WATER AND SANITATION PROGRAM: LEARNING NOTE 56970 Global Scaling Up Handwashing Project Key findings · Having a tangible product such as a handwashing device facilitates Peru: A Handwashing behavior change. Behavior Change Journey · The scope of the project in Peru goes beyond traditional health, education, water, and sanitation sectors. August 2010 Engaging the private sector facilitates scale and has helped to standardize tools and approaches. INTRODUCTION skills to manage soap for handwashing · Policy and agreements that clearly In 2003, a national multi-sectorial purposes. By 2006, the program define roles and responsibilities Handwashing Initiative (HWI) was methodology had been implemented can lead to budget and resource created in Peru to increase handwashing in 14 regions, resulting in over 150,000 allocations when partners perceive with soap among mothers and children. mothers reached through an estimated that there is two-sided compliance. The early years of the HWI focused on laying groundwork, including a formative 9,000 trained field agents. These agents · Integration within ongoing public research study in 2004; the creation were managed by government agencies programs such as education and of a consultative committee by the and nongovernmental organizations nutrition provides a strong platform Ministry of Health (MoH); and a national (NGOs) from various sectors. In parallel, for sustainability. decree formalizing the HWI. The Water a mass media campaign with the theme and Sanitation program (WSP) has of Manos Limpios, Niños Sanos (Clean coordinated the HWI since its inception. Hands, Healthy Children) was designed to raise awareness of the importance of In 2005, through support from the handwashing with soap and its link with Japanese Social Development children's health. National broadcast Foundation (JSDF), a program of the mass media campaign, which methodology and supporting tools to includes a radio soap opera and television promote handwashing were developed and radio spots, began in 2005. In total, for use in small group discussions between 2005­2007, 48 public and with mothers. The methodology was private institutions added resources and developed by a local NGO specialized provided technical assistance to widen in health and hygiene. It was based the scope of the HWI. on findings from the 2004 formative research study and revised by technical In 2007, a second phase began though teams from the ministries of health and support of WSP's Global Scaling education. Up Handwashing Project to expand handwashing with soap promotion to 24 Rather than following a traditional hygiene of the country's 25 regions. WSP's project approach focused on germ theory, the is focused on learning how to apply program methodology was designed to innovative promotional approaches to motivate mothers and strengthen their behavior change to generate widespread 2 Peru: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project and sustained improvements in handwashing with soap at Figure 1. Mother-Teacher-Child Information Pathway scale among women of reproductive age (age 15­49) and in Peru primary school-aged children (ages 5­9). Local and national governments are implementing the project in Peru, Senegal, Tanzania, and Vietnam with technical support from WSP. In Peru, the objective is to stimulate and sustain handwashing behavior change in a total of 1.3 million women. This Learning Note profiles the behavior change component of the second phase with a focus on how it was designed, implemented, and monitored. Challenges and lessons learned are included to assist program managers as they make decisions to develop and manage a handwashing promotion initiative. Peru provides an interesting case study because the intervention itself is interwoven with efforts to strengthen capacity, policies, partnerships, and other aspects of the enabling environment including immediately before or after critical times (using the required to sustain handwashing with soap programs. Though latrine, changing diapers, eating or preparing food). Primary detangling these various program components is a challenge, school­aged children were also studied to provide insights this note on the behavior change journey attempts to do so. into their day-to-day reality, aspirations, and attitudes toward hygiene. A key finding was that mothers, children, and teachers PROBLEM STATEMENT together formed a critical information pathway (Figure 1) In Peru, diarrheal diseases are one of the leading causes of through which hygiene messages could be conveyed, morbidity in children under the age of five. Though hygiene supporting the HWI's hypothesis that children are a key promotion had been implemented prior to HWI, the 2004 channel and potential agents of change in the household. formative research study1 revealed that only 6 percent of mothers washed their hands with soap before cooking and only In 2008, a baseline survey for the impact evaluation was 14 percent washed their hands after going to the toilet. conducted. Questions based on the Global Scaling Up Handwashing Project's behavior change framework, known The 2004 study uncovered some of the underlying factors of as FOAM (Figure 2), were included.2 the low rates of handwashing with soap: Convenient access to soap at critical times was restricted by the fact that soap Data analysis explored differences between mothers who was usually located where cleaning and washing activities wash their hands with soap and those who do not, similar took place (e.g., laundry or dishes), which was distant from to the segmentation approach used in the "doer/non-doer" the latrine. When soap ran out, women did not always study in Senegal.3 The knowledge determinant was quickly replenish it. Many women surveyed also believed that constructed from a single question that asked mothers if they repeated rinsing with water would clean the hands as well as knew the best way to wash hands. It was assumed to be using soap. correct if they responded "with soap and water." For other determinants, women were asked to state their degree of A follow-up to the 2004 study was conducted in 2008. Focus agreement or disagreement to specific statements (Box 1). group discussions revealed that, because mothers spent their days cleaning, with their hands immersed in water, they did Findings revealed that access/availability, knowledge, and not always feel it necessary to wash their hands with soap, attitudes/beliefs toward soap and water were statistically 1 A.B. PRISMA. 2004. Behavioural Study of Handwashing with Soap in Peri-urban and Rural Areas of Peru. Lima: USAID/Environmental Health Project. 2 This framework is based on the PERForM framework of Population Services International. For additional information, see Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs, available at www.wsp.org/scalinguphandwashing. 3 For more information, see Senegal: A Handwashing Behavior Change Journey, available at www.wsp.org/scalinguphandwashing. www.wsp.org Global Scaling Up Handwashing Project Peru: A Handwashing Behavior Change Journey 3 Figure 2. FOAM Behavior Change Framework Communications Strategy A multi-channel approach combining interpersonal communication (IPC), mass media, and direct consumer contact (DCC) is being used to reach the target populations. Although the first phase had included radio and television, the second phase's mass media component is using radio exclusively for the following reasons: · Radio has a large reach and listenership. Women in particular tend to listen to the radio Monday through Friday at selected times, particularly early in the morning, correlated with the practice of handwashing with soap. These at mid-day, and from 4 P.M. to 7 P.M. areas were identified as critical determinants of handwashing · Unlike television broadcast, radio broadcast can be with soap and selected by the project team in Peru as the directed to specific geographic areas, helping the starting point of the behavior change journey in the second intervention to conform to the design of the impact phase of the project. evaluation that will compare "treatment" (intervention) and "control" (nonintervention) groups.4 ACTION IPC uses the same methodology rolled out in the first phase. Target Populations and Behaviors Front-line workers drawn from a wide range of organizations In the project's second phase (2007­ 2011), the HWI is targeting two BOX 1: DETERMINANT QUESTIONS FOR ACCESS/AVAILABILITY populations living in peri-urban and rural AND ATTITUDES/BELIEFS areas in 24 regions: mothers of children Access/Availability of Soap and Water under the age of five and children · You know of a place where you can buy soap. between the ages of 5­12. Primary · There is always enough water to wash your hands when you need to. school-aged children were included · You can buy soap when you decide to do it without asking someone else. because of the opportunity to instill good · Soap and water are always available in your house to wash hands after habits early in life and their potential as going to the toilet. agents of change within the family. The · You can always find soap when you need to use it. project identified targeted behaviors for · Soap and water are always available in your house to wash hands before each population segment: eating. Mothers--handwashing with soap at · Soap must be placed in handwashing areas (kitchen, bath/toilet). four critical times: before cooking, after Attitudes/Beliefs about Soap and Water toilet, after changing a baby's diaper, · If you wash your hands really well with water you don't need to use soap. and before eating; and placing soap next · You only need to wash your hands with soap if they look dirty or smell bad. to the kitchen and toilet. This second · Washing your hands with soap before feeding a child is important only if behavioral objective is to ease some of the you use your hands to feed them. difficulties related to access/availability, a · Washing hands uses up water in a household that could be better used critical behavioral determinant identified for other purposes. in the formative research study. · You don't need to wash your hands with soap if you know you have not touched anything dirty. Children--handwashing with soap at · If you wash your hands many times with water you do not need to use soap. two critical times, after using the toilet and before eating. 4 For more information on the project's impact evaluation study in Peru, see "Publications & Tools" at www.wsp.org/scalinguphandwashing. www.wsp.org 4 Peru: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Table 1. Topics and Main Themes Covered in IPC Program Methodology the power); in the second, the audience learns they can appropriate SJ's power Order Topic Main Themes/Messages by using soap (I have the power); in the 1 Motivation Being clean provides self-esteem. third, the listener lets others have the Handwashing with soap is part of a mother's duty. Poverty is no excuse for being dirty. power of SJ (I share the power). Together, the spots mirror the development of a 2 Resources Place soap near kitchen and bathroom. Cut soap up into smaller pieces or install a new social norm--that of handwashing handwashing station and prepare liquid soap. with soap. The radio spots and a related Proper handwashing with soap technique. song or jingle have been broadcast in 3 Knowledge Fecal contamination routes. three waves: October­December 2009, Critical times for handwashing with soap. April­July 2010, and August­October All feces are dangerous, even children's/babies'. 2010 (pending). In terms of content, all of the radio spots are designed to remind mothers of the four critical (Table 1) convene small group meetings or visit mothers at times to handwash with soap--after using the toilet, after home. Their aim is to reach mothers through two to three changing a baby's diaper, before preparing food, and before sessions during which three main topic areas are discussed eating--and stress the importance of washing hands with in the order indicated in Table 1. soap immediately before or after these critical times. They also remind mothers to place the soap next to the latrine It should be noted that though the program methodology or in the kitchen. In addition, the SJ superhero concept was developed prior to the development of FOAM, several itself embodies the importance--or power--of soap when of the determinants included in the framework (knowledge, washing hands. To build continuity from the first phase the access/availability, beliefs) are addressed. radio spots and related print materials reprise the slogan from the first phase, Manos Limpios, Niños Sanos (Clean Hands, As mentioned above, research revealed that there were Healthy Children). lingering misconceptions, including the belief that rinsing hands in water was sufficient to clean them and that The SJ concept also forms the basis of DCC events (Figure 3). handwashing with soap was necessary only when hands Larger DCC events are envisioned as fairs with simultaneous were visibly dirty. The research showed that these beliefs activities taking place, including games for children, live were negatively correlated with handwashing. To counter theater, and kiosks where demonstrations and advice on these beliefs, the project team developed a communications where to place soap and how to set up a handwashing station concept for mass media and direct consumer contact can be shared with mothers. To facilitate implementation by (DCC). The campaign features a superhero named Super various agencies (see Implementation Arrangements below), 5 Jaboncín (SJ) who gains the power to fight germs by adding a SJ kit was developed. This kit includes: soap to water. As described below, SJ provides a powerful platform for the implementation of entertainment-education · A SJ superhero costume approaches. · Three games with large props to engage audience participation From Concept to Execution: Bringing a · Support materials such as posters and comic strips Superhero to Life featuring the SJ superhero to distribute to the audience · A guide on how to use the kit materials and conduct an To bring SJ to life, three 30-second radio spots were event. developed: the first introduces SJ and his power (I discover 5 No exact translation is possible but jabón means soap in Spanish. Therefore, "Super Soaper" may be the closest equivalent in English. www.wsp.org Global Scaling Up Handwashing Project Peru: A Handwashing Behavior Change Journey 5 Figure 3. Super Jaboncín Mascot at a Large DCC Event Handwashing Stations: Bringing SJ to Homes To address a main barrier to handwashing with soap-- convenient access to water and soap at critical times--a private sector partner, Duraplast, designed a simple handwashing device made of recycled plastic. The device holds two 3-liter soda bottles (commonly found), one for water and one for home-made liquid soap, and can be mounted on walls (Figure 4). Leveraging the appeal and recognition of SJ, the device was named Super Jaboncín. The Super Jaboncín handwashing device was field tested in coastal, mountain, and forest regions for over five months. The first batch of 37,000 units was produced by the HWI and distributed, promoted, and monitored by partners in the field. The devices were distributed in schools and exchanged for plastic bottles--an environmental hazard--in households. Printed leaflets featuring SJ and including user-friendly set-up instructions are used to support the promotion. Even in areas where the device is not yet available, front-line workers Developed for smaller DCC events, a basic kit includes encourage households to build their own handwashing an overview of main messages and sample scripts for stations using artisanal techniques and locally available sketches. The kit-based approach allows for some degree materials (Figure 5). of standardization across regions and events, while ensuring integration and synergy with the mass media component. Implementation Arrangements: A True It also increases the likelihood that teams delivering the Multi-Sectorial Approach events stay "on message." Regional coordinators, facilitating In Peru, the project operates in a highly decentralized agencies, and partners monitor the DCC events. environment: regional and local coordination and integration Figure 4. Super Jaboncín Handwashing Device The Super Jaboncín handwashing device is made from recycled plastic. It holds two 3-liter soda bottles (one for water and one for home-made liquid soap) and can be mounted in locations such as health centers (left), schools (middle), or households (right). www.wsp.org 6 Peru: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Figure 5. Handwashing Station Using Artisanal sustain the behavior change journey once the project comes Techniques and Local Materials to an end. A leading communications agency was contracted to produce the mass media spots and design the SJ kits for DCC. This firm also instructs the various facilitating agencies on the use of the kit. Seven local theater groups were contracted to write scripts and develop and implement follow-up action plans. Trainings were held to improve communication skills and techniques. The theater groups are supervised by facilitating agencies and regional coordinators. Implementation of the larger DCC events is carried out through two national firms. The four facilitating agencies carrying out DCC events in collaboration with local theater groups have been trained by an organization specialized in street theater. Monitoring and Evaluation In areas where the Super Jaboncín handwashing device is not The project developed a performance monitoring system to yet available, front-line workers encourage households to build follow both the quantity of activities (outputs) and the quality their own handwashing stations using artisanal techniques and locally available materials. of the intervention. Its main components include: Management Information System (MIS). The MIS tracks outputs from the facilitating agencies through progress efforts have been critical to implementation. To this end, four reports submitted on a regular basis. Outputs tracked facilitating agencies were contracted to support and oversee activities in 14 of the 24 regions; in eight other regions, four Figure 6. Handwashing Training Workshop for Health regional coordinators were recruited; in the other two regions and Education Sectors where only mass media and DCC events have been held, the project team decided that neither a field-based coordinating firm nor a coordinator was required. The facilitating agencies and regional coordinators play a pivotal role in Peru's behavior change journey. They engage other partners to broaden the reach of the project and share tools that contribute to consistent messaging. They also train master trainers, who, in turn train the front-line workers--principally health care providers, local community development workers, and teachers (Figure 6). As a result of the partnership building process, roles and commitments are defined. Front-line workers employed by partners (public and private institutions, including local governments, national and local social programs, NGOs, mining companies, and agriculture export firms) integrate the IPC program At a training workshop, teachers and health agents learn about methodology into ongoing programs. These institutions the IPC program methodology. They paint their hands to make supervise the front-line workers to achieve explicit HWI a handprint, thereby sealing their commitment to promote objectives. This project design seeks to build a foundation to handwashing behavior change. www.wsp.org Global Scaling Up Handwashing Project Peru: A Handwashing Behavior Change Journey 7 include key indicators from the country and the global Measuring behavioral determinants. Though segmenting results framework such as number of front-line workers "doers" from "non-doers" on the basis of behavioral trained and estimated target audience reached through the determinants is common in public health interventions communication channels. The MIS has been useful to track such as condom use, applying this analytical approach to implementation in treatment and control districts to ensure handwashing with soap has involved a significant learning that the impact evaluation design is adhered to. curve, both for Peru and other project countries. The series of questions used to measure each determinant in FOAM had Field supervision. Facilitating agencies and regional to be created from scratch and then translated into Spanish coordinators are required to supervise field-based activities, and sometimes Quechua, two additional complexities. As particularly the training of trainers and DCC events. The WSP a result, it has not yet been possible to measure all of the team travels frequently to the field to conduct spot checks, ensure determinants reliably. Subsequent rounds of the monitoring, quality control, and capture emergent learning. This process has longitudinal, and endline surveys will hopefully allow for some led to strategy revisions and adaptations to different scenarios improvements to be achieved. based on cultural, demographic, and geographic diversity. Managing the demand for Super Jaboncín. The project In addition to tracking activities or outputs, the project is has been unable to meet the demand for the Super Jaboncín monitoring outcomes as follows: handwashing device. It is apparent that the device fills an important need for households (see Lessons Learned below) Regular intercept studies. To determine whether the key and that plays a role in handwashing promotion. The project behavioral determinants are moving "in the right direction" and to team is currently in discussion with partners to determine follow the level of exposure among mothers to the intervention, how best to further scale up production, distribution, and a series of intercept studies around market places have been promotion regionally or nationally. Currently, one regional planned. The first study was conducted in November 2009, and government has approved funding for the production of a second one is planned for August 2010. 30,000 SJ handwashing devices and approvals from two more are in process. The HWI will produce an additional Longitudinal surveys of impact evaluation. As part 30,000 devices that will be distributed according to the of the Global Scaling Up Handwashing Project's impact partnership approach previously used. evaluation on health, ten rounds of longitudinal surveys will be carried out. Though the main purpose of these surveys Monitoring and quality assurance. Monitoring the is to track diarrheal incidence, a limited number of questions quantity and quality of implementation, particularly IPC, in a can be added to support the intervention itself. highly decentralized environment and on a large scale (400 districts) is challenging. There are 16,000 front-line workers Baseline and endline surveys of impact evaluation. Both from a wide range of organizations who are not under the the baseline and endline surveys of the impact evaluation direct control and supervision of the project. The project will measure handwashing behavior using the global team provides technical assistance to local public and private measurements guidelines developed and other indicators such partner institutions to transfer the monitoring methodology. as diarrhea, nutritional status, and household productivity.6 To this end, capacity­building workshops and sessions have been carried out to standardize tools and integrate them within existing regional monitoring systems. KEY CHALLENGES AND LESSONS LEARNED Challenges Message consistency across all languages and The behavior change journey in Peru has encountered dialects. As front-line workers and community event challenges, some of which are described below: organizers carry out their handwashing promotion activities, 6 For more information on measuring handwashing behavior, see Practical Guidance for Measuring Handwashing Behavior, available under "Publication and Tools" at www.wsp.org/scalinguphandwashing. www.wsp.org 8 Peru: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project they frequently need to translate into A multi-sector approach facilitates local languages (such as Quechua) scale. The scope of the project in Peru Acknowledgements that also have regional dialects. Kits goes beyond traditional health, education, The authors wish to thank Doris Alfaro, with standard message briefs are water, and sanitation sectors. Engaging Carlos Augusto Claux, Hnin Hnin Pyne, being used to maximize message the private sector, particularly mining and and Nathaniel Paynter. consistency. agriculture, has permitted the project to Balancing the goal for sustainability not only dramatically scale up, but also to standardize tools and approaches. About the project with the need for evidence- Global Scaling Up Handwashing is based approaches. The program Policy and agreements can lead a WSP project focused on learning methodology for IPC among mothers to resource allocation. Policy how to apply innovative promotional and in primary schools has considerable and agreements in which roles and approaches to behavior change to institutional traction. It has been endorsed responsibilities are clearly defined can generate widespread and sustained by the Ministry of Education, rolled out lead to budget and resource allocation improvements in handwashing with into 18 of the country's 25 regions, and when partners perceive that there is a soap at scale among women of is being implemented through some two-sided compliance. reproductive age (ages 15­49) 16,000 front-line workers. Though the and primary school-aged children Integration provides a platform (ages 5­9). Local and national methodology was informed by research for sustainability. Integration within governments are implementing findings from the 2004 study and ongoing public programs such as the project with technical support updated in response to findings from the education and nutrition provides a strong from WSP. For more information, 2008 study, the motivational factors and platform for sustainability. please visit www.wsp.org/ other behavioral determinants are likely to change over time. Periodic research scalinguphandwashing. will be encouraged and inserted into the RESULTS national programming to ensure that the As of June 2010, the behavior change HWI program methodology is relevant intervention in Peru has been scaled Contact us and will lead to improved handwashing up and is meeting, and in some cases For more information, please visit practices. surpassing, targets. In the second phase, www.wsp.org or email Rocío Flórez an estimated 6.1 million population (target Peschiera at wsplac@worldbank.org Lessons Learned pop.) have been reached through the The behavior change journey in Peru broadcast of radio spots; 230,000 people has uncovered several lessons: (target) have been reached through DCC events; and approximately 217,000 Having a handwashing station mothers and children have been reached supports behavior change. Having through some 21,400 trained front-line a tangible product such as the SJ workers. handwashing device facilitates behavior change. This lesson is shared in Senegal --By Jacqueline Devine and Tanzania. and Rocío Flórez Peschiera The Water and Sanitation Program (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. © 2010 Water and Sanitation Programs (WSP)