Behavior Change

The behavior change module introduces the theory of change and key components of the approach WSP used in the project. This module includes four presentations:

  • Behavior Change Overview;
  • FOAM Framework;
  • Enabling Products; and
  • Monitoring.

The Tools section includes a link to a database of enabling products for handwashing maintained by WSP, and the Country Intervention tab provides links to the country pages which shares documents, videos, and other materials used during implementation. 

Key TermsKeep in Mind

advertising agency brief

behavioral determinants

creative brief

doer non-doer study


enabling products


formative research

learning note

management information system (MIS)


P Process

process indicators

program coverage


  • Observation is often essential.
    Rather than simply using data to check your project’s status, measuring handwashing with soap behavior often requires direct observation of either the practice itself or of key facilities, such as verifying the presence of handwashing stations with soap.
  • Carefully consider your communication approach.
    Different communication channels have different strengths; mass media can effectively transmit knowledge, but interpersonal communication is often better for building skills or countering misconceptions.
  • The benefits of FOAM.
    Using the FOAM framework not only helps you prioritize specific behavioral determinants, it can also reveal research gaps that might otherwise undermine the project.
  • Re-evaluate your strategy over time.
    Monitoring and tracking project data can reveal new information that you can use to adjust or even reformulate your original project strategy.
Country InterventionsReportsTools
  • Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs
    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), which was+F6 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.
  • Brochure: Multi-Country Impact Evaluation Study
    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.
  • Practical Guidance for Measuring Handwashing Behavior
    Accurately measuring handwashing behavior is a critical step in understanding and improving overall health. However, the lack of a universally applicable method for measuring handwashing behavior makes gathering reliable data a challenge. This Working Paper addresses that gap and offers researchers and public health professionals practical guidance on how to accurately measure handwashing behaviors in a variety of settings.
  • Synthesis of Four Country Enabling Environment Assessments for Scaling Up Handwashing
    WSP’s Global Scaling Up Handwashing Project conducted enabling environment assessments of strategic project implementations 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.
  • 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 showed that 47% of caregivers reported washing hands with soap after using the toilet and less than one-third washed their hands with soap at other critical times, such as before preparing food. However, the survey also revealed that 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 laid 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.
  • Peru: A Handwashing Behavior Change Journey
    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 project's behavior change component, focusing 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.
  • Senegal: A Handwashing Behavior Change Journey
    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.
  • Tanzania: A Handwashing Behavior Change Journey
    Using formative research and integrated communication channels including mass media, WSP's Global Scaling Up Handwashing Project aims to identify evidence-based approaches to increase sustainable handwashing with soap at scale among women and children. This Learning Note documents the project's development, focusing on how it was designed, implemented, and monitored. Challenges and lessons learned are highlighted to assist program managers in designing and managing evidence-based handwashing with soap and/or other hygiene promotion programs.
  • Involving Men in Handwashing Behavior Change Interventions in Senegal
    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.
  • Entertainment Education Programme to Promote Handwashing among Primary School Children in Vietnam
    To help children improve their hygiene habits, the Vietnam Handwashing Initiative developed a children’s campaign that included a national mass media campaign and a school-based interpersonal communication activities campaign with Youth Union members and teachers. The campaign's development began in July 2008 with research in rural and semi-urban schools; the campaign itself launched in August 2009. This paper describes the process of developing the program and appeared in Sharing Experiences: Effective Hygiene Promotion in South-East Asia and the Pacific (2010), a joint publication by WaterAid, International Water Center and the IRC International Water and Sanitation Center and funded by AusAID.
  • Insights from Designing a Handwashing Station for Rural Vietnamese Households
    The Water and Sanitation Program’s (WSP) Global Scaling Up Handwashing Project (HWWS) is testing an array of interventions to promote handwashing with soap among mothers and children in rural Vietnam. These interventions include mass media and interpersonal communication through organizations such as the Vietnam Women’s Union. Of particular and growing interest is the role of handwashing stations. In a household setting, a handwashing station is a designated space bringing together water and soap to wash hands, ideally in close proximity to the latrine or the food preparation area. Handwashing stations influence individuals’ chance to perform a behavior, regardless of their ability and motivation to do so.1 While sinks in kitchens and bathrooms are the norm in developed nations, they are not in most resource-scarce countries.
  • Enabling Technologies for Handwashing with Soap: A Case Study on the Tippy-Tap in Uganda
    A qualitative case study was carried out May 11–18, 2010 in Uganda to learn about two projects, described below, in which health workers and village-level volunteers promoted the tippy-tap, provided health education and carried out household inspections. The purpose of this study was to document the process through which tippy-taps were promoted to qualitatively explore the results and to draw out lessons for future interventions. Data were collected through nine key informant interviews, forty-seven interviews with householders from model and non-model villages, and twenty-two spot-check observations of handwashing facilities.