Publications and Tools

A core activity of the Global Scaling Up Handwashing Project is to document and share project learning to make a contribution to the sector and support replication. Working Papers, Learning Notes, Technical Papers, Tool Kits, and other knowledge products are released on a rolling basis. These documents can be downloaded and disseminated at no charge. For additional information, please contact us.
 
Component Focus:
Programming
| Enabling Environment | Monitoring and Evaluation | Learning

Country Focus:
Global
| Peru | Senegal | Tanzania | Vietnam 
 


Global
 

Four-Country Synthesis of the Enabling Environment for Handwashing with Soap Endline Analysis (WSP: O’Brien and Favin; 2012)
Results from endline assessments of the enabling environment (EE) in four Global Scaling Up Handwashing Project (HWWS) countries (Peru, Senegal, Tanzania, and Vietnam) show that stakeholders in three of the four countries successfully involved government agencies in promoting handwashing with soap, and stakeholders in all countries developed public and private partnerships. Advances in program methodology were also significant, with stakeholders in Peru adopting the HWWS methodology, and stakeholders in Vietnam working with HWWS staff to develop a handwashing with soap integration kit. Although some progress was made in monitoring and evaluation (for example, national surveys and community-based systems were implemented in Tanzania and a robust performance-monitoring system was developed in Senegal) and financing, further work is needed in these two dimensions.

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Measuring the Behavioral Determinants of Handwashing with Soap (2012)
A six-step methodology used in Peru and Senegal to identify the relationship between behavioral determinants (factors that influence a behavior) and handwashing practices found that of eight determinants measured, only two (access/availability and habit) served as predictors in more than one site; the other six served as predictors in one site but not the other. To be usable, the scales used to measure determinants must be both valid and reliable; however, not all valid scales are reliable. Moreover, predictors can vary depending on the context and the juncture—for example, determinants that predict handwashing with soap after defecation may in fact be different from those predicting handwashing with soap before eating or before feeding a child. Qualitative formative research may help explore the significance of these different junctures for target populations.
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Enabling Technologies for Handwashing with Soap: A Case Study on the Tippy-Tap in Uganda (2011)
WSP conducted qualitative research in six villages in Uganda to assess the acceptance and uptake of tippy-taps to promote handwashing with soap at critical junctures. Uptake appeared to be driven more by the “push” of the intervention and concerns surrounding household inspections by health workers rather than the “pull” of the technology. In addition, there seemed to be little knowledge of tippy-taps in non-model villages.
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Global Scaling Up Handwashing: Annual Progress Report  (2010)
During the past year of project implementation (July 1, 2009 to June 30 2010),  WSP's Global Scaling Up Handwashing Project reached more than 2.1 million people (68% of end of project target, or EOP) through interpersonal communication, and more than 615,000 people through direct consumer contact events (91% of EOP).  In addition, mass media channels carried behavior change messages to more than 20 million  people from July through December 2009 and nearly 18 million people  from  January through June 2010. Overall, the  project’s target numbers for  people reached through integrated communication channels were achieved or are on track in each of the project countries.
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Brochure: Multi-Country Impact Evaluation Study (2010)
The impact evaluation (IE) study is an integral component of WSP’s Global Scaling Up Handwashing. The cross-country IE, implemented using randomized controlled designs, aims to support thoughtful and analytical learning and to generate robust evidence on the effects of handwashing with soap on relevant health and welfare outcomes. This introduction summarizes the approach and shares best practices that can be adopted to design IEs for future multi-country interventions.
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| Learn More:  IE Baseline in Peru | Learn More: IE Baseline in Vietnam

Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs (2010)
In November 2006, WSP began implementing a handwashing behavior change program, the Global Scaling Up Handwashing Project, across four countries. In response to the need for a common conceptual framework, WSP spearheaded the development of the FOAM framework, guided by Population Services International's PERForM framework. FOAM (Focus on Opportunity, Ability, and Motivation), developed at a March 2007 workshop in Hanoi, Vietnam, is based on behavioral determinants that either promote or constrain behavior change. FOAM can be used by program managers implementing handwashing behavior change initiatives, and is easily adaptable to a variety of socioeconomic settings.
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Improving Measures of Handwashing Behavior (2010)
As handwashing promotion is scaled up and adopted by more organizations, the need for field-friendly, affordable, and readily adaptable monitoring and evaluation techniques has increased. A WSP study in Bangladesh set out to determine the most effective methods for measuring handwashing behaviors, with particular interest in the utility of sensor soap. Included are study findings and recommendations for researchers and public health professionals tasked with measuring handwashing behavior.
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Brochure: Global Scaling Up Handwashing Project (2010)
Handwashing with soap is one of the most cost-effective ways to prevent diarrhea. However, worldwide rates are low. This introduction to WSP’s Global Scaling Up Handwashing Project provides a brief overview, including learning goals, programmatic approaches, and targets.
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Practical Guidance for Measuring Handwashing Behavior: 2013 Update (WSP: Ram, 2010/2013)
The first edition of “Practical Guidance for Measuring Handwashing Behavior” was published by the Water and Sanitation Program in 2010. There has been substantial research relevant to handwashing behavior measurement since the previous publication. Based on the substantial continued interest in measuring handwashing behavior among researchers and practitioners alike, we present here the first update to this document. We have updated the format to address the validity of each measure as compared with other handwashing measures and health outcomes, potential for bias or data collection errors, use in evaluating handwashing programs, as well as the bottom line for researchers and practitioners.
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Emergent Learning About Learning
(2010)
A challenge for projects implemented at scaleand in multiple countries is to capture and disseminate learning in a way that is systematic, timely, and of benefit to country teams, clients, partners, and programmers. Another challenge is to continuously test key assumptions underlying the program design and activities. WSP’s Global Scaling Up Handwashing Project has implemented a culture of learning to help meet these challenges and achieve the project’s learning goals.  
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Progress Report July 1, 2009 – December 31, 2009 (2010)
This reporting period marks the beginning of the final year of implementation of WSP’s Global Scaling Up Handwashing Project. Globally, the project expects to meet or exceed expected end-of-project (EOP) targets for behavior change communication interventions and strengthening enabling environments.
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Guidelines for Assessing the Enabling Environment Conditions for Large Scale, Effective and Sustainable Handwashing with Soap Projects (2008)
What factors and elements need to be in place to facilitate the success of a sustainable handwashing program? What are the necessary frameworks and methodologies to assess handwashing initiatives at scale? Based on preparatory work for WSP’s Global Scaling Up Handwashing Project, this paper provides guidance to programmatic staff in the water supply and sanitation (WSS), health, and other sectors charged with assessing the enabling environments of handwashing programs.
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Synthesis of Four Country Enabling Environment Assessments for Scaling Up Handwashing (2008)
WSP’s Global Scaling Up Handwashing Project conducted enabling environment assessments to strategize project implementation in Peru, Senegal, Tanzania, and Vietnam. Included are findings, preliminary conclusions, lessons learned, and recommendations to strengthen enabling environments. Conclusions encompass the importance of involving local government in the scaling-up process; developing case studies on linkages between handwashing and other programs; striking a balance between mass media and interpersonal communications; and tracking the private sector’s involvement in public-private partnerships.
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Global Learning Strategy (2008)
Findings on what works, and what doesn’t, in scaling up and sustaining handwashing programs can be short lived unless a structured process for generating, sharing, capturing, and disseminating knowledge is established. Included are recommendations based on a learning strategy developed by WSP’s Global Scaling Up Handwashing Project.
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Peru

Promoting Handwashing Behavior in Peru: The Effect of Large-Scale Mass-Media and Community Level Interventions (World Bank Policy Research Working Paper/WSP: Galiani, Gertler, Orsola-Vidal; 2012)
This World Bank Policy Research Working Paper from WSP evaluates a large-scale intervention (The Handwashing Initiative), implemented in Peru over a three-year period (2007 – 2010) that included a mass media provincial campaign and a district-level community component. Evaluation results show that a behavior change campaign consisting of radio, print and public events alone was not successfully recalled by target audiences and did not prove to stimulate any behavior change. However, when this strategy was coupled with more intensive activities in community and school settings, the program positively affected the handwashing practices of caretakers of young children, although not to an extent that showed improved child health. Key points are summarized in an 8-page Research Brief.
Download PDF: Working Paper / World Bank Policy Research Working Paper Landing Page | Research Brief: English / Spanish

The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children: The Cases of Vietnam and Peru (2011)
Case studies from Peru and Vietnam found that formative research on the behavior, beliefs and influences of primary school children is critical for effective behavior change campaigns targeting children. Teachers are also important advocates but they need technical support. Regardless of the approach taken, both case studies demonstrate the importance of working with children as key agents for changing behavior.
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Behavioral Determinants of Handwashing with Soap Among Mothers and Caretakers: Emergent Learning from Senegal and Peru (WSP: Devine, et al.; 2012)
Using the FOAM framework to analyze data from two large household surveys, the authors found that two behavioral determinants, beliefs and access to soap and water, can be correlated with handwashing with soap behaviors in both countries for the proxy measures used. In addition, different behavioral determinants will likely have an influence depending on critical time or juncture for washing hands with soap. For example,  evidence from Senegal suggests that ease of access to soap and water is associated with the presence of a handwashing station with soap and water at or near a kitchen facility, but not at or near a toilet facility.
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Endline Assessment of the Enabling Environment in Peru (WSP: Favin; 2011)
Research to assess the enabling environment for handwashing with soap in Peru indicates that it has been strengthened at both national and regional levels since 2007, and it is likely that handwashing with soap interventions will continue to be implemented at a large scale in many regions. In addition, efforts to integrate handwashing with soap behavior change into national, regional, and local policies related to health and nutrition, education, water, and sanitation, and to institutionalize behavior-change methodologies and tools in these sectors have largely been achieved. Recommendations to further strengthen the enabling environment include assisting public sector partners in planning, implementing, monitoring, and evaluating multisector water, sanitation, and hygiene investments; and encouraging regional governments to include funding and activities to promote handwashing in their development plans.
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Peru: A Handwashing Behavior Change Journey (2010)
WSP’s Global Scaling Up Handwashing Project is focused on learning how to apply innovative promotional approaches to behavior change to generate widespread and sustained improvements in handwashing with soap at scale among women and children. This Learning Note discusses the behavior change component of the project, with a focus on how it was designed, implemented, and monitored in Peru. Challenges and lessons learned are included to assist program managers as they make decisions to develop and manage a handwashing promotion initiative.
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Scaling Up Handwashing Behavior: Findings from the Impact Evaluation Baseline Survey in Peru (2010)
WSP’s Global Scaling Up Handwashing Project is testing approaches to learn what works to create and sustain handwashing with soap behavior change. To establish the causal effect of project interventions on specific health and welfare measures, the project is conducting impact evaluation studies using a randomized-controlled experimental design.  This report shares baseline results from research conducted in 3,526 households in the project area in Peru.
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| Research Brief

Enabling Environment Assessment: Peru (2008)
WSP’s Global Scaling Up Handwashing Project in Peru aims to inculcate handwashing habits at critical times in 1.3 million mothers and children. An enabling environment assessment was completed to determine the existing conditions for the scalability and sustainability of the project. Nine dimensions of scalability and sustainability in Peru were examined through individual and group in-depth interviews, surveys, and document reviews. Included are recommendations for regional, provincial and district partnerships; planning and implementing dynamic advocacy and communication strategies; and developing an appropriate exit strategy.
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Senegal
 

Behavioral Determinants of Handwashing with Soap Among Mothers and Caretakers: Emergent Learning from Senegal and Peru (WSP: Devine, et al.; 2012)
Using the FOAM framework to analyze data from two large household surveys, the authors found that two behavioral determinants, beliefs and access to soap and water, can be correlated with handwashing with soap behaviors in both countries for the proxy measures used. In addition, different behavioral determinants will likely have an influence depending on critical time or juncture for washing hands with soap. For example,  evidence from Senegal suggests that ease of access to soap and water is associated with the presence of a handwashing station with soap and water at or near a kitchen facility, but not at or near a toilet facility.
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Developing a Decentralized Performance Monitoring System in Senegal (WSP; Koita; 2011)
WSP Senegal developed and used a decentralized monitoring information system (MIS) tomonitor performance. The system, which is capable of managing a large volume of data, is influencing ongoing projects by multiple agencies. This database has been recognized as a model by other public sector organizations, such as AGETIP for implementation of the Global Sanitation Fund in Senegal and the Municipality of Dakar.
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Scaling Up Handwashing Behavior: Findings from the Impact Evaluation Baseline Survey in Senegal (WSP; Orsola-Vidal, Yusuf; 2011)
In Senegal, less than one- third of households had  a designated place for handwashing with soap and water, according to rapid observations conducted in 1,600 households and 110 clusters. The observations  were part of the impact evaluation survey conducted in 2008 to collect baseline data for WSP’s Global Scaling Up Handwashing Project in Senegal. The baseline data will be used to track changes in handwashing with soap behavior in Senegal and to evaluate the project’s impact on child health and caretaker productivity. The evaluation study seeks to measure and learn about the impact of the intervention on handwashing behavior change with the hope that these lessons will be used to guide future projects and policy in Senegal and globally.
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| Research Brief

Senegal: A Handwashing Behavior Change Journey (2010)
Launched in 2006, WSP's multi-country Global Scaling Up Handwashing Project works to improve handwashing with soap behaviors at scale and in a sustainable manner. From inception, the project has emphasized emergent learning and performance monitoring to allow for evidence-based, mid-course adjustments. This Learning Note profiles the behavior change component of the project, with a focus on how it was designed, implemented, and monitored in Senegal.  Challenges and lessons learned are included to assist program managers as they make decisions to develop and manage a handwashing promotion initiative.
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Involving Men in Handwashing Behavior Change Interventions in Senegal (2010)
In Senegal, women play a central role in caring for the family and women’s hygiene behaviors are strongly correlated to reducing or transmitting fecal contamination within the household.  However, as heads of household, men allocate financial resources for household items such as soap. Thus, while the Global Scaling Up Handwashing Project in Senegal initially focused on women as the target audience for project implementation, the project team soon realized they should also target men. The steps taken to target both women and men, along with key learnings, are discussed.
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Enabling Environment Assessment: Senegal (2008)
WSP’s Global Scaling Up Handwashing Project in Senegal aims to inculcate handwashing habits at critical times in 490,000 mothers and children. An enabling environment assessment was conducted to determine the existing conditions for the scalability and sustainability of the project. Nine dimensions of scalability and sustainability in Senegal were examined through individual and group in-depth interviews, surveys, and document reviews. Recommendations include the development of a government-endorsed national hygiene policy; establishment of technical committees on handwashing; and agreements with the Government of Senegal concerning institutional leadership and decentralized implementation.
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Tanzania
 

Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania (WSP: Briceno and Yusuf; 2012)
This technical report provides a snapshot of the conditions of the target population prior to the start of WSP’s sanitation and handwashing program in Tanzania, which was phased into 10 rural districts during the second half of 2009. The report presents summary descriptive statistics for key demographic, socioeconomic, hygiene, health, and child development variables based on a survey of approximately 1,500 households in five of the 10 districts (due to unexpected problems with data reliability collection was limited to five districts). The survey revealed limited baseline knowledge of the critical handwashing times among the target households prior to the program, indicating room to improve handwashing behavior. Likewise, the survey indicated limited access to improved water sources, a scarcity of pit latrines with slabs, and a non-negligible percentage of open defecation practice as reported by the studied households, suggesting the need for continued efforts toward improving the sanitation situation in the country.

Technical Paper

Tanzania: A Handwashing Behavior Change Journey (WSP: Coombes and Paynter; 2011)
WSP’s Global Scaling Up Handwashing Project aims to identify evidence-based approaches to increase handwashing with soap at scale among women and children, in a sustainable manner. The project uses formative research and integrated communication channels including mass media, interpersonal communication, and direct consumer contact events. Research shows that the FOAM framework can be an effective tool for analyzing formative research and developing communication objectives, and that a communication campaign that uses integrated channels in a mutually supportive manner can be particularly effective in changing behaviors. In addition, small-scale spot research can help fill in gaps in the research, particularly with regard to beliefs and knowledge about links between handwashing and disease.
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Enabling Environment Assessment: Tanzania (2008)
WSP’s Global Scaling Up Handwashing Project in Tanzania aims to inculcate handwashing habits at critical times in 1.3 million mothers and children. An enabling environment assessment was conducted to determine the existing conditions for the scalability and sustainability of the project. Nine dimensions of scalability and sustainability in Tanzania were examined through research, document reviews, and interviews with main stakeholders. Recommendations include: agreeing on a shared vision with project partners, allocating funding for handwashing facilities at schools, creating district-level project management teams, and ensuring that all partners can access monitoring and evaluation systems.
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Vietnam

Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam (2012)
The Water and Sanitation Program (WSP) supported implementation of a large-scale handwashing campaign in three provinces of Vietnam over a four-year period (2006-2010). This World Bank Policy Research Working Paper from WSP and the Development Economics Group describes key findings from an impact evaluation of the campaign, known as the Vietnam Handwashing Initiative. Focused on caregivers of children under five years of age, the campaign achieved four key objectives, which are captured in a Learning Note. Key points from the Working Paper are summarized in a 4-page Research Brief.
Download PDF: Working Paper /  World Bank Policy Research Working Paper Landing Page | Learning Note | Research Brief

The Power of Primary Schools to Change and Sustain Handwashing with Soap among Children: The Cases of Vietnam and Peru (2011)
Case studies from Peru and Vietnam found that formative research on the behavior, beliefs and influences of primary school children is critical for effective behavior change campaigns targeting children. Teachers are also important advocates but they need technical support. Regardless of the approach taken, both case studies demonstrate the importance of working with children as key agents for changing behavior.
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Vietnam: A Handwashing Behavior Change Journey for the Caretakers’ Program (2012)
This learning note profiles the behavior change component of the project, with a focus on how it was designed, implemented, and monitored in Vietnam.  Challenges and lessons learned are included to assist program managers as they make decisions to develop and manage a handwashing promotion initiative. One key lesson is how as target audiences move beyond knowledge, communication messages must also be adjusted to ensure that they are relevant and persuasive.
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Scaling Up Handwashing Behavior: Findings from the Impact Evaluation Baseline Survey in Vietnam
In Vietnam, a baseline survey was conducted in 3,150 households in the Global Scaling Up Handwashing Project area. The research shows that 47% of caregivers report washing hands with soap after using the toilet and  less than one-third wash their hands with soap at other critical times, such as before preparing food. However, the survey also reveals the prevalence of diarrhea is significantly lower than the most recent national statistics, findings that shifted the IE focus in Vietnam from tracking disease to measuring behavior change. The baseline surveys lay the groundwork for the impact evaluation (IE) component of the Global Scaling Up projects, designed to establish the causal impacts of handwashing with soap behavior change and sanitation improvements on specific health and welfare measures, generating robust evidence on a cross-country basis.
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 | Download Brief

The  Development of an Entertainment Education Program to Promote Handwashing with Soap among Primary School Children in Vietnam (2010)
Research conducted by WSP in Vietnam revealed  that a leading motivator for handwashing with soap is the desire to prevent others from getting sick (especially younger brothers and sisters). This finding was incorporated into  a behavior change communications campaign for children using  the theme “pride of the family”. From Sharing Experiences: Effective hygiene promotion in South East Asia and Pacific , published by WaterAid, International Water Centre, and IRC International Water and Sanitation Centre.
http://www.wateraidcommunity.org.au/Document.Doc?id=29
 

Insights from Designing a Handwashing Station for Rural Vietnamese Households (2010)
Multiple iterations of prototyping and field-testing of a handwashing station prior to manufacturing are critical to identify user preferences and practices. Discussed are the design process and emergent learning on handwashing station preferences and handwashing practices in rural Vietnam.
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Enabling Environment Assessment: Vietnam (2008)
WSP’s Global Scaling Up Handwashing Project in Vietnam aims to inculcate handwashing habits at critical times in 2.3 million mothers and children. An enabling environment assessment was carried out to determine the existing conditions for the scalability and sustainability of the project. Nine dimensions of scalability and sustainability in Vietnam were examined through surveys and individual and group in-depth interviews. The authors conclude that the project’s success in creating an enabling environment in Vietnam could serve as a model for other programs in the region.
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