget, and finalize based on com- f. Were halo effects reported/observed (e.g., inter- ments received from WSP and partners. est in other innovations such as improved stoves, 2. Conduct case study.21 other improved hygiene practices, etc.)? 3. Prepare PowerPoint presentations outlining key g. Were any other environmental factors present findings and recommendations. that would have influenced outcomes (e.g., chol- 4. Prepare final report and finalize based on comments era outbreak)? from WSP and partners. h. What perspective do local stakeholders have with respect to results and outcomes? Annex Partial List of Research Questions for Case Studies 3. Lessons Learned: 1. Implementation Strategy: a. What are key lessons learned from project de- a. What implementation model was used (e.g., sign, implementation, research, and M&E? What community-based, private sector, etc.)? could have been done differently, less, more, or b. Was effort part of a stand-alone handwashing ini- better? tiative or part of an integrated/multiple behaviors b. What limitations to achieving greater scale can project? be reported and how could these have been over- c. What were roles and responsibilities of organizations/ come or overcome in the future? agencies involved? 21 Peru may be considered as WPS/Peru is currently piloting a handwashing station 22 in collaboration with a plastics manufacturer and soft drink producer. Experiences As the case study is qualitative, no survey is expected to discuss results and and emergent learning from this innovative implementation model need to be outcomes. However, it is expected that any secondary data available would be documented. examined. 18 Global Scaling Up Handwashing A Case Study on the Tippy-Tap in Uganda Appendix 4: Schedule of Activities Appendix 4: Schedule of Activities Date Activities May 10, 2010 Travel to Uganda May 11, 2010 Travel to Mbarara District Meeting with ACORD May 12, 2010 Meeting with Chief Administrative Officer Mbarara District Interview with volunteer coordinator for ACORD model village Interviews with households in ACORD model village in Mwizi sub-county May 13, 2010 Interviews with households in neighboring village 1, Mwizi sub-county May 14, 2010 Interviews with households in neighboring village 2, Mwizi sub-county May 15, 2010 Meeting with Assistant Chief Administrative Officer Ibanda District Meeting with Assistant District Health Officer Ibanda District Meeting with Health Inspector, Ibanda District Interviews with households in Mbarara District model village May 16, 2010 Travel to Ibanda Interviews with households in sub-county model village, Ibanda District May 17, 2010 Interviews with households in neighboring village, Ibanda District Travel to Mbarara May 18, 2010 Wrap up Meeting in Mbarara District Travel to Kampala May 19, 2010 Travel to UK www.wsp.org 19 By Adam Biran London School of Hygiene and Tropical Medicine Acknowledgments This Working Paper is one in a series of knowledge products designed to The author wishes to thank Hannart Nalweysiyo (National showcase project findings, assessments, and lessons learned in the Global Scaling Up Handwashing Project. This paper is conceived as a work in Handwashing Secretariat) for logistical support throughout progress to encourage the exchange of ideas about development issues. the study; Umar Masereka (District Health Inspector) for additional support and translation in Mbarara District; Vincent WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and Mugisha (District Health Inspector) and Gerard Yehamye sustainable access to water and sanitation services. WSP's donors include (Health Assistant) for additional support and translation in Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Ibanda District. In addition, the author would like to thank Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, WSP, including Harriet Nattabi, Chris Nsubuga-Mugga, Switzerland, United Kingdom, United States, and the World Bank. Yolande Coombes, and Jacqueline Devine (Task Manager for WSP reports are published to communicate the results of WSP's work this project) Harriet who helped access information to select to the development community. Some sources cited may be informal a study site, contributed to the study design, and reviewed documents that are not readily available. drafts of this report. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its Photographs courtesy Adam Biran. affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. Global Scaling Up Handwashing is a WSP project focused on learning how to apply innovative promotional approaches to behavior change The material in this publication is copyrighted. Requests for permission to generate widespread and sustained improvements in handwashing to reproduce portions of it should be sent to wsp@worldbank.org. with soap at scale among women of reproductive age (ages 15­49) WSP encourages the dissemination of its work and will normally grant and primary school-aged children (ages 5­9). The project is being permission promptly. For more information, please visit www.wsp.org. implemented by local and national governments with technical support from WSP. For more information, please visit www.wsp.org/ © 2011 Water and Sanitation Program scalinguphandwashing.