Using soap: the ultimate challenge in hygiene behaviour change

SNV’s Sustainable Sanitation and Hygiene for All approach was implemented between 2014 and 2017 in partnership with three district governments in Lampung Province, Indonesia. Locally referred to as STBM (Sanitasi Total Berbasis Masyarakat) the project sought to increase access to an improved sanitation facility, and improve handwashing with soap (HWWS) practice.

Prior to STBM implementation, 13% of all households were found to be practising HWWS (SNV baseline, 2014). This despite the availability and affordability of water and soap, and handwashing practice considered as one of Islam’s precepts to cleanliness. In a country where 98% of the local population practise Islam, formative research found that handwashing as a religious practice did not translate to hygienic practice for improved health outcomes.

Revisiting our strategies

With the above findings in mind, SNV supported local governments to integrate health-related handwashing with soap messages in overall sanitation and hygiene campaigning. A year later, SNV conducted a mid-term review, which found that HWSS rates had increased by 162%.

To maintain rates of HWSS increase, SNV revisited its own strategy and adapted the social affiliation [1] method to further enhance its campaign. Social affiliation makes use of people’s need to belong, and to comply with wider, socially-acceptable behaviours within their own local community. The strategy was clear: to launch a community-wide movement with messages that establish handwashing with soap (HWWS) as a desirable (and expected) social norm.

To disseminate our messages, SNV used existing modes of communication particularly popular to the local population, and capable of drawing large audiences. Traditional, cultural and social initiatives, e.g., leather puppet performances, flat horse dances, religious songs, aerobic exercises for women’s collectives, and artwork competitions, were used for this purpose.

We worked closely with professional art groups, women’s associations and schools, and embedded HWWS messages in narratives, songs and visual displays. Our campaign was later known as the “handwashing with soap through local culture campaign," and was implemented in two districts over a period of eight weeks.

Monitoring as we go

To ensure that our campaign was working towards our intended results, and to secure sufficient space for us to make relevant and timely adjustments, SNV conducted continuous monitoring. At the end of each event, random sampling of participants was conducted to quickly assess effectiveness and outreach of our messages, and the potential for HWWS to be practised at household level. Results showed that 79% of our audiences spontaneously mentioned HWWS; 47% expressed the need to hand wash with soap before/after eating/food preparation, and after defecation (suggesting a ‘deeper’ understanding of our messages), and 45% stated the willingness to improve their hygiene behaviour.

Two months after the campaign, the final results were measured through an end line assessment. Similar to the baseline and mid-term, the existence of a handwashing station and soap at household level was examined; this considered a proxy indicator to measure HWWS behaviour change. Following the 8-week cultural campaign, we found that HWWS rates had increased by 12%. Most surprisingly though, the number of handwashing stations without soap had increased by a remarkable 345%. Clearly, the importance of handwashing was effectively conveyed through the campaign, however, the use of soap was not.

Soap use, a “tough nut to crack”

Discussions with government and development partners [2] have led to two possible explanations for these puzzling results. Firstly, many Indonesians eat with their hands, and some find it unpalatable to eat with a hand smelling like perfumed soap. Secondly, the religious practice of cleansing – which excludes the use of soap, is likely being melded with HWWS for improved health outcomes. This suggests that the reigning belief is that washing hands with water is “hygienic enough”.

To improve hygienic practice of households already with a handwashing facility (minus the soap), some entry points to consider for future interventions include:

• Marketing/promoting the use of odourless soap to address the challenge of washing hands before eating or food preparation.

• Working with religious leaders to encourage people to recognise the value of soap as hygienic practice, and to not conflate this with the religious practice of cleansing.

Clearly our experience in Lampung shows that to be effective, behaviour change campaigns do not only require adaptive management, and constant monitoring, as well – longer-term and intensive intervention strategies.

Notes

[1] In 2009, Curtis, Danquah, and Aunger published an 11-country review on the application of the social affiliation method as a strategy to improve handwashing with soap behaviour. Access abstract here.

[2] This topic was presented and discussed by the author during the WASH Futures Conference, Brisbane, 2018. Full presentation available here.