WATER P-NOTES ISSUE 35 APRIL 2009 47934 Handwashing Programs for Better Hygiene T he Handwashing Handbook advocates hand- washing-with-soap programs to fight the spread Figure 1. Chief causes of child deaths of disease. It covers the following components: laying the foundation for a National Handwashing Measles Program; understanding the consumer; and imple- Aids 2% Other menting the program. The Handbook explains how 5% 13% to research consumer needs, communicate with Malaria target audiences, design appropriate and appeal- 13% ing messages, and implement a multi-channel pro- motional program. Handwashing with soap can dramatically reduce the leading causes of child mortality. The vast majority of child mortality occurs among the world's poorest populations in low- and middle-income Acute Diarrheal respiratory Diseases countries, with diarrhea and respiratory infections Infections 35% responsible for two out of three deaths (Figure 1). 32% Handwashing with soap interrupts one of the main Source: World Health Organization. transmission routes of diarrhoea, respiratory infec- tions, skin infections and trachoma. Soap plays a key role in stopping tramsmission; just washing with water has little or no effect. Studies have shown Creating a National Handwashing that handwashing with soap can reduce diarrheal Program incidence by almost half and respiratory infections by a third. Building a national handwashing program takes time, resources, effort, and commitment. The first Despite the acknowledged benefits of handwash- step is to determine if a health need exists. How ing, rates of handwashing with soap are very low. prevalent are the diseases linked to poor hand- The challenge is to make it a habit--a social washing practices? How prevalent is handwash- norm--on a worldwide basis. The new approach ing? Experience has shown that the only feasible to changing handwashing behavior on a national and reliable way to obtain a valid measure of scale draws on lessons from commercial marketing handwashing practice is through direct observa- approaches and from public health strategies. Its tion from well trained and supervised field work- core feature is a focus on the handwasher as the ers. Handwashing is critical at three junctures: agent of change. after using the toilet; after cleaning a child; and before handling food. This note reports key messages from "The Handwashing Handbook: A Guide for Developing a Hygiene Promotion Program to Increase Handwashing with Soap." The guide was produced by the World Bank in collaboration with the Global Public Private Partnership for Handwashing with Soap. Readers may down- load the complete handbook from www.worldbank.org/water. WATER P-NOTES The next step is to determine the interest and capac- A Key Element: Understanding the ity of key stakeholder groups, such as government, Consumer the private sector (for example, soap manufactur- ers or other companies seeking to improve social It is impossible to change long-held handwashing well-being), aid donors, and other partners, such habits without a firm understanding of the factors as nongovernmental organizations. The private sec- that shaped those habits. A marketing approach tor can contribute marketing expertise and under- looks at handwashers as "consumers" whose needs standing of the consumer to promote appropriate and perspectives determine the nature and scope of products, as well as other resources and expertise. all promotion activities. The heart of the marketing Partnerships between government and business task is thus to find out what consumers want and (public private partnerships) are often the most then to offer it to them in an appealing way. Con- effective way to forge a powerful national program. sumer research provides a baseline for measure- To succeed, advocates will have to make the case ment and understanding of the target audience by for handwashing to government, the private sec- answering four broad questions: Who engages in tor, and potential funders. An analysis of strengths, risky practices? What environmental factors encour- weaknesses, opportunities, and threats can identify age those practices, and what factors might change the factors that must be addressed when engaging them? How do people communicate about health stakeholders. issues (Figure 2)? · To make the case to government, the scale of Handwashing programs usually target mothers and the health problem related to handwashing caretakers of children under five years old as well must be demonstrated and linked to govern- as school-aged children. Sometimes secondary ment goals such as reducing poverty and the audiences--neighbors, fathers, and elder children-- economic cost of disease. should be addressed because of their influence on the primary audience. To change behavior, three · The potential benefits to the private sector include key interventions are involved: increasing sales, raising visibility, and improving political contacts. Attracting private sector sup- · Lowering barriers to facilitate change. Analysis port may mean addressing issues such as the of quantitative surveys of basic environmental use of branding in programs and the degree of information--e.g. availability of soap, distance exclusivity to be offered in return for support. to water, and access to sanitation--can be complemented with in-depth interviews follow- · To obtain donor support, it is important to ing behavior trials to help reveal barriers and determine donors' priorities, where decision- facilitators. making authority lies, and the mechanisms for obtaining funding. Financing is needed to cover the costs of program Figure 2. start-up, consumer research, and a mass media The consumer research process campaign. Financing mass media activities has been particularly challenging in several countries. A Who carries standardized methodology for the economic analy- out risk Target audiences sis of handwashing interventions can help the part- practices? nership conduct a persuasive cost-benefit analysis What are Target that will demonstrate the impact of handwashing in handwshing Comsumer's handwashing a broad context. To develop the program organiza- practices? view Experts' practice tion and ensure coordination among partners, it is What can view Drives, helpful to jointly lay out an initial vision, expecta- change habits, tions, commitments, partnership structures and behavior? facilitators milestones. A country coordinator or catalyst should How do be named (an individual or organization) to bring people Meida mix public and private partners together and provide comunnicate? drive, enthusiasm, and expertise in public health, management, and communications. Source: The Handwashing Handbook. 2 ISSUE 35 · APRIL 2009 · Transforming old habits into new. Successful boards); direct consumer contact (through public promotion will instill a habit that is triggered meetings, street theater, educational sessions in with every contaminating event. Habits are best schools and health facilities); and communications documented using structured observations, in- through governments and partner agencies (schools depth interviews, and behavior trials for new and clinics, for example). The mix of communica- habits. tions channels should be laid out clearly in a public · Finding drivers that can create new habits. Par- relations plan aligned with the broad communica- ticular behaviors are motivated by drivers, both tion effort. Each channel has its own advantages innate and learned. Country-specific research is and disadvantages (Table 1). needed to identify and understand which moti- Monitoring and evaluation are essential to ascer- vators are strong enough to anchor an effective tain the extent and effectiveness of the program. marketing campaign. Monitoring involves three broad steps: a baseline Research must also determine where the target survey, ongoing monitoring of program activities, audience obtains information, the reach and trust and a post-intervention survey. Evaluation measures level of different channels of communication, and outcomes both during and after the intervention to the best languages to use. Existing data can be determine the success of the program. It usually suf- complemented with primary research to learn more fices to look for impact on behavior as proof that about channels of communication from the moth- the program is achieving its objectives. ers' perspective. Behavioral trials and focus group discussions with mothers and school children can deepen understanding of motivations and favored Program Organization communication channels. A team with experience in commercial consumer research should manage Public-private partnerships provide an effective and supervise research, while handwashing experts model for handwashing programs because they should provide advice, support the qualitative combine the health objectives of the public sector research work, and analyze results. with the marketing expertise of the private sector. However, when partners from different backgrounds are not accustomed to working together, it takes Program Implementation time to build common aims and mutual trust. The experience of previous handwashing cam- Consumer research informs the design and imple- paigns in Central America, Ghana, Nepal, and mentation of the handwashing campaign, which is Senegal suggests that a coordinator-committee based on product, price, place, and promotion-- model for public-private partnerships is an effective the "Four Ps." Promotion, the focus of the Hand- way to manage a program with a diverse group book summarized here, requires thorough planning of partners. The coordinator manages day-to- and the involvement of a professional communi- day operations, keeps stakeholders engaged and cations agency that can turn the objectives and informed, and ensures that the whole initiative is insights of marketers into a comprehensive cam- moving toward its objectives. The steering com- paign. A "creative brief" must be prepared, outlin- mittee includes the key stakeholders that provide ing the tasks to be accomplished, based on the resources. The consultative committee comprises findings of consumer research. The target audience stakeholders who have a specific interest in the pro- must be segmented into groups with similar behav- gram and can provide occasional feedback, advice, iors and needs, so that promoters can address the and approval on specific issues. needs of each segment with different strategies. Messages must be tailored to each group. Mes- A business plan provides potential stakeholders with sages and concepts must be tested and revised to the justification for contributing and shows them ensure maximum success. where resources are needed. Evolving with the initiative, the business plan helps participants con- Successful handwashing programs rely on multiple solidate ideas and reach consensus. The first draft strategies for behavior change executed through a outlines the vision for the partnership; updated ver- variety of communication channels. Those chan- sions reflect participation of new partners and the nels include mass communications (TV, radio, bill- completion of components. 3 WATER P-NOTES Table 1. Advantages and Disadvantages of Different Approaches to Communication Approach Description Advantage Disadvantage Mass media Messages crafted to be Low cost per capita, Needs high saturation transmitted through an can be highly (6+contacts) to affect optimized mix of radio, memorable, can raise behavior change TV, billboard, and the political profile of other channels handwashing, easy to Audience cannot interact monitor Difficult to fund Direct Events organized by Good audience High cost per capita consumer professional event interaction, high Uncertainty about contact management agencies, impact, memorable impact and optimal held in schools, public size of audience places, community groups Public Using the ability of Potentially highly Hard to control channels government agencies to sustainable, if Low staff motivation deliver handwashing handwashing Contact with target messages through promotion becomes audiences may be schools and health part of curriculum, infrequent, resulting in centers job description of health low coverage agent, promoted at ante- Low ability to monitor and post-natal contact activities Source: The Handwashing Handbook. Handwashing promotions and educational activities One drawback of public-private partnerships is that sponsored by the private sector can be linked to the they can be slow to build and even slower to show national initiative. Such leveraging helps to ensure results. sustainability by tying handwashing messages to expanding soap brands. In 1998, Colgate-Palmolive launched a global education initiative known as Building on Gains to Date "Clean Hands, Good Health." From its initial base in the United States, the program has been expanded Although campaigns conducted to date have gener- to millions of children in Asia, Latin America, and ated good outcomes and provided useful lessons, Africa. It now includes a structured school curriculum more clearly demonstrating the cost-effectiveness and community programs. Mexico's "Safeguard" bar of handwashing programs will help improve accep- soap has run a multi-element campaign to promote tance. Research comparing the effectiveness of dif- handwashing among children. Safeguard provides ferent approaches to generating behavior change expertise and materials, while the media, government will help optimize implementation. Clarifying roles institutions and educational partners reach people. and responsibilities among stakeholders will improve Unilever's Swasthy Chetna (Awakening to One's acceptance and sustainability. Often, hygiene does Health) program uses multiple channels to promote not have a single institutional home--to be sus- everyday handwashing and bathing with soap in tained, programs need ownership in several sectors, India. The goal is to reach 100 million people. notably water and sanitation, health, and education. The Water Sector Board Practitioner Notes (P-Notes) series is published by the Water Sector Board of the Sustainable Development Network of the World Bank Group. P-Notes are available online at www.worldbank.org/water. P-Notes are a synopsis of larger World Bank documents in the water sector. 4 THE WORLD BANK | 1818 H Street, NW | Washington, DC 20433 www.worldbank.org/water | whelpdesk@worldbank.org