Tanzania: A Handwashing Behavior Change Journey

This 5-page "Learning Note" brief shares the experience of the Global Scaling Up Handwashing programme, a World Bank Water and Sanitation Programme (WSP) project focused on applying behaviour change approaches to improve handwashing with soap among women of reproductive age (ages 15-49) and primary school-age children (ages 5-9). Implemented by local and national governments with technical support from WSP, the campaign is taking place in Peru, Senegal, Tanzania, and Vietnam. The brief discusses the development of the project, with a focus on how it was designed, implemented, and monitored. Challenges and lessons learned are highlighted to assist programme managers in designing and managing evidence-based handwashing with soap and/or other hygiene promotion programmes.

The first steps toward developing the behaviour change programme focused on research to better understand the intended audience, including current understandings, feelings, and actions toward handwashing. Initial formative research indicated that people tended to rinse hands when they were visibly dirty, but that the use of soap for handwashing was not widespread. Additionally, respondents indicated that handwashing with soap was an extra burden, and many of those surveyed felt they were too busy to wash their hands with soap. In order to identify the "trigger" that would motivate women to improve their handwashing behaviour, representatives from the hygiene sector generated several creative concepts based on the results of the formative research, their own experience, and a field visit.

An important insight was that mothers felt burdened with responsibility for raising children, but were rarely thanked or rewarded, and asking them to focus on handwashing with soap was felt to be an extra burden. Two ideas emerged from this experience: "Mother is the Pillar of the Home" ("Mama Nguzo") and "Heroes Make Heroes". Both concepts acknowledged mothers for all they did, including teaching handwashing with soap, rather than rebuking them for what was not done. Following testing, a creative brief was developed at a multi-sectoral workshop. The brief was provided to an advertising agency that ultimately developed the communications idea "Mikono Yenye Fahari" ("Hands To Be Proud Of"). This concept formed the backbone of the campaign, tapping into mothers' aspirations for recognition, their pride in the work they do for their families, and their role as the central pillar of the family.

Key messages were promoted through multiple integrated channels, which WSP says has been shown to be effective for behaviour change in other sectors such as HIV/AIDS, malaria, and reproductive health. When an individual receives a consistent message through multiple channels, it reinforces social norms around the behaviour. Messaging across three channels - mass media, direct consumer contact (DCC), and interpersonal communication (IPC) - was harmonised by the development of a single creative brief. A marketing team from a private soap company developed a five-stage, phased approach to help carry the audience from an initial stage, becoming aware of the importance of handwashing, to building skills to conduct improved handwashing, to sustaining handwashing with soap behaviour. As of the writing of this brief, the first two phases were completed.

Phase I: Awaken and Inspire

Phase I focused on increasing knowledge about the importance of using soap, critical times for handwashing, and inspiring women to prioritise handwashing. This phase highlighted the knowledge portion of the ability determinant, based on formative research that showed key gaps in understanding about the importance of handwashing with soap. Mass media, including radio spots, call-in shows, and DJ mentions, focused on when to wash hands with soap. Handwashing posters were also produced and distributed. IPC focused on building knowledge and skills to build tippytaps, managing availability of soap and water, and handwashing at critical times. DCC events focused on improving knowledge around handwashing with soap and introducing the tippytap, which many participants had not seen before. Events were carried out by two teams: "Pathfinders" reached out to smaller communities with a programme that included a sound truck, master of ceremonies, and dancers; "Handwashers" reached out to larger villages with a programme that included music, dancers, skits, and tippy-tap demonstrations.

Phase II: Empower and Amplify

To increase the emotive impact of the campaign, the team developed a creative brief centred on the concept of Asante Mama, which acknowledged, praised, and thanked mothers for the things they did every day for their family and children, including washing hands with soap. This phase of the campaign focused on making handwashing an intrinsic behaviour, increasing women's understanding of the tippy-tap and building skills to better manage soap and water. Mass media focused on social support (ability determinant), beliefs and attitudes, outcome expectations, and intentions (motivation determinant). Asante Mama was integrated into a soap opera through the character of a hero-mother who is recognised for her importance in the family, including handwashing with soap. IPC included the development and distribution of a "comic book" that illustrated, step-by-step, how to build a tippy-tap. The storyline incorporated characters from the soap opera, thereby integrating with mass media, and was distributed by Front-Line Activators (FLAs) in 30 wards. DCC focused on attitudes and beliefs, outcome expectations, and intention (all part of the motivation determinant), social norms (opportunity determinant), and social support (ability determinant). A competition was held in ten districts in which audience members were invited to go on stage to share why their mother was their hero, with the winner selected by audience response.

The report identifies the following challenges, among others:

• Developing the Creative Concept: The time needed to develop a positive, professional, communications campaign was underestimated. It took over six months of working with the advertising firm to develop a concept that met the criteria in the creative brief and established emotive messages. This delay impacted the development of communication materials and timing of intervention across all channels.
• Strengthening the Motivation of FLAs: Since FLAs are not paid, there is also less motivation for preferential selection. However, without compensation or an institutional structure, ongoing volunteerism has lagged. Several challenges have emerged. First, FLAs feel that they should be compensated or at least better recognised by local authorities for their efforts. The government cannot afford to provide the volunteers with transportation or reimbursement for their time. Second, volunteers are constrained by transportation and limited geographic influence.
• Value of Data: FLA monitoring forms record process indicators such as number of people reached, location, and duration of visits, but many officials place a low value on this data. This situation impedes the process of collecting the forms at each level, decreasing the likelihood that FLA forms will be institutionalised. FLAs have requested feedback from government officials on their reporting as well as site visits to see progress. Without this feedback, FLAs are unlikely to maintain motivation.
• Message Creep:During DCC events, the implementing firm would naturally
  start to play for laughs, and key messages would gradually drop away. This can be mitigated through: independent supervision by either the local government or the hiring entity; Event Impact Survey results, which will show if the firm is not delivering the message effectively; and message checklists..

According to the brief, as of December 2010, the project had exceeded project targets for mass media and DCC, and had reached 52 percent of the target for IPC.