WATER AND SANITATION PROGRAM: WORKING PAPER 56966 Global Scaling Up Handwashing Project Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs Yolande Coombes and Jacqueline Devine August 2010 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. Yolande Coombes Senior Hygiene & Sanitation Specialist Water and Sanitation Program Jacqueline Devine Senior Social Marketing Specialist Water and Sanitation Program This report was reviewed by Jason Cardosi, Hnin Hnin Pyne, WSP is a multi-donor partnership created in 1978 and administered by and Eduardo A. Perez of the Water and Sanitation Program, the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP's donors include and Maria Elena Figueroa of Johns Hopkins University, Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda School of Public Health. Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. Global Scaling Up Handwashing is a WSP project focused WSP reports are published to communicate the results of WSP's work on learning how to apply innovative promotional approaches to the development community. Some sources cited may be informal to behavior change to generate widespread and sustained documents that are not readily available. improvements in handwashing with soap at scale among The findings, interpretations, and conclusions expressed herein are entirely women of reproductive age (ages 15­49) and primary school- those of the author and should not be attributed to the World Bank or its aged children (ages 5­9). The project is being implemented affiliated organizations, or to members of the Board of Executive Directors by local and national governments with technical support of the World Bank or the governments they represent. The World Bank from WSP. For more information, please visit www.wsp.org/ does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any scalinguphandwashing. map in this work do not imply any judgment on the part of the World Bank Group concerning the legal status of any territory or the endorsement or This Working Paper is one in a series of knowledge products acceptance of such boundaries. designed to showcase project findings, assessments, and The material in this publication is copyrighted. Requests for permission lessons learned in the Global Scaling Up Handwashing Project. to reproduce portions of it should be sent to wsp@worldbank.org. WSP This paper is conceived as a work in progress to encourage encourages the dissemination of its work and will normally grant permission the exchange of ideas about development issues. For more promptly. For more information, please visit www.wsp.org. information please email Yolande Coombes and Jacqueline © 2010 Water and Sanitation Program Devine at wsp@worldbank.org or visit www.wsp.org. Contents I. Overview .................................................................................... 1 Introduction ............................................................................. 1 Objectives ............................................................................... 1 The Burden of Diarrheal Disease and Acute Respiratory Infections ................................................... 1 Why the Rates for Handwashing with Soap Are Low ......................................................................... 2 Handwashing and Human Behavior........................................ 2 Developing a Behavior Change Framework ........................... 3 Behavioral Determinants ......................................................... 4 II. The FOAM Framework .............................................................. 5 Focus: Who Is the Target Audience and What Is the Desired Behavior? ......................................... 5 Opportunity: Does an Individual Have the Resources to Perform a Behavior? ................................... 5 Ability: Is the Individual Capable of Performing the Particular Behavior? ....................................... 6 Motivation: Does the Individual Want to Perform the Behavior? ....................................................... 6 Opportunity Determinants ....................................................... 6 Ability Determinants ............................................................... 8 Motivation Determinants ........................................................ 9 Evolution of the FOAM Framework ...................................... 11 III. Applying the FOAM Framework ............................................. 13 Formative Research .............................................................. 13 Doer/Non-doer Studies ......................................................... 14 FOAM Operational Matrix ..................................................... 15 IV. Conclusion ............................................................................... 18 www.wsp.org iii Introducing FOAM Contents Appendix A: FOAM Glossary................................................................. 19 Tables 1: Rates of Handwashing by Mother or Caregiver at Key Times ....................................................... 3 2: FOAM Links with Existing Hygiene and Behavior Change Approaches and Programs............ 11 3: Illustrative Example of a Doer/Non-doer Study ................ 14 4: FOAM Operational Matrix ................................................ 16 Boxes 1: FOAM Framework ............................................................... 5 2: Access to Soap in Kenya .................................................... 7 3: Attributes of Soap in Uganda .............................................. 8 4: Research Findings from Vietnam ....................................... 9 5: Research Findings from Tanzania ..................................... 10 6: Adapting the FOAM Framework in Vietnam ...................... 12 7: Main Research Questions Addressed through Formative Research on Handwashing .............................. 13 8: Quantitative Research ....................................................... 13 9: The Four Ps ....................................................................... 15 References ............................................................................................ 21 iv Global Scaling Up Handwashing I. Overview Introduction FOAM is a framework FOAM (Focus on Opportunity, Ability, and Motivation) is a framework designed to help in the development, monitoring, and evaluation of handwashing behavior designed to help in the change programs. FOAM was developed for use in resource-poor settings, but it can also be adapted for other socioeconomic environments. development, monitoring, and evaluation of This working paper is intended for use by program managers implementing handwashing behavior change initiatives, as well as multilateral and bilateral handwashing behavior agencies, academic institutions, and government and nongovernmental organiza- tions (NGOs) working in water and sanitation. change programs. Objectives The objectives of the paper are to: · Increase awareness among program managers on the value of using the FOAM framework in handwashing behavior change programs. · Understand how FOAM can be applied at all stages of program design and implementation. · Discuss other behavior change frameworks and approaches that have been incorporated into FOAM. In addition to this working paper, more detailed guidance and case studies from the field are planned to illustrate how FOAM can be applied. The Burden of Diarrheal Disease and Acute Respiratory Infections Acute respiratory infections (ARIs) are the leading cause of death in children under age five in developing countries, closely followed by diarrhea. Diarrheal disease and acute respiratory infections account for one-third of the global bur- den of disease, with children accounting for most of the mortality from these causes.1 It is estimated that more than four billion cases of diarrhea occur annu- ally and that more than half of these are experienced by children under age five.2 In developing countries, diarrhea accounts for the deaths of about 1.5 million children under age five every year, or 16 percent of all deaths for this cohort of the population, while ARIs account for 17 percent of all deaths in the same cohort. On a global basis, approximately two million children under five die from ARI each year, accounting for nearly one in five child deaths worldwide.3 More than 150 million episodes of pneumonia are estimated to occur every year among children under five in developing countries, accounting for more than 95 percent of all new cases worldwide. Between 11 and 20 million children with pneumonia will require hospitalization. South Asia and Sub-Saharan Africa have 1 UNICEF 2009. 2 UNICEF 2009. 3 UNICEF 2010. www.wsp.org 1 Introducing FOAM Overview the highest incidence of pneumonia cases among children under five. These two The simple act of washing hands regions combined bear the burden of more than half the total number of with soap can cut the risk of diarrhea pneumonia episodes worldwide.4 by almost half and respiratory tract infection by a third. This makes handwashing a better option for disease Both diarrheal disease and acute respiratory infections are considered preventable prevention than any single vaccine.5 via effective interventions such as access to and use of adequate sanitation, im- proved access to clean water, and frequent handwashing with soap. Why the Rates for Handwashing with Soap Are Low Handwashing may seem to be a relatively simple task, but it is one that many people fail to carry out, particularly handwashing with soap. Some people wash their hands with soap after defecating, but some do not. Likewise, some people wash their hands before preparing food, but others do not. Table 1 shows handwashing rates among mothers and caretakers in various coun- tries at key times: after using the toilet, after cleaning a child's stools, and before feeding a child. For example, rates for handwashing with soap after using the toilet range from 3 percent to 42 percent, indicating that handwashing with soap is far from a universal practice. Handwashing and other hygiene-related behaviors require time and resources, which must be diverted from other daily activities such as preparation of meals, farming, tending to livestock, and taking care of family members. Socioeconomic, cultural, gender, and environmental factors exert considerable influence over whether and to what degree individuals perform hygiene-related behaviors. A recent study undertaken in Kenya found that 71 percent of respondents under- stood the importance of washing their hands after defecation but only 31 percent did so.6 This finding is illustrative of the knowledge-behavior gap7 encountered by antismoking and condom-use initiatives, among others, and reflects the com- plexity of human behavior. Handwashing and Human Behavior There are many variables that influence an individual's choices. Theoretical mod- els and frameworks allow researchers to hypothesize about the factors or determi- nants of a particular behavior. Health-related behavior change models have been developed primarily in the fields of psychology and the social sciences. The FOAM framework draws on a range of models, including the Health Belief Model,8 the Theory of Reasoned Action/Planned Behavior,9 Health Locus of 4 UNICEF 2009. 5 Water and Sanitation Program 2007. 6 Steadman Group (Kenya) 2007. 7 The "knowledge-behavior gap" refers to the finding from many studies and programs that people may know what to do to improve their health or other living conditions but for various reasons may not act on that knowledge. 8 Rosenstock 1974. 9 Ajzen and Fishbein 1980. 2 Global Scaling Up Handwashing Introducing FOAM Overview TABLE 1: RATES OF HANDWASHING BY MOTHER OR CAREGIVER AT KEY TIMES Washes Washes Washes Hands with Washes Washes Washes Hands with Hands with Soap after Hands with Hands with Hands only Soap after Soap after Cleaning Soap before Soap before with Water Base of Using the Cleaning Child Child's Stools Feeding Child Handling after Using Country Respondents Toilet (%) (%) (%) (%) Food (%) the Toilet (%) China (Sichuan) 78 13 -- 16 6 -- 87 China (Shaanxi) 64 12 -- -- 16 -- 14 Ghana 500 3 2 -- 1 -- 39 India (Kerala) 350 42 -- 25 -- -- -- Kyrgyzstan 65 18 0 49 Madagascar 40 4 -- -- 12 -- 10 Peru 500 14 -- -- 6 -- -- Senegal 450 23 18 -- -- 18 -- Tanzania 30 13 13 13 4 -- 33 Uganda 500 14 19 11 6 8 44 Vietnam 720 -- 14 23 5 -- 51 Average (weighted) 17% 13% 19% 5% 13% 45% Notes: The figures given for Tanzania are the same because observation was based on whether the caregiver washed their hands after wiping a child's bottom or cleaning a child's feces. For Peru, figures for handwashing with all types of soap product have been aggregated. Source: Curtis, Danquah, and Aunger 2007. Control,10 Stages of Change Model,11 and Social Learning In response to this need, participants from the Global Scal- Theory.12 ing Up Handwashing Project met in Hanoi, Vietnam, in March 2007 to develop the FOAM framework (Box 1) to Developing a Behavior Change Framework inform the design and implementation of the project and In November 2006, the Water and Sanitation Program strengthen formative research, monitoring and evaluation, began implementing the Global Scaling Up Handwashing and develop a shared technical vocabulary among project Project to test whether innovative promotional approaches team members. The framework, based on the PERForM can generate widespread and sustainable increases in rates framework of population Services International,13 was devel- of handwashing with soap at critical times among the oped through a systematic process that relied on group con- poor and vulnerable in Peru, Senegal, Tanzania, and ceptual exercises building on theory and findings from Vietnam. research. It soon became apparent that the project teams needed a The key categories of determinants are based on behavior common conceptual framework to guide and monitor change, or social cognition, models.14 Social cognition handwashing behavior change across the participating models have long been used to guide and predict behavior countries. change. However, health-related models have tended to 10 Conner and Norman 1996. 11 Prochaska and DiClemente 1984. 12 Bandura 1986. 13 Chapman 2010. 14 Conner and Norman 1996. www.wsp.org 3 Introducing FOAM Overview focus on changing behavior related to such risk factors as alcohol use, smoking, lack of exercise, poor diet, and sexually transmitted infections. In developing the FOAM framework, workshop participants reviewed the most commonly used social cognition models. Participants found that no single model or framework captured all the determi- nants pertinent to handwashing behavior. Therefore, they decided to identify the behavioral determinants by consensus and assign each one to the following cate- gories: Opportunity, Ability, and Motivation. This system of classification is often used in consumer behavior15 and social marketing16 contexts. Behavioral Determinants Behavioral determinants are internal Behavioral determinants can be internal (factors which take place within a per- or external factors that influence son's mind, e.g., an individual's knowledge or a belief ) or external (factors which whether a person engages or not are beyond the control of an individual, factors that happen to them, e.g., avail- in a given behavior. ability of a product or social pressure from peers). Some examples of behavioral determinants are as follows: · Ready access to toothpaste is an external determinant of brushing one's teeth. · Knowledge of the risks posed by measles to a baby is an internal determi- nant of one's choice to vaccinate a child. · Fear of contracting HIV/AIDS is an internal determinant of condom use. 15 MacInns, Moorman, and Jaworski 1991. 16 Chapman 2010. 4 Global Scaling Up Handwashing II. KEY POINT The FOAM Framework In the acronym FOAM, the letters stand for: · Focus · Opportunity · Ability · Motivation Focus: Who Is the Target Audience Handwashing with soap is and What Is the Desired Behavior? Clearly defining the target audience and the desired behavior are the critical ele- the desired behavior, but ments of any intervention. Examples of audiences for handwashing behavior change include school children, primary caregivers of children under age five, and street implementers must also vendors involved in food preparation. Handwashing with soap is the desired behav- decide whether interventions ior, but implementers must also decide whether interventions will be aimed at pro- moting frequent and regular handwashing, or handwashing only at key moments, will be aimed at promoting such as after defecation or before handling food. An intervention may also describe how handwashing should be performed (for example, the duration of handwash- frequent and regular ing, performance with or without running water, drying, and so forth). handwashing or handwashing Opportunity: Does an Individual Have only at key moments. the Resources to Perform a Behavior? Derived from Diffusion of Innovation theory, health promotion, and quality- of-care research,17 opportunity determinants influence the chance of the behav- ior being performed. They include but are not limited to social norms, product attributes, and access to or availability of products or services.18 Oppor- Opportunity determinants influence tunity determinants are often the most external factors affecting a person's the chance of the behavior being behavior, over which they may have less control. performed. BOX 1: FOAM FRAMEWORK Focus Opportunity Ability Motivation Access/ Belief and Target availability attitudes Knowledge behavior Outcome Product expectations attributes Threat Target Social population Social support norms Intention 17 Ibid. 18 Ibid. www.wsp.org 5 Introducing FOAM The FOAM Framework Ability: Is the Individual Capable of Performing the Particular Behavior? Ability determinants reflect an Ability determinants reflect an individual's perceived or actual capacity to per- individual's perceived or actual form a given behavior (contingent on opportunity and motivation). Some abil- capacity to perform a given behavior ity determinants are knowledge, self-efficacy (an individual's belief in his (contingent on opportunity and capacity to carry out a specific behavior), and social support. The concept of motivation). ability was developed from social cognition models and theories from social psychology and other disciplines that examine interpersonal determinants of behavior change.19 Cognitive processes are the mental processes of perception, memory, and information processing, by which individuals acquire information, make plans, and solve problems. Motivation: Does the Individual Want to Perform the Behavior? Motivation determines whether, given Motivation determines whether, given opportunity and ability, performing the opportunity and ability, performing behavior is in an individual's self-interest. Some motivation determinants are per- the behavior is in an individual's self- sonal risk assessment (e.g., Am I at risk for HIV/AIDS?) and outcome expecta- interest. tions (e.g., What will happen if I get tested for HIV/AIDS?). FOAM's motivation determinants are drawn mostly from social cognition models of behavior change. Within the framework, motivation is thought to have a direct influence on behavior, though it is moderated by both ability and opportunity. For example, a minibus passenger may want to use a seatbelt because she fears the risk of an accident (motivation), but if there are no seatbelts installed (opportunity) or she does not know how to fasten a seatbelt (ability), then she cannot carry out this behavior. The reverse is equally feasible. A man may be near a kiosk that sells condoms (opportunity) and know how to use them (ability), but not perceive he is at risk of HIV/AIDS with his current partner (motivation). Opportunity Determinants In the context of handwashing, there are three opportunity determinants: Access/Availability Soap and water must be readily Access/Availability refers to access to soap and water for handwashing. A recent accessible in the right places and at review by the London School of Hygiene and Tropical Medicine of formative the right times to enable household research in 11 countries found that some type of soap was available in almost members to wash their hands. every household, as was water.20 However, it is not sufficient for soap and water to be present in the home; both must be readily accessible in the right places and at the right times to enable household members to wash their hands. A compari- son of Senegalese women who wash their hands with soap with those who do not use soap revealed that convenient access to soap and water at critical times may well be the most important determinant; having a designated place within the household to wash hands with soap may be key to ensuring consistent handwash- ing with soap.21 This finding is supported by other studies, such as the one in 19 Ibid. 20 Curtis, Danquah, and Aunger 2009. 21 Analysis in progress, using data collected in December 2008. 6 Global Scaling Up Handwashing Introducing FOAM The FOAM Framework rural Bangladesh households, which concluded, "Interventions that improve the presence of water and soap at the designated place to wash hands would be ex- pected to improve handwashing behavior."22 There must also be equality of access, so that young children can wash their hands with soap and water as easily as adults. Visual cues are also critical in encouraging the development of habitual behavior. If a handwashing station is next to a latrine, people are far more likely to wash their hands immediately after latrine use. Soap and, increasingly, water are precious and even scarce resources; their provision may require forethought and innovation. If necessary, water should be kept in ba- sins or buckets next to latrines or near food preparation areas. Where water is scarce, devices such as Tippy Taps can be installed. The Tippy Tap is a simple, hand-made device for handwashing with running water. Soap must also be protected from be- coming too wet, being stolen, or being eaten by rodents. Combining soap and water, these stations must be readily accessible and kept functional for handwashing to take place (Box 2).23 Product Attributes Soap and water have certain attributes that may function as either a catalyst or an Key product attributes include soap's obstacle to handwashing, depending on when and where the soap is used (Box 3). smell, size, type, and the ability to produce lather; water's clarity, color, Key attributes of soap include its smell, size, type (laundry, bathing, or dishwashing, and odor; and the cleanliness, and for instance), and the ability to produce lather. This is especially true in resource- odor of the handwashing facility. poor settings where soap is used for multiple purposes. For example, if a household uses laundry powder with a strong scent as the main soap product, a caregiver may wash her hands with it after a meal of fish but may not before she feeds her child. For water, attributes such as clarity, color, and odor influence handwashing. The attributes of a handwashing facility, such as cleanliness and odor, may also influ- ence its use and, therefore, handwashing behavior. BOX 2: ACCESS TO SOAP IN KENYA For handwashing with soap to occur, household access to water and soap is required. A study undertaken in Kenya revealed that moth- ers often wrapped soap carefully and stored it where children could not get it and waste it. As a consequence, the study found, house- hold members used soap for bathing and washing clothes but not for washing hands throughout the day. Source: Steadman Group (Kenya) 2007 22 Luby, et al. 2009. 23 For more information on Tippy Taps and other enabling technologies for handwashing, visit WSP's Enabling Technologies for Handwashing Database at http://www.wsp.org/scalinguphandwashing/enablingtechnologies/. www.wsp.org 7 Introducing FOAM The FOAM Framework BOX 3: ATTRIBUTES OF SOAP IN UGANDA In Uganda, many survey respondents found the smell of soap on their hands off-putting as they ate and therefore preferred not to use strong- smelling soap before they eat. Conversely, findings from Kenya show individuals in communities with a fish-rich diet prefer using perfumed soaps after they eat, as these counteract the smell of fish. Source: Steadman Group (Uganda) 2007 Social Norms These are the rules that govern how Social norms are the rules that govern how individuals in a group or society be- individuals in a group or society have. Any behavior outside these norms is considered abnormal.24 With respect behave. Any behavior outside these to handwashing, norms may be objective or observable within the community. norms is considered abnormal. For example, an individual may learn that handwashing is the social norm by see- ing others wash their hands in a public place. There are also household norms. A child knows whether or not he is expected to wash his hands with soap before eating a meal with the family. Household norms are reinforced by parental sanc- tion or reward and praise. Realignment of social norms takes time and may require the intervention of a role model or figures of authority such as religious leaders or doctors who can per- suade others, through public display or endorsement, to carry out a particular behavior. An example of this is provided by former Zambian president Kenneth Kaunda who publicly took an HIV test in 2002 and urged "all Zambians, with- out exception," to be tested for HIV.25 Ability Determinants There are two ability determinants in FOAM: Knowledge Knowledge is acquired through Knowledge is acquired through learning and may pertain to objects or products, learning and may pertain to objects behaviors, and even outcomes. It is important to emphasize that knowledge, or products, behaviors, and even while critical, is not adequate to spur behavior change. The knowledge-behavior outcomes. gap explains in part why individuals engage in certain behaviors even when they are aware of the associated risks. Social Support Social support is the physical and Social support is the physical and emotional comfort given individuals by family, emotional comfort given individuals by peers, friends, co-workers, and others. Social support takes several forms: physical family, peers, friends, co-workers, and (a mother helps her child to work up lather from soap); emotional (a health others. worker praises a mother for washing her hands before feeding her infant); or 24 Kelly 1955. 25 Shacinda 2002. 8 Global Scaling Up Handwashing Introducing FOAM The FOAM Framework informational (a teacher tells children why they should wash their hands with soap before eating). Support may also take the form of practical advice (a woman helps her neighbor build a handwashing station). Motivation Determinants Four determinants provide motivation for handwashing with soap: Attitudes and Beliefs Attitudes and beliefs represent an individual's understanding and perceptions Attitudes and beliefs represent about handwashing with soap. Beliefs may not be correct and may actually im- an individual's understanding and perceptions about handwashing with pede adoption of positive behavior practices. Individuals are often unaware of soap. Individuals are often unaware of their beliefs and attitudes. their beliefs and attitudes. One key aspect of attitude or belief is an individual's perceptions about the main causes of events in his or her life: this is usually referred to as locus of control. In- dividuals with an internal locus of control have a strong sense of authority over their own lives. For example: "The more I study, the better grades I get."26 By contrast, to possess an external locus of control is to believe that God, fate, pov- erty, or some extrinsic force exerts control over one's circumstances or behavior. Individuals with an external locus of control are less likely to engage in healthy behavior and may display high levels of resignation and apathy about the future. These individuals are also more prone to believe illness and suffering are an inevi- table part of life (Box 4 and Box 5). Expectations Expectations are perceptions of the consequences of handwashing with soap. If Expectations are perceptions of the perceived outcomes are positive or beneficial, the behavior is more likely. The consequences of handwashing with converse applies as well. For example, a mother may not wash her hands with soap. If perceived outcomes are positive or beneficial, the behavior is more likely. BOX 4: RESEARCH FINDINGS FROM VIETNAM In a formative research study conducted in 2006, half of the mothers surveyed said they did not use any kind of soap when washing their hands. Sixty percent of these women said they did not believe soap was necessary. The overwhelming majoring of mothers interviewed (85 percent) cited weather or climate change as the major cause of diseases found in their community (such as respiratory infections or diarrhea)--reflecting an external locus of control. Based on these find- ings, the Vietnam Handwashing Initiative designed a behavior change campaign aimed at changing these beliefs and other motivational barri- ers to handwashing with soap. Source: Indochina Research Ltd 2007 26 Gershaw 1989. www.wsp.org 9 Introducing FOAM The FOAM Framework BOX 5: RESEARCH FINDINGS FROM TANZANIA Research undertaken in Tanzania found that subjects believed indi- viduals who washed their hands were of higher social status, better educated, generally "nicer," and more trustworthy. People who did not regularly wash their hands were characterized as the opposite. Given these perceptions, an individual might consider herself of insufficiently high status to wash her hands frequently. Source: LMS International/Steadman International 2006 a strong-smelling soap before she feeds her child if she expects this will cause the child to fuss. Expectations can also be longer term (mothers may perceive that handwashing will lead to decreased immunity). Although expectations are themselves a form of belief or attitude, they are classified separately because of their potential impor- tance in assessing why individuals wash their hands. Another type of expectation is the subjective norm, the anticipated opinion or approval of an important or influential person relative. For example a woman may perceive that she is expected by her mother-in-law to wash her hands before feeding an infant. Threat Threat can be defined as perceived Threat can be defined as perceived dangers or negative outcomes linked to hand- dangers or negative outcomes linked washing with soap. Threats has two dimensions: perceived susceptibility, which is to handwashing with soap. an individual's assessment of the risk posed by a particular condition or illness, and perceived severity, an individual's assessment of the seriousness of the condi- tion and its potential consequences.27 Perceived severity is influenced by other considerations and factors. For example, a mother will worry more about a cold in a two-week-old baby than in a three-year-old child, particularly if she is aware babies are more susceptible to pneumonia. The threat of epidemics such as chol- era may provide immediate motivation to wash hands with soap. Intention Intention is a person's plan on how to Intention is a person's plan on how to handwash with soap. This might entail handwash with soap. An individual who buying soap, fetching water, or ensuring a handwashing station is functional. intends to is more likely to wash their Intention is thought to be a powerful motivator of behavior and, according to hands than someone who does not. the Theory of Reasoned Action,28 is a predictor of behavior change. An 27 Rosenstock 1974. 28 Ajzen and Fishbein 1980. 10 Global Scaling Up Handwashing Introducing FOAM The FOAM Framework individual who intends to is more likely to wash their hands than someone who does not. Habits are routines of behavior that are repeated regularly and without direct or conscious thought about those behaviors. Frequent performance of a particular activity in stable circumstances leads to habit formation. Habits can be an ob- stacle to an individual's intentions. An individual who intends to begin hand- washing after using the latrine must override the habit of not handwashing and requires changes in the supporting circumstances. Evolution of the FOAM Framework After its initial conceptualization and development at the Vietnam workshop, the framework was shared with hygiene and behavioral science specialists for review, feedback, and assessment. Currently, FOAM is being implemented in handwashing programs in Peru, Senegal, Tanzania, and Vietnam. The FOAM framework is not static; it builds on other hygiene behavior change approaches and programs (Table 2). Users have an important role to play in refining and adapting it for country- or population-specific contexts, which means the FOAM framework is continually evolving to reflect current best practice. It is TABLE 2: FOAM LINKS WITH EXISTING HYGIENE AND BEHAVIOR CHANGE APPROACHES AND PROGRAMS Existing Approach Description Elements Integrated into or Sourced for FOAM The Hygiene Improvement HIF is based on three core components: An emphasis is placed on access and the en- Framework (HIF) access to water and sanitation hardware, abling environment. hygiene promotion, and a strengthened enabling environment. Behavior-Centered BCP informs inquiry into the determinants of FOAM identifies both enabling factors and Programming (BCP) pre-intervention behaviors then tests "enhanced" obstacles to desirable behavior in the con- behaviors to produce a spectrum of strategies text of the Opportunity, Ability and Motivation intended to motivate adoption of the latter. framework. Public Private The PPP approach to hygiene is based on the FOAM may inform PPP interventions. For Partnership (PPP) premise that both private commercial firms and instance, the Global Scaling Up Handwashing public entities (principally, national or regional Project has partnered with Unilever in ministries of health) would benefit from Tanzania to integrate FOAM into behavior collaborating to promote handwashing for change communications. public health. Participatory Hygiene PHAST involves participatory methods and Subsequent to the identification of behavioral and Sanitation tools to assist communities to change hygiene determinants, a PHAST approach can be used Transformation (PHAST) practices and improve and manage water sup- to operationalize FOAM. ply and sanitation facilities. Happy, Healthy, and This is a social marketing approach to hygiene FOAM is underpinned by an approach that Hygienic/Saniya Hygiene promotion emphasizing simple, attractive relies on identification of key behavioral Project (Burkina Faso) promotional messages that are delivered to determinants to focus social marketing specific audiences through appropriate interventions. communication channels. www.wsp.org 11 Introducing FOAM The FOAM Framework likely that new handwashing behavior change determinants, particularly for different target populations such as school children (Box 6), will be identified and subsequently incorporated into FOAM. BOX 6: ADAPTING THE FOAM FRAMEWORK IN VIETNAM The Global Scaling Up Handwashing Project has developed a varia- tion of the FOAM framework for primary school children. This variation, called FOAM-EM (Focus on Ability, Opportunity, and Motivation-- Ecological Model), builds on findings from an innovative research study conducted in Vietnam with technical support by the London School of Hygiene and Tropical Medicine. In Vietnamese, "EM" means "little brother or sister," so FOAM-EM is a memorable acronym. FOAM-EM identifies key factors influencing primary school children's handwashing behavior as well as their relationships with family, school, and community. FOAM-EM and insights from this study will be used to improve the design of the primary school program in Vietnam. The program was launched in the first half of 2009 with support from imple- menting agencies and stakeholders. For more information on the social ecological approach to health promotion, see Stokols 1996 and Stokols et al 1996. 12 Global Scaling Up Handwashing III. Applying the FOAM KEY POINTS · Formative research can assist program managers Framework to research and understand target audiences, plan interventions, and allocate resources efficiently. · Doer/non-doer analysis often reveals factors important in promoting behavior change. · Research can include quantitive and qualitative studies. Formative Research Formative research into handwashing behavior change can BOX 8: QUANTITATIVE RESEARCH assist program managers in determining the focus (target Quantitative research involves the measurement audience and desirable behavior) of an intervention (Box 7). and analysis of data in a numerical way. Knowl- Just as important, it enables program planners to gauge edge, attitudes, beliefs, and practices (KABP) is a whether members of a target audience possess the opportu- common type of quantitative study that has been nity, ability, and motivation to wash their hands and which implemented in several fields, such as HIV/AIDS determinants need to be prioritized in the intervention. and reproductive health. Typically, formative research is carried out through focus group In qualitative studies, the data collected from discussions with members of the target audience, in-depth in- interviews and observations is not measured or terviews, and the gathering of baseline data. At the formative analyzed in numerical ways. Focus group research stage, FOAM provides a useful checklist as well as a discussions are a commonly used qualitative tool. framework for organizing the findings. FOAM can also inform the design of questionnaires and observation tools. whether handwashing rates are uniform across the entire Prior to the launch of a handwashing initiative, program community and provide critical demographic (gender, age, managers may also wish to undertake quantitative research physical location) and socioeconomic data. to ascertain the current (baseline) rates of handwashing with soap in the target community. Knowledge of these Ideally, handwashing rates are measured through direct obser- rates will in turn enable program goals and targets to be vation. In interviews, respondents tend to over-report the fre- established. Quantitative studies (Box 8) also establish quency with which they wash their hands. However, direct observation is not always feasible because of time and resource constraints. When being observed, people may also wash their hands more often. Questions should be asked in a variety of BOX 7: MAIN RESEARCH QUESTIONS ADDRESSED ways to validate the accuracy of self-reporting. The Global THROUGH FORMATIVE RESEARCH ON Scaling Up Handwashing Project and other projects, such as HANDWASHING those under the Child Survival and Health Grants Program of · Pre-intervention handwashing rates and USAID,29 use the presence of soap and water next to the la- behaviors trine as a proxy measurement for handwashing behavior.30 · Demographic and social characteristics of the target population Formative research also enhances more efficient allocation · Behavioral determinants for handwashing of resources. For example, research conducted through · Media consumption and communications WSP's Global Scaling Up Handwashing Project has con- habits of the target population firmed the existence of a knowledge-behavior gap with re- spect to handwashing with soap. Thus, an intervention to 29 See www.childsurvival.com. 30 For more guidance on measuring handwashing behavior, see Practical Guidance for Measuring Handwashing Behavior (2010), available under "Publications and Tools" at www.wsp.org/scalinguphandwashing. www.wsp.org 13 Introducing FOAM Applying the FOAM Framework change behavior by a traditional information, education, The data required for a handwashing doer/non-doer study and communication campaign will be insufficient. is essentially identical to that needed for quantitative for- mative research: In addition to conducting formative research on the target · Demographic data (age, gender, religion, educa- population, an enabling environment assessment should tional attainment, geographic location) also be considered. The enabling environment refers to con- · Media habits (at which times members of the au- ditions such as policies and organizational capacity that dience listen to the radio or watch television, and may either facilitate or hamper the scaling up and sustain- which stations; and which newspapers are read) ability of a handwashing program. Key enabling environ- · Behavioral determinants ment questions include the following: · Handwashing behavior · What resources are available for a handwashing program? In the data analysis stage, a FOAM doer/non-doer study first · Which partners are involved or interested in imple- identifies those members of a community who are at risk of menting a handwashing program and what is their diarrhea or at risk of ARI. Secondly, it defines those people capacity? who consistently wash their hands with soap (doers). The · What structures exist to facilitate a handwashing remainder of the community are non-doers. The researchers program?31 look at the behavioral determinants, media consumption habits, and demographic characteristics of the two samples Doer/Non-doer Studies and the differences between doers and non-doers. Table 3 Doer/non-doer analysis is a quantitative research method- provides an illustrative example of handwashing behavior in ology that compares segments of an at-risk population (e.g., mothers of children under age five broken down by O, A, for diarrhea or ARI) and who carry out a particular behav- and M determinants and demographic characteristics. ior and those who do not. Doer/non-doer analysis often reveals factors important in promoting behavior change To illustrate, Table 3 shows that a large proportion of both and can be used during the formative research stage as well doers and non-doers are aware that handwashing with soap as to monitor ongoing behavior change interventions.32 can prevent diarrhea. Based on this information, a message TABLE 3: ILLUSTRATIVE EXAMPLE OF A DOER/NON-DOER STUDY Doers Non-doers (Mothers Who Wash Their Hands with (Mothers Who Do Not Wash Their Hands Soap Each Time They Defecate) with Soap Each Time They Defecate) 1 Know that handwashing with soap can 78% 74% prevent diarrhea 2 Have a handwash station next to latrine 58%* 23%* 3 Believe acute respiratory infections 25%* 15%* (ARIs) are nonpreventable in children 4 Are of high socioeconomic status, i.e., likely to own such goods as bicycles, 75%* 38%* radios, mobile phones Note: *p = 0.05 statistically significant 31 WSP has developed a methodology for assessing the enabling environments for handwashing behavior change programs. See www.wsp.org/scalinguphandwashing for further information. 32 There are various approaches and variations to doer/non-doer studies. Barrier analysis for example, is a rapid assessment tool that can be used to identify relevant behavioral determinants. See http://barrieranalysis.fhi.net for more information. Population Services International carry out segmentation to assess behavers and non-behavers. See http://www.psi.org/resources/research-metrics/publications/toolkits/dashboard-analysis-series-three-segmentation-analys. 14 Global Scaling Up Handwashing Introducing FOAM Applying the FOAM Framework about the benefits of handwashing would probably not be Operational Matrix details the behavior change program an effective use of resources. plan from the conceptual stage through formative research to implementation of the plan of action. By contrast, there is a significant difference between doers and non-doers with access to a handwashing station. Doers are twice as likely to have one next to the latrine as non-doers. This BOX 9: THE FOUR Ps suggests that a key component of an intervention may be to Product: The product can be a commodity or item promote installation of handwashing stations or strengthen (soap), a concept (hygiene), or a behavior (hand- the skills of caregivers to ensure soap and water are always washing with soap).33 available and accessible for handwashing in the household. Price: Whatever is needed to acquire the product. Although there is a significant difference between doers and For handwashing, there is the financial cost of buy- non-doers in terms of their perceptions about the prevent- ing soap as well as the time and/or money required ability of ARIs, both groups have low recognition. A pro- to obtain water. The opportunity costs are also im- gram to educate the entire community about ARI prevention portant and include the loss of income from going might be an effective use of resources. to market to buy soap. There is also the social cost of going against community norms and risking os- There are considerably more doers of high socioeconomic tracism and stigma. status than non-doers. A program manager should assess whether the cost of setting up a handwashing station is pro- Place: The distribution channel used to get the hibitively high. commodity to the consumer at a specific location. For soap, this might be a shop, kiosk, or school. FOAM Operational Matrix For handwashing, the place is the site where hand- The FOAM Operational Matrix (Table 4) was developed to washing takes place such as near the latrine or in help put the framework in action using a social marketing the kitchen. approach. It enables the integration of FOAM's determi- nants with formative research findings as well as potential Promotion: This includes which and how key solutions and strategies. The marketing mix (Column 6 of messages are communicated to the consumer Table 4) refers to the "Four Ps": getting the right product, at through mass media such as radio and television, the right price in the right place and with appropriate pro- posters, newspapers, t-shirts, leaflets, point- motion (Box 9). In the example, the target audience is of-sale merchandising, road shows, and direct mothers with children under five years of age; the desired interaction with community or health workers, to behavior is consistent handwashing with soap after defeca- list but a few. tion and before feeding children under age five. The FOAM 33 For practical purposes, in this document, behavior can be considered a product. www.wsp.org 15 16 TABLE 4: FOAM OPERATIONAL MATRIX 4. Possible Research Topics ( to Be Expanded 6. Marketing Mix Introducing FOAM into Research 5. Research 1. Category 2. Determinant 3. Examples Tools) Findings Product Price Place Promotion Opportunity Access/ · Distribution · Can individu- · In this com- ·Smaller bars Set price for Fix sales · Encourage Availability of products, als procure munity of soap. Tippy Taps. points for mothers to cut e.g., water, products as soap is not · Promotion of Tippy Taps. laundry or bar soap, hand- needed? available at handwashing soap and place washing · Are water and critical times stations. at handwashing stations. soap avail- because stations. · Social mar- · Convenient able in the many moth- · Build skills keting of access to household? ers do not through in- Applying the FOAM Framework Tippy Taps. soap at want children terpersonal · Is soap at home at criti- to waste it in communication hand at critical cal locations/ handwashing. aimed at con- times? times. serving soap · How much do · Convenience, and making products cost i.e. cost, dis- it available to and are they tance, and all household affordable? time factors members. · Who makes in procuring · Encourage the decision to products. setup of more buy products? than one hand- washing station per household. Product · Soap type, · Do individuals · Mothers per- More durable More afford- Rural out- · Convince Attributes scent, color, like the smell ceive only anti- soap able soap lets and mothers shape, and color of bacterial soap via bicycle that all brand, and the soap? to be truly salespeople soap is effect on · Is the soap effective for effective skin. antibacterial? handwashing. for hand- · Water · Mothers con- washing. · Do individu- cleanliness, als perceive sider soap too color, and expensive and · Promote the water to perceived too quickly the use of be clean? quality. consumed more du- for use in rable soap handwashing specifically for hand- washing. Global Scaling Up Handwashing TABLE 4: (Continued) 4. Possible Research Topics www.wsp.org ( to Be Expanded 6. Marketing Mix Introducing FOAM into Research 5. Research 1. Category 2. Determinant 3. Examples Tools) Findings Product Price Place Promotion Social The rules that · Do commu- · Few commu- · Provide com- Norms govern how nity members nity members munications individuals wash their wash their on the "invis- within a group hands with hands with ibility" of dirt or society soap? soap unless and germs. behave. · Are children dirt is visible. taught in · Encourage school to · Children are schoolteach- Applying the FOAM Framework hand wash not taught in ers to teach with soap? school to wash about the im- their hands portance of · If community with soap. handwashing members with soap. wash their hands only at certain times, which are these? Note: For illustrative purposes, only the Opportunity Determinants of FOAM have been included. 17 IV. KEY POINT Conclusion FOAM can be applied to do the following: · Focus interventions · Analyze results of available formative studies · Inform the design of new research · Inform the development of the program · Monitor appropriate indicators It is expected that FOAM will The FOAM framework was designed to help improve our understanding of why people sometimes wash their hands with soap and why sometimes they don't. evolve as additional research The FOAM framework can help program managers analyze and explain hand- washing behaviors of various target populations. findings are incorporated and new studies are conducted. Conceptual frameworks such as FOAM serve to strengthen formative research, planning, implementation, and monitoring and evaluation of the behavior change interventions. They also provide common concepts and a shared language for pro- gram managers. More specifically, FOAM can be applied to do the following: · Focus the interventions: Prioritize the target populations and behaviors to change. · Analyze the results of available formative studies: Findings are mapped into each of the determinants. This may lead to the identification of gaps to be investigated through additional spot research. · Inform the design of new research: A series of questions can be devel- oped to explore all or a subset of the determinants. · Inform the development of the program: Once relevant determinants have been identified, the appropriate interventions can be developed. · Monitor the appropriate indicators: Indicators aimed at measuring changes in the determinants can be formulated and tracked (as outcomes or intermediary results) over time. It is expected that FOAM will evolve as additional research findings are incorpo- rated and new studies are conducted. FOAM was developed primarily to assist with handwashing interventions in low-resource settings, which is the context used in this document. However, the framework can be adapted to many dif- ferent target populations and behaviors, and we find the emergence of potential determinants of particular interest. This paper introduces FOAM and describes how it was developed. Sharing les- sons learned from the field, publications planned for later release will provide more detailed guidance on how to apply FOAM. These publications are intended for use by program managers responsible for the implementation of handwashing and/or hygiene promotion interventions, as well as members of multilateral and bilateral agencies, academic institutions, and government and nongovernmental organizations (NGOs) that work in the water and sanitation sector. 18 Global Scaling Up Handwashing Introducing FOAM Appendix A: FOAM Glossary Appendix A: FOAM Glossary A Behavior Change Framework: a diagram that represents Expectations: What an individual thinks will happen as a all the various determinants (factors) of a behavior that is result of performing the behavior. Expectations include: desirable in order for a public health outcome to occur. · Subjective Norms: The belief that people important to one feel the behavior should or should not be per- Access/Availability34: Ease of obtaining water and soap formed (Fishbein and Ajzen 1975) needed for the behavior. Main dimensions are as follows: · Outcome expectations (positive: comfort, protec- · Availability of soap at a convenient point-of-sale tion, relief from disgust; negative: irritate skin--par- · Access to water ticularly in children, diminish immunity, etc.) · Access to resources/gender equity · Convenient access to HW station at juncture pro- FOAM: A conceptual framework of handwashing behavior that moted (e.g., near latrine or kitchen) can be used to guide or inform design, implementation, moni- · Cost of access (economic, time) toring, and evaluation of handwashing promotion programs.35 Focus: Reminds the program managers to define Attitudes and Beliefs: Beliefs are perceptions about an ob- the target audience and desired behavior. ject, behavior or person which may or not be true. Atti- Opportunity: Institutional or structural factors that tudes are an evaluation or assessment of an object (Eagly influence an individual's chance to perform a behavior. and Chaiken 1993). Research has shown that health beliefs Determinants within Opportunity include: access/ are not the most important ones. Main dimensions which availability, product attributes, and social norms. may influence HW are as follows: Ability: An individual's skills and proficiency to per- · Perceived benefits of using/adding soap when HW form a behavior. Determinants within Ability in- · Attitudes toward soap clude: knowledge and social support. · Perceived affordability (in both time and money for Motivation: The drives, wishes, urges, or desires soap and water) that influence an individual to perform a behavior. · Self-image Determinants within Motivation include: attitudes · Image of those who wash their hands (e.g., good and beliefs, expectations, threat, and intention. mothers, responsible, etc.) · Beliefs about diarrhea, acute respiratory illnesses, Intention: An individual's plan to perform or facilitate the and other childhood illnesses behavior (Fishbein and Ajzen 1975). Dimensions that · Locus of control (internal vs external/fatalistic): an would influence behavior include: individual's perceptions about the main causes of the · Habit (role of visual cues or sensory cues) events in his or her life (Rotter 1966) · Willingness to pay for soap and fetch/pay for water for HW Determinants: Internal or external factors that influence · Willingness to install HW station (e.g., net for soap whether a person is likely to engage in a behavior. for children's use) 34 See for example, Conteh and Hanson 2003; Duncan, Jones and Moon l996; Kearns and Moon 2002; Weir, Pailman, Mahlalela, Coetzee, Meidany and Boerma 2003. 35 Opportunity, ability, and motivation are concepts derived from marketing and advertising, public health, social psychology, economics, consumer behavior (see, for example, MacInnis, Moorman, and Jaworski 1991; Andreasen 1995). www.wsp.org 19 Introducing FOAM Appendix A: FOAM Glossary Knowledge: Facts accumulated through learning about ob- · Household norms/behavioral modeling from other jects, actions, and events (Clarke 1992). It should be noted family members that this determinant may be necessary, but it is not suffi- · Social influence: within community (neighbors, cient for behavior change to occur. In the case of HW, opinion leaders, etc) and within household (e.g., in- knowing why HW is important including notions of germ laws, grandmother) theory would form part of this determinant. Social Support: The physical, emotional, or informational Product Attributes: Perceived or actual characteristics of assistance an individual gives or receives for a behavior water and soap. Main dimensions that can influence behav- within the community (Seeman and Berkman 1988) or ior are as follows: household. Main dimensions are as follows: · Type of soap agent or purpose (laundry, beauty, · Advice from health or community worker, relatives, dishwashing) friends, opinion leaders, neighbor, media · Type of soap format (powder, liquid, bar) · Assistance in getting water or buying soap (e.g., male · Soap characteristics (e.g., scent, color, brand, etc.) head of household) · Water characteristics (e.g., clarity, smell, etc.) · Physical assistance for children or elderly Social Norms: Standards that exist in the community or Threat: The perceived danger or harm associated with per- within the family for an individual to follow (Andreasen forming or not performing the behavior (Witte 1992). It 1995). Main dimensions are as follows: can be health and non-health related (e.g., social shunning). · Objective (observable) norms (e.g., presence of HW Threat includes two dimensions: susceptibility (how likely is stations in public toilet facilities or schools) the threat) and severity (how serious are the consequences). 20 Global Scaling Up Handwashing Introducing FOAM References References Ajzen, I. and M. Fishbein. 1980. Understanding attitudes Eagly, A. and S. Chaiken. 1993. The psychology of attitudes. and predicting social behavior. Englewood Cliffs, NJ: Fort Worth, TX: Harcourt Brace Jovanovich. Prentice-Hall. Fishbein, M., and I. Ajzen. 1975. Belief, attitude, intention Andreasen, A. R. 1995. Marketing social change: Changing and behaviour: An introduction to theory and research. behavior to promote health, social development, and the Reading, MA: Addison-Wesley. environment. San Francisco: Jossey-Bass. Gershaw, D. A. 1989. "Locus of control, line on life." Bandura, A. 1986. 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