WATER AND SANITATION PROGRAM: Global Scaling Up Handwashing Project LEARNING NOTE 66306 Global Scaling Up Handwashing Project Key findings Vietnam: A Handwashing • Behavior change begins with our partners: introducing Behavior Change Journey handwashing promotion approaches that hinge on mothers’ for the Caretakers’ Program aspirations rather than their knowledge of germ theory requires December 2011 that stakeholders and partners understand and support the approach. INTRODUCTION The Vietnam Handwashing Initiative This Learning Note documents the • Evidence based programming: (HWI) was launched in January 2006 by development process of the caretakers’ In order to design an effective the Ministry of Health (MoH) with funds program with a focus on how it was behavior change program, from the Danish Embassy in Vietnam designed, implemented, and monitored. formative research must be and technical assistance from the Water Lessons learned and challenges are conducted to inform development and Sanitation Program (WSP). The also highlighted to assist program of the communications strategy, initial phase consisted of a nine-month managers in designing and managing program interventions and the multi-channel campaign utilizing mass evidence-based handwashing with monitoring and evaluation system. media, direct consumer contact, and soap and/or other hygiene promotion interpersonal communications targeting programs. A separate publication will • As the target audiences mothers of children younger than age focus on the process of developing the move beyond knowledge, five in 40 communes throughout 1 children’s handwashing program. communication messages must Vietnam. In 2008, HWI built on the also be adjusted to ensure that Illustration 1: Mother Washing initial work with a refined interpersonal Hands with Her Child they are relevant and persuasive. communications approach and worked Having effective monitoring through the Vietnam Women’s Union systems is critical to inform these (VWU) to expand the interpersonal decisions. communications activities to another 260 communes, and were complemented by • Availability of a handwashing ongoing mass media spots. In July 2009, station can act as a reminder to activities were scaled up to another 240 practice the behavior and serve communes for a total of 540 communes to facilitate the behavior. in ten provinces and reaching over 1.76 million mothers through the integrated behavior change approach. In Vietnam the project objective is to stimulate and change handwashing behavior change wsp in a total of 2.1 million women and children. water and sanitation program 1 Communes are the lowest administrative unit in Vietnam consisting of 5-45 villages, depending on location, and with an average population of 78,000 people. 2 Vietnam: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Figure 1. FOAM Framework PROBLEM STATEMENT Although Vietnam has experienced rapid economic growth Focus Opportunity Ability Motivation within the last ten years and is now positioned to achieve Access/ Beliefs and attitudes the Millennium Development Goals for water supply, practice Target behavior availability Knowledge Outcome of improved handwashing behaviors remains low. Formative 2 expectation Product research study findings in the intervention areas revealed that attributes only 5 percent of mothers were observed to handwash with Threat Target Social support soap before feeding their child and only 14 percent washed population Social norms Intention with soap after cleaning their child’s bottom . The 2002 3 Demographic and Health Survey reported a national diarrhea prevalence of 11 percent and symptoms of acute respiratory The findings from the formative were analyzed using a infection prevalence of 19.5 percent . Given the combination 4 framework called FOAM that can be used to identify 6 of poor handwashing practices and a high prevalence of determinants influencing handwashing behaviors of a target diarrheal disease and acute respiratory infections, there was group (Figure 1). The FOAM framework helped the team a need for a behavior change initiative to move audiences develop objectives for the communication campaign based towards adopting and maintaining hygienic behaviors. on research findings and determinants (Table 1). ACTION Phase I: Initial Implementation (January – In 2007, the HWI conducted formative research to investigate September 2008) handwashing with soap practices among mothers of children On the basis of the research findings, a creative brief younger than age five, understand motivating factors and (guidelines) was developed, which defined the communication barriers to handwashing with soap at critical junctures, and 5 objectives for the campaign. The campaign centered on document media habits. The research included focus group promoting handwashing with soap as part of being a “Good discussions with mothers, structured observations within Mother� among rural women to help ensure that their children households to observe actual handwashing with soap rates, reached their developmental milestones. and product trials where mothers were provided with soap for use within a week followed by an in-depth interview. Key An international advertising firm was hired to use the findings included: guidelines to develop mass media and direct consumer contact activities. A final communications concept was • 92 percent of mothers reported rinsing hands at critical developed around a traditional children’s counting song (“One junctures; plus one is two, two plus two is four, four plus one is five, • 60 percent of those who rinsed their hands with water did all five fingers clean�). The song associated the practice of not feel that soap was important or necessary; handwashing with soap with the development aspirations of • Mothers were most concerned with ensuring that their mothers. This concept was validated through pre-testing with children met developmental milestones; mothers and executed through posters and a television spot • Many mothers reported “soap was too expensive,� yet that was broadcast during lunchtime and after the evening most households had at least one type of soap; news, when mothers were most likely to watch television. The • 80 percent of mothers interviewed watched television message was further reinforced with a tagline (“Remember nightly, but only 15 percent listened to the radio; to Wash Your Hands with Soap for Children’s Health and • Women’s Union Members and health workers were cited Development�) that was included in all promotional products as the most trusted sources of information for rural women. and materials. 2 Improved handwashing behaviors are washing hands with soap after defecating or cleaning an infant’s bottom, and before cooking or eating. 3 Consumer Research Baseline Survey. 2007. Vietnam: WSP. 4 Committee for Population, Family and Children, Vietnam Standard Demographic and Health Survey, 2002. Hanoi, Vietnam and ORC Macro, Calverton, MD, USA. 5 Before preparing food, before feeding children, after using the latrine and after cleaning a baby’s bottom 6 See J. Devine, Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs (WSP; 2009), available at www.wsp.org/wsp/sites/wsp.org/files/publications/ WSP_IntroducingFOAM_HWWS.pdf www.wsp.org Global Scaling Up Handwashing Project Vietnam: A Handwashing Behavior Change Journey 3 Table 1. Findings, Determinants, and Communication Objectives Research Finding FOAM Determinant Communication Objectives High incidence of hand rinsing with Knowledge Have mothers know that clean-looking and clean- only water smelling hands can still have germs Low prioritization of using soap while Intention Have mothers use soap whenever they rinse hands handwashing High value in ensuring children reach Belief Have mothers feel that washing their hands is an developmental milestones easy way to help their children achieve milestones High incidence of forgetting to wash Intention Have mothers remember to wash hands with soap hands before and after contact with at the critical times feces The Direct Customer Contact activities were designed to on germ theory and establishing a link between handwashing provide community members with an opportunity to obtain with soap and disease. These determinants were already well more information on handwashing with soap through games, established, according to formative research. However, the handwashing demonstrations, and question and answer materials overlooked important determinants such as belief in sessions. The Direct Customer Contact activities used the the importance of handwashing with soap, and skill building same logo and images from mass media activities to promote on how to manage soap and water. a consistent look for the program. Second, only a single set of materials had been developed, The third component of the intervention, interpersonal which was used by both the master trainers in their Training of communications, was developed based on the experience Trainers sessions as well as by the trainees when they worked of the handwashing project in Peru . The MoH took the lead 7 with the ultimate beneficiaries. As a result, the trainers did in developing, training, and overseeing the interpersonal not have adequately tailored materials to engage mothers. A communications activities in the initial 40 communes within handwashing motivators manual was needed. eight provinces. The interpersonal communications focused Illustration 2: Scene from a Skit on Why It Is Important on transmitting messages to promote the health benefits of to Use Soap to Clean Dirty Hands handwashing with soap with a strong focus on the negative health consequences of not handwashing with soap. In all, 2,400 motivators (primarily village health workers, village leaders and Vietnam Women’s Union members) were trained in communication skills and on how to execute handwashing with soap promotion, including household visits and holding group meetings. At the end of Phase I several lessons emerged. First, a detailed review of interpersonal communications materials developed for health workers found that the materials were too focused 7 See J. Devine and R. Flórez Peschiera, Peru: A Handwashing Behavior Change Journey (WSP; 2010), available at www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_PeruBehaviorChange_HWWS.pdf www.wsp.org 4 Vietnam: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Figure 2. Main poster (left) and four critical junctures Phase II: Scaling Up (May 2008 – November 2010) poster (right) From May 2008, additional resources for HWI were provided by WSP to expand the behavior change activities and reach millions more Vietnamese women and children. Mass media activities were continued as under Phase I, while the Vietnam Women’s Union was contracted as the key implementing agent to scale up interpersonal communications activities (Box 1). Through several rounds of revisions and pretesting, the interpersonal communications curriculum developed for motivators evolved from a top-down, health-education approach based on threat of disease towards a behavior change approach that highlights the benefits of handwashing with soap. By focusing on handwashing as an easy way to ensure the health and development for children, the interpersonal communications activities were better aligned to address key determinants such as improving understanding of critical times to handwash with soap and strengthening the intention to place soap near handwashing areas. Improvements to the interpersonal communications curriculum included the development of detailed, easy to use guidelines to assist motivators when they conducted group meetings with mothers and follow-up household visits, Posters promote a call to action. The tagline urges mothers to “Handwash with Soap and the development of simple, open-ended questions that for the Health and Development of Your Children.� motivators could use during group discussions to make the sessions more targeted and engaging. In addition, a simple but detailed monitoring system was developed including Box 1. The Vietnam Women’s Union sign-in sheets for each motivator to track attendance of The Vietnam Women’s Union is a mass organization – a each mother to group meetings and household visits. From political and social institution established by the government their tracking sheets, each motivator then provided monthly as a way to communicate down to the grassroots level updates to commune level committees who submitted data about national government programs and initiatives. The to the district, which were aggregated to the national level. Vietnam Women’s Union’s objective is to promote gender equity, foster the development of women, and protect the rights of Vietnamese women. It shares the same vertical MONITORING AND EVALUATION structure as a line ministry. The Vietnam Women’s Union The project developed a performance monitoring system to receives resources from the Government of Vietnam, and follow both the quantity of activities (outputs) and the quality external agencies such as UNICEF and the World Bank, of the intervention. Its main components include: and from its members. The presence and structure of mass organizations such as the Vietnam Women’s Union Management Information System. The management in Vietnam presented the HWI with a unique opportunity information system tracks outputs from the implementing to reach millions of women and children with face-to-face communications activities. agencies through progress reports submitted on a regular basis. Outputs tracked include indicators such as number www.wsp.org Global Scaling Up Handwashing Project Vietnam: A Handwashing Behavior Change Journey 5 of motivators trained and estimated target audience reached Interpersonal communications. A monitoring tool was through the communication channels. The system has also developed for the Vietnam Women’s Union to monitor its been used by the Vietnam Women’s Union to obtain real- interpersonal communications implementation. Based time data on the implementation progress of each province on these data, the HWI agreed on the need to move the in order to follow up on support and supervision as needed. target audience from knowledge to intention by reminding The management information system tracks the following them when to wash hands with soap, convincing people components: to put soap in handwashing areas, and motivating those Mass media. A local media monitoring firm tracks mass who wash their hands with soap to make it a habit. media, including how often spots were aired, on which channels, and which times in order to ensure that they are Field supervision. Alongside the Vietnam Women’s Union, aired when it is most likely to be seen by mothers. who is responsible for supervising field-based activities, WSP actively supported supervisory missions, particularly during Direct Consumer Contact. The Direct Consumer key project components such as training and implementation Contact implementing firm reports on evidence of each of activities. As a result of the field supervision, the content event, including photos, press clippings, videos, and of the Interpersonal communications component evolved as summary statistics. described above. Illustration 3: Ministry of Health, a Vietnam Women’s Union Representative and a Schoolchild Wash Hands with Soap During Launch Ceremony of the Vietnam Handwashing Initiative www.wsp.org 6 Vietnam: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Illustration 4: Direct Consumer Contact Event Participants at a Direct Consumer Contact wash their hands before entering the event (left); at one station, hands are smeared with powder that is visible only under ultra-violet light. This demonstrates that clean looking hands may still be dirty. Baseline and endline surveys of impact evaluation. together at a convenient place for handwashing. Having a Both the baseline and endline surveys of the impact handwashing station would help caretakers to access soap evaluation will measure handwashing behavior using the and water at the right place and time and provide a physical global measurements guidelines and other indicators such reminder to help reinforce the behavior. as diarrhea, nutritional status, and household productivity. Behavior change begins with our partners. Social Household monitoring surveys. To identify progress marketing is a relatively new approach to behavior change on key behavioral determinants and to follow the level of communications in Vietnam, which has historically exposure among mothers to the intervention, three rounds implemented communication activities in a top-down manner. of household monitoring surveys were carried out before, In developing the mass media materials, and, in particular, during, and after the project intervention. A final round in the interpersonal communications materials, the first step the endline evaluation is expected to provide evidence of was to convince partners and implementing agencies that improved behaviors. communications based on the aspirations of mothers for their children would be more effective and engaging than KEY FINDINGS simply presenting facts and figures related to bacteria and Promotion without product. Discussions with mothers, the causes of diarrhea. and results from pre-testing handwashing stations, revealed 8 that although knowledge of handwashing with soap after Grounding the campaign upon evidence. Policy makers using the toilet is high, they will forget if there is not a physical and program managers are often under pressure to quickly reminder right outside the latrine. Formative research also roll out a communications program, especially if they are indicated availability of water and soap in the majority stretched in terms of time or financial resources, and thus may of households, although they were not always available be tempted to skip or shortcut the consumer research stage. 8 See J. Devine, Insights from Designing a Handwashing Station for Rural Vietnamese Households (WSP; 2010), available at www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_Designing_Handwashing_ Station_HWWS.pdf www.wsp.org Global Scaling Up Handwashing Project Vietnam: A Handwashing Behavior Change Journey 7 However, based on our experience in Vietnam, this first step guidelines provided. The agency brief serves as an important is the most crucial in designing an evidence-based campaign tool and constant reference document to guide and assess as the research findings are critical to identifying behavioral the agency’s work. determinants that subsequently guide the development of the communications program objectives. The program Audiences change and so must the approach, including objectives will then be used as the basis for monitoring and channels and message. As the target audiences move evaluation systems. beyond knowledge towards intention to handwash with soap, the HWI messages must also be modified. Each phase The brief is the foundation to an effective campaign. of the HWI presented us with an opportunity to fine-tune the Advertising agencies do not always base their creative ideas interpersonal communications activities based on feedback on evidence and research data. Although WSP provided from the field and from the household monitoring data. A rapid the advertising agency with detailed guidelines, the creative assessment in 2008 revealed that after the intervention, nearly ideas that were developed, though visually appealing, were 90 percent of mothers knew that handwashing with soap was in many cases inconsistent with the research insights and linked to diarrhea, up from 10 percent before the intervention. Illustration 5: Interpersonal Communications Activities Vietnam Women’s Union members use cue cards and demonstrate handwashing at a group meeting. www.wsp.org 8 Vietnam: A Handwashing Behavior Change Journey Global Scaling Up Handwashing Project Illustration 6: A Grandmother Washing Hands at a Market Meeting Acknowledgments The authors wish to thank Jacqueline Devine, Amy Lynn Grossman, Hnin Hnin Pyne and Almud Weitz. About the Project Global Scaling Up Handwashing is a Water and Sanitation (WSP) project focused on applying innovative behavior change approaches to improve handwashing with soap behavior among women of reproductive age (ages 15-49) and primary school- age children (ages 5-9). It is being In addition, very few children in the RESULTS implemented by local and national survey had experienced an episode of Since May 2007, HWI has scaled up governments with technical support diarrhea in the two weeks before the handwashing with soap activities in from WSP in four countries: Peru, survey. Based on this, before the scale 540 communes in ten provinces. Over Senegal, Tanzania, and Vietnam. For up of the program in the remaining 15,000 motivators have been trained more information, please visit 240 communes, significant emphasis in handwashing with soap promotion www.wsp.org/scalinguphandwashing. was placed on communicating to and, to date over 1.76 million women mothers that handwashing with soap is have been reached via interpersonal an easy way to ensure the health and communications activities. The development of children, rather than television spot has reached over 14 focusing on diarrhea, and on helping mothers to ensure that soap and water million people, while Direct Consumer Contact activities have exposed Contact Us were readily available in places for almost 5,000 people to handwashing For more information, please visit handwashing. messages. www.wsp.org or email Nga Kim Nguyen at wsp@worldbank.org By Nga Nguyen, Nat Paynter and Minh Hien Thi Nguyen 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 wsp 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. water and sanitation program © 2011 Water and Sanitation Programs (WSP)