Water and sanitation program: Learning Note 73134 Global Scaling Up Handwashing Project Key findings Results, Impacts, and Learning • Although the country’s vertical structure facilitated efficient scale from Vietnam up, the system may be more suitable to delivering information, but potentially less effective in September 2012 motivating caretakers to change and sustain handwashing behavior. Overview children under two. Although much has been learned about how to implement • Because Vietnam’s most The Vietnam Handwashing Initiative sustainable channel is (HWI) began in January 2006 with the a nation-wide communication program interpersonal communication goal of reducing morbidity and mortality in Vietnam, behavior change at scale via the government’s system of from diarrheal diseases in children under has proven challenging. frontline workers, in order for five years of age. In December 2006, handwashing to be sustained Vietnam became one of four countries1 Background within those systems, it had to be in the Water and Sanitation Program’s Consumer research conducted in 2006 integrated into other programs (WSP) Global Scaling Up Handwash- in Vietnam indicated that reported and rather than implemented as a ing project. The objective of the project actual handwashing behavior was low stand-alone program. was to learn how to stimulate improved among mothers with children under handwashing behaviors at large scale, five. Only 3% of mothers reported • The lack of substantial changes in sustain the activities after the project washing hands with soap before pre- handwashing behavior resulting ended, and measure the impact on be- paring food, and only 11% of mothers from the project suggests the havioral, health, and welfare outcomes.2 reported washing hands with soap difficulty of changing behavior after handling a child’s feces. Further, at scale, even under seemingly This Learning Note presents the observations revealed that only 9% optimal conditions where achievements, learning, and reflec- of mothers washed hands with soap knowledge about handwashing tions that resulted from implementing with soap and access to soap immediately before feeding a child. Of a large-scale handwashing program and water are not key barriers. the mothers who rinsed hands with in Vietnam and provides recommen- only water, 60% did not feel that soap • Availability of soap and water at dations for future hygiene promotion was important.3 the right place and at the right initiatives. During the four-year imple- time is a key factor in consistent mentation (2006­ –2010), the program In 2008, WSP’s Economics of Sani- handwashing with soap. In achieved all four of its key objectives. tation Initiative estimated that poor resource-poor settings, do-it- sanitation, including hygiene, contrib- yourself handwashing stations However, a randomized control trial uted to nearly 7 million diarrhea cases; are widely recommended, but (RCT) impact evaluation found no 2.4 million cases of scabies, hel- consumer insights from Vietnam significant changes in handwashing minthes, hepatitis A, and trachoma; and revealed that rural households behavior and no impact on health in 0.9 million malnutrition-related cases prefer a new product specifically designed for handwashing. 1 The other countries were Peru, Senegal, and Tanzania. 2 From 2007 to 2010, the Global Scaling Up Handwashing project was funded by the Bill & Melinda Gates Foundation under grant #42563, Global Scaling Up Handwashing with Soap Behavior Change. A one-year, no-cost extension was awarded in 2010. For more information, visit www.wsp.org/scalinguphandwashing. 3 Vietnam National Handwashing Initiative Consumer Research Baseline Survey: Final Report, Hanoi: Indochina Research (Vietnam) Ltd., 2007. 2 Results, Impacts, and Learning from Vietnam Global Scaling Up Handwashing Project annually in Vietnam. This equated to a loss of approximately 2. learn how to strengthen the enabling environment; US$780 million per year,4 or 1.3% of Vietnam’s gross domes- 3. monitor and evaluate behavioral, health, and welfare tic product.5 Although evidence from research studies shows impacts; and that improved handwashing behaviors can dramatically re- 4. share evidence-based learning and guidance for scaling duce diarrheal diseases and acute respiratory infections—two up, sustaining, and replicating handwashing behaviors in of the leading causes of child mortality and morbidity—much of this evidence has been based on small-scale interventions Vietnam and other countries. carried out in controlled settings.6 Until recently, an evaluation Table 1 summarizes these objectives and measurable targets of the health impact from a large-scale handwashing with (where applicable). soap intervention had not been conducted. Measuring Results and Impacts Testing New Approaches to Working Progress toward these objectives was measured through at Scale continuous monitoring and periodic evaluations using a The HWI included a multi-channel campaign targeted at variety of approaches. A country performance monitor- caregivers of children under five that used mass media; ing system was developed to track progress on an ongo- large, community-based events (sometimes called direct ing basis, including a series of rapid assessments to monitor consumer contact, or DCC); and interpersonal communica- program reach and message recall, and a database to track tion (IPC) activites carried out by Vietnam Women’s Union the VWU’s interpersonal communication activities. A media (VWU) members and health workers. The program began agency was hired to provide third-party monitoring to ensure with an initial phase in 40 communes7 in eight provinces that TV spots were aired as per the media plan. through the Ministry of Health (MoH). With resources from the Global Scaling Up Handwashing project, the HWI was Throughout the project, learning events were organized scaled up to another 500 communes in seven provinces for provincial VWU representatives to review progress and for a total of 10 of the country’s 63 provinces. This effort, capture lessons learned before further expansion of activi- carried out by the VWU with technical assistance from ties. Enabling environment assessments were conducted in WSP, occurred from 2007–2010. Details of the intervention, 2007 and 2010 to gauge changes in the policy, institutional including the school handwashing campaign, are available arrangements, financing, and other dimensions that could af- in separate publications.8 fect the sustainability of an at-scale handwashing program. Finally, an RCT impact evaluation study was conducted to Objectives and Targets measure the project intervention’s behavioral, child health, The project’s overall goal in Vietnam was to design and im- and welfare impacts. plement an innovative large-scale, sustainable program to improve handwashing with soap behavior at critical times in Results and Learning 750,000 women (ages 15–49) and children (ages 6–10, when children in Vietnam attend primary school). To reach this goal, Objective 1: Design and implement a large-scale, the project identified four key objectives: handwashing behavior change program Third-party monitoring data estimated that, by November 2010, 1. design and implement a large-scale handwashing mass media had reached more than 14 million Vietnamese behavior change program; women (ages 15–49) and children (ages 6–10) with handwashing 4 Based on 2005 prices. 5 Pham Ngoc Thang, Hoang Anh Tuan, and Guy Hutton, Economics Impacts of Sanitation in Vietnam, World Bank Water and Sanitation Program, 2008; www.wsp.org/ wsp/sites/wsp.org/files/publications/529200894722_ESI_Long_Report_Vietnam.pdf. 6 P. A. Haggerty et al., “Community-Based Hygiene Education to Reduce Diarrhoeal Disease in Rural Zaire: Impact of the Intervention on Diarrhoeal Morbidity,� International Journal of Epidemiology, vol. 23, no. 5, 1994, pp. 1050–1059. 7 Communes are the lowest administrative unit in Vietnam, consisting of five to 45 villages (depending on location), with an average population of 78,000 people. 8 Nga Kim Nguyen, Nat Paynter, and Minh Hien Thi Nguyen, Vietnam: A Handwashing Behavior Change Journey for the Caretakers’ Program, World Bank Water and Sanitation Program, 2011; http://www.wsp.org/wsp/sites/wsp.org/files/publications/WSP-FA-Vietnam-LN-HWWS-lowres-DEC-2011.pdf; Handwashing with Soap—Two Paths to National Scale Programs, World Bank Water and Sanitation Program, 2011; http://www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_HWWS-National-Scale- Programs.pdf; The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children, World Bank Water and Sanitation Program, 2011; http:// www.wsp.org/wsp/sites/wsp.org/files/publications/WSP-handwashing-schools-vietnam-peru.pdf. www.wsp.org Global Scaling Up Handwashing Project Results, Impacts, and Learning from Vietnam 3 Table 1: Objectives and Targets Objective 1: Design and Implement a Large-scale Handwashing Behavior Change Program Target by November 2010 Progress by November 2010 Number of women (ages 15–49) and children 2.1 million 2.2 million 9 (ages 6–10) reached through interpersonal communication Number of women (ages 15–49) and children 40,000 5,000 (ages 6–10) reached through direct consumer contact events Number of women (ages 15–49) and children 17.4 million 14.2 million (ages 6–10) reached through mass media Number of frontline workers trained 15,185 14,40010 Objective 2: Learn How to Strengthen the Enabling Environment Strengthen the capacity of public and private institutions to carry out and sustain large- scale handwashing Handwashing with soap integrated into programming of government, N/A See narrative nongovernmental organizations, and other implementing agencies Funding sources and implementing entities identified and confirmed to continue maintenance program for the foreseeable future Objective 3: Monitor and Evaluate Health and Welfare Impacts Number of target population with improved 750,000 Self-reported handwashing after handwashing with soap at critical junctures fecal contact and before feeding a child significantly higher in treatment group, but there was no evidence of significant difference between the control and intervention areas when handwashing behavior was directly observed.11 Objective 4: Share Evidence-Based Learning Solid guidance (such as training manuals, guidebooks, and workshops), data, and evidence developed for scaling up, sustaining, N/A See narrative and replicating handwashing behaviors in Vietnam and other countries 9 Some women or children could have been double-counted and hence 2.2 million might represent person-contacts rather than individual people. 10 Nga Kim Nguyen, Global Scaling Up Handwashing Final Report for Vietnam, 2011 (unpublished). After November 2010, the number of frontline workers trained continued to increase, exceeding the target by the end of 2011. See “Progress Since 2011� on page 7. 11 Claire Chase and Quy-Toan Do, Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam, World Bank Policy Research Working Paper Series, 2012 (forthcoming). www.wsp.org 4 Results, Impacts, and Learning from Vietnam Global Scaling Up Handwashing Project Figure 1: Reach of IPC, DCC, FLW Activities by November 2010 2,500,000 35,000 30,000 Population Reached by DDC Population Reached by IPC 2,000,000 25,000 FLWs Tranied 1,500,000 20,000 15,000 1,000,000 10,000 500,000 5,000 12/08 06/09 12/09 06/10 12/10 EOP IPC DCC FLW with soap messages; and IPC activities reached roughly in other publications,13 efforts were made in this area, but 2.2 million women and children in the target age ranges. improving the capacity of frontline workers to convey mes- As Figure 1 shows, the project exceeded its goal (the dot- sages beyond knowledge—in an effort to change beliefs, so- ted line) for the number of target audiences reached by cial norms, and so on—remains a challenge. Future behavior IPC. A limited number of DCC activities were initially carried out change programs in Vietnam might consider allocating more in 2008, but an additional phase of DCC was cancelled due to resources to improve frontline worker capacity. the difficulty of finding qualified firms and the limited reach of these activities. Thus, the project was unable to achieve the tar- get for audience reach from DCC. Results from the RCT impact Objective 2: Strengthen enabling environment evaluation study revealed that caretakers in the treatment group The HWI’s second objective was to build an enabling environment were nearly two-thirds more likely than those in the control group where handwashing with soap could be sustained after the end to have talked to someone from the VWU about handwashing.12 of the project. The enabling environment was measured through nine dimensions: 1) policy, strategy, and direction; 2) institutional There are two distinct factors in the Vietnam context that fa- arrangements; 3) implementation capacity; 4) partnerships; cilitated a large-scale communication program. First, the 5) financing; 6) monitoring and evaluation; 7) program method- highly centralized, vertical government structure and WSP’s ology; 8) availability of products and tools; and 9) cost-effective partnership with the VWU—a mass organization formed by implementation. According to the endline enabling assessment, the government to disseminate messages at the grassroots progress was made in six of nine dimensions.14 level—enabled rapid and relatively smooth scale up of inter- personal communication activities in 500 communes. In addi- In the policy, strategy, and direction dimension, WSP’s ac- tion, television spots were concentrated during high viewership tivities, in concert with those of other stakeholders in the food times, such as the evening news, when only one program is safety and the water, sanitation, and hygiene sectors helped to aired throughout the country, resulting in national reach. increase the government’s awareness of the role of improved hygiene. In 2010, the endline enabling environment assessment Key learning: Although the vertical structure facilitated effi- indicated that most stakeholders agreed that handwashing with cient scale up, the system may be more suitable to delivering soap was considered an integral and important part of Viet- information, but potentially less effective in motivating moth- nam’s hygiene and sanitation programming, and a stand-alone ers to change and sustain handwashing behavior. As detailed policy on handwashing with soap was not required. The National 12 Claire Chase and Quy-Toan Do, Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam, World Bank Policy Research Working Paper Series, 2012 (forthcoming). 13 Nga Kim Nguyen, Nat Paynter, and Minh Hien Thi Nguyen, Vietnam: A Handwashing Behavior Change Journey, 2011. 14 Catherine O’Brien and Michael Favin, Four-Country Synthesis of the Enabling Environment for Handwashing with Soap Endline Analysis, World Bank Water and Sanitation Program, 2012 (forthcoming). www.wsp.org Global Scaling Up Handwashing Project Results, Impacts, and Learning from Vietnam 5 Target Program for Water Supply and Sanitation, 2012–2015,15 cited the HWI as an example of a successful hygiene promotion program. The program placed particular focus on evidence- based communication programming, coupled with a compre- hensive training curriculum for partner institutions. In addition, two Handwashing with Soap Integration Kits were developed for use by health workers and VWU members to give them tools to better emphasize handwashing with soap messages across their various functions or sectors.16,17 Partnerships were established with public and private institutions, as well as several World Bank investment proj- ects, to facilitate scale up of activities and integration of handwashing with soap into programs beyond the sanitation sector and outside of WSP’s direct support areas.18 However, Contestants washing hands before preparing food during the idea of a formal public–private partnership (PPP), which was cooking contest originally pursued in other countries, did not materialize in Vietnam because the MoH did not see a need for a PPP model National Target Program. Ultimately these indicators were to promote handwashing with soap. Stakeholders agreed that, not adopted, but the MoH and Unicef did incorporate two in the Vietnam context, the best way to promote handwashing indicators in the nationally representative 2011 Multiple with soap was to work with the MoH (which was responsible Cluster Indicator Survey: 1) observations of whether households for hygiene promotion), mass organizations such as the VWU, had a specific place for washing hands, and 2) whether water and the Ministry of Education and Training.19 and soap (or other local cleansing materials) were present at a The product and tools area included development of training specific place for handwashing.21 curriculum and Handwashing with Soap Integration Kits for Key learning: A key HWI objective was to sustain hand- health workers and VWU members to promote handwashing washing activities after the life of the project. The most with soap as stand-alone activities or as part of larger health sustainable channel in Vietnam is through interpersonal com- and water and sanitation programs, respectively. The program munication via the government’s system of health workers, also supported the intitial design of a commercially produced VWU members, and teachers. For Vietnam, this meant that handwashing station with WaterSHED, a USAID-supported handwashing had to be integrated into other programs in nongovernmental organization, which resulted in leveraging a water, sanitation, and health, rather than implemented as a grant for further business development and the commercial standalone program. The Handwashing with Soap Integra- introduction of the handwashing device in Vietnam.20 With tion Kits serve as institutional resources to guide the content regards to financing, handwashing with soap has been and delivery of handwashing with soap within existing and mentioned in both the National Target Program 2012–2015 new programs that have ongoing funding and support. and the draft National Rural Water Supply and Sanitation Communications Plan. However, it is unclear how much will be allocated to handwashing activities until the government Objective 3: Monitor and evaluate behavioral, issues cost norms for implementing these programs. health, and welfare impacts The communication campaign’s aims were three-fold: to dis- In the Monitoring and Evaluation area, WSP engaged with pel existing caretaker beliefs and convey the message that the MoH to include Handwashing with Soap indicators in the even clean-looking and clean-smelling hands can have germs; 15 The National Target Programme on Rural Water Supply and Sanitation, Period 2012–2015 (Final draft), Australian Agency for International Development, 2012. 16 Claire Chase and Quy-Toan Do, Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam, World Bank Policy Research Working Paper Series, 2012 (forthcoming). 17 Nga Kim Nguyen, “Designing Evidence-based Communications Programs to Promote Handwashing with Soap in Vietnam,� Waterlines Journal, October 2010. 18 Claire Chase and Quy-Toan Do, Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam, World Bank Policy Research Working Paper Series, 2012 (forthcoming). 19 Catherine O’Brien and Michael Favin, Four-Country Synthesis of the Enabling Environment for Handwashing with Soap Endline Analysis, World Bank Water and Sanitation Program, 2012 (forthcoming). 20 http://www.watershedasia.org/div-hand-washing/ 21 Viet Nam Multiple Indicator Cluster Survey 2011, General Statistics Office Final Report 2011, Vietnam; http://www.un.org.vn/images/stories/pub_trans/20062012%20 MICS4%20EN.pdf. www.wsp.org 6 Results, Impacts, and Learning from Vietnam Global Scaling Up Handwashing Project to increase knowledge of the four critical times to wash hands; Although the impact evaluation findings show that the pro- and to generate a habit of washing hands with soap. Results gram was successful in reaching the target audience, the re- from the RCT impact evaluation study show that the campaign sulting behavior change was not of the magnitude anticipated. was successful in reaching its target audience and led to greater Changing behavior at scale remains a critical challenge. knowledge of good handwashing practice. Caretakers in treat- ment communities reported greater exposure to handwashing messages and were nearly two-thirds more likely to have talked Objective 4: Share evidence-based learning with someone from the VWU about handwashing in the past The Global Scaling Up Handwashing project was a global month than in the control communities (56.4% in treatment vs. initiative, so lessons learned at the country level were cap- 34.7% in control). Caretakers also reported washing their hands tured and disseminated at both country and global levels. In with soap more often. However, when observed in the home, Vietnam, annual learning events were organized for provin- rates of handwashing at the key times emphasized by the cam- cial and district representatives of VWU before further scale paign were low. The improvements in handwashing behavior up, with the goal of improving future activities.23 In addition, reported by caretakers were not sufficient to result in impacts on several workshops to share lessons learned in developing child health or reductions in time spent caring for sick children.22 and implementing evidence-based communication programs were organized for all partners working in Vietnam’s water Key learning: Given the lack of substantial changes in hand- and sanitation sector. One workshop brought in experiences washing behavior resulting from the project, no impact on from other countries, including a water and sanitation social child health or reductions in time spent caring for sick chil- marketing program conducted by Population Services Inter- dren were found. These results suggest that even under national in Madagascar. seemingly optimal conditions—where knowledge about handwashing with soap and access to soap and water are WSP also organized exchange visits for delegations from India not key barriers—changing behavior at scale is difficult. and Laos to observe Vietnam’s handwashing activities with the objective of improving or replicating these activities in their Some hypotheses for why health impacts were not seen include: own countries. In addition, WSP supported a visit to Indonesia by a Vietnamese delegation of key stakeholders so they could a. The causal chain between handwashing with soap and learn about the Indonesian government’s strategy for sanitation reductions in diarrhea is incorrect; however, this is unlikely and hygiene, which includes handwashing with soap as one of because efficacy studies have demonstrated the linkages. five key pillars. The project also disseminated its experiences b. The intensity (duration and frequency) and quality of mes- through several WSP publications and in peer-reviewed journals saging were not sufficient to achieve significant changes (see Box 1). in behavior and therefore in health. This is a possibility, particularly since the project took place on a large scale, Key learning: One of the challenges to consistent handwash- across several provinces spread throughout Vietnam and ing with soap is the availability of soap and water in the right was not implemented in a controlled pilot setting. place and at the right time. In resource-poor settings, do-it- c. The population exposed to the intervention was found yourself handwashing stations that households can assemble to have low rates of child diarrhea and high access to with locally available materials have been widely recom- mended. Consumer insights from Vietnam revealed that rural improved water and sanitation infrastructure. It is pos- households do not want a simple, homemade device assem- sible that if the study had been done on a more vulner- bled with reusable materials; they’re willing to pay for a new able population, the reported changes in handwashing product specifically designed for handwashing if the device is behavior would have resulted in health impacts. attractive, durable, and can be installed in a location visible to d. The behavioral determinants addressed in the commu- their neighbors. These insights, along with the human-centered nication campaign were chosen based on findings from design process used in developing the handwashing station formative research conducted in 2006; however, it is in Vietnam, have challenged previous assumptions of what plausible that the wrong determinants were selected for low-income consumers aspire to and are willing to pay for in inclusion in the communication campaign. a handwashing station. 22 Claire Chase and Quy-Toan Do, Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam, World Bank Policy Research Working Paper Series, 2012 (forthcoming). 23 Vietnam Women’s Union quarterly reports. www.wsp.org Global Scaling Up Handwashing Project Results, Impacts, and Learning from Vietnam 7 workers and supporting 258 more primary schools. By the Box 1: HWI PUBLICATIONS end of 2011, the HWI had reached a total of 790 communes 1. Nga Kim Nguyen, “Designing Evidence-based and 758 schools in 25 provinces, and 15,380 frontline work- Communications Programs to Promote Hand- ers had been trained in areas supported directly by WSP and washing with Soap in Vietnam,� Waterlines beyond through the various partnerships.24 Journal, October 2010. 2. Nga Kim Nguyen, Sharing Experiences: Effective One outcome of the partnership efforts has been the provin- Hygiene Promotion in South-East Asia and the cial-wide scale up of handwashing with soap within schools Pacific, WaterAID, International Water Centre, in Nghe An province, one of the largest and most populated International Water and Sanitation Centre, 2010. provinces in Vietnam. Vinh City, the capital of Nghe An prov- 3. Claire Chase and Quy-Toan Do, Scaling Up ince, is one of three cities included within the World Bank’s Handwashing Behavior: Findings from the Impact Medium Cities Development project. The partnership between Evaluation Baseline Survey in Vietnam, World WSP and the Department of Education and Training (DoET) Bank Water and Sanitation Program, 2010. initially covered only Vinh City and one other semi-urban dis- 4. Jacqueline Devine, Insights from Designing trict. WSP’s support included two training courses and ma- a Handwashing Station for Rural Vietnamese terials for 22 urban schools.25 After attending the training and Households, World Bank Water and Sanitation seeing the potential for replication, the DoET sent instructions Program, 2010. to all districts within Nghe An province asking them to carry out 5. Penelope Dutton, Handwashing with Soap— training courses on handwashing with soap for all teachers in Two Paths to National-Scale Lessons from the the province. Participants in the HWI training served as master Field: Vietnam and Indonesia Programs, World trainers, and the DoET provided financial support. Bank Water and Sanitation Program, 2011. 6. Penelope Dutton, Rocio Florez, and Nga Kim As mentioned earlier, in late 2011 WSP supported the devel- Nguyen, The Power of Primary Schools to opment of two sets of Handwashing with Soap Integration Change and Sustain Handwashing with Soap Kits to assist MoH staff and VWU members in integrating among Children, World Bank Water and Sanita- handwashing with soap messages into their ongoing sanita- tion Program, 2011. tion, nutrition, food safety, and emerging infectious diseases 7. Nga Kim Nguyen, Nathaniel Paynter, and Minh programs. Both the VWU and MoH have issued requests for Thi Hien Nguyen, Vietnam: A Handwashing all provinces to begin integration in 2012.26 Behavior Change Journey for the Caretakers’ Program, World Bank Water and Sanitation Beyond Vietnam, the program has influenced the design of Program, 2011. several other sanitation and hygiene programs, including one 8. Claire Chase and Quy-Toan Do, Handwashing in Bhutan where WSP provided training to the SNV Neth- Behavior Change at Scale: Evidence from a erlands Development Organization and their partners in de- Randomized Evaluation in Vietnam, World Bank veloping evidence-based behavior change communication Policy Research Working Paper Series, 2012 programs using the FOAM and SaniFOAM behavior change (forthcoming). frameworks.27 Since the 2011 collaboration, SNV Bhutan has built national and district counterparts’ capacity to develop Progress Since 2011 and implement behavior change campaigns in rural and After completing the intensive intervention phase in 2010, the urban Bhutan using the two FOAM frameworks. HWI continued to scale up and replicate its model through partnerships with government and nongovernment institu- Conclusions tions working in education, health, and water and sanitation Practical tools enable replication and expansion. The programs. These partnerships enabled the program to scale program’s evidence-based approach extended beyond up to another 15 provinces, training 980 additional frontline mass media products. During the development of the IPC, 24 Nga Kim Nguyen, Global Scaling Up Handwashing Final Report for Vietnam, 2011 (unpublished). 25 Memorandum of Understanding between the Department of Education and Training Nghe An and the World Bank. 26 Introducing SaniFOAM: A Framework to Analyse Sanitation Behaviours to Design Effective Sanitation Programs, World Bank Water and Sanitation Program, 2009; http://www.wsp.org/wsp/sites/wsp.org/files/publications/GSP_sanifoam.pdf. 27 Nga Kim Nguyen, Global Scaling Up Handwashing Final Report for Vietnam, 2011 (unpublished). www.wsp.org 8 Results, Impacts, and Learning from Vietnam Global Scaling Up Handwashing Project Handwashing with Soap Integration Kits, and their corresponding training been a challenge. In 2006, existing data in Vietnam revealed low rates Acknowledgments manuals, several rounds of pretesting of handwashing with soap; however, The authors wish to thank Claire were carried out for each product to the formative research study con- Chase, Craig Kullmann, Yolande ensure that the messages were clear ducted for the HWI did not explore Coombes, Minh Thi Hien Nguyen, and the tools were user friendly. Once how social norms could affect indi- Almud Weitz, and Eduardo Perez the tools and training methodology vidual hygiene behavior. At that time, for their valuable contributions. were presented to potential partners, experience from other countries indi- they were eager to partner with the cated that researching and targeting About the project HWI because the approach was inno- disgust or affiliation were key drivers Global Scaling Up Handwashing vative, concrete, and practical. in changing handwashing behav- is a project by the Water and ior. Since then, practical experience Sanitation Program (WSP) focused Champions can facilitate greater and learning from programs such on applying innovative behavior program reach. In Vietnam’s soci- as Community Led Total Sanitation change approaches to improve ety, highly motivated and supportive show that social norms have an im- handwashing with soap behavior leaders—whether from the national or mense role in catalyzing individual among women of reproductive age provincial government—can signifi- and community collective action.28 (ages 15–49) and primary school- cantly multiply the program’s achieve- Within the context of Vietnam, where age children (ages 5–9). It was ments. The DoET-facilitated provincial government, families, and commu- implemented by local and national scale up in Nghe An province is an nity are very influential in socializa- governments with technical support example of how one or two critical tion and behavior adoption, the role from WSP in four countries: Peru, decision makers can be the key for of social norms merits further explo- Senegal, Tanzania, and Vietnam. scaling up an entire province. ration and focus for future hygiene For more information, please visit promotion programs. Look beyond individual motivations www.wsp.org/calinguphandwashing. to change behavior. As discussed —Nga Kim Nguyen above, behavior change at scale has and Jacqueline Devine Contact us For more information, please visit www.wsp.org or email the authors 28 Ashok Dyalchand, Manisha Khale, and S. Vasudevan, What Communication and Institutional at wsp@worldbank.org. Arrangements Influence Sanitation Related Social Norms in Rural India? Community Led Total Sanitation, 2009; http://www.communityledtotalsanitation.org/resource/what-communication-and- institutional-arrangements-influence-sanitation-related-social-norms. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. © 2012 Water and Sanitation Program