Helping people get into healthy hygiene habits

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Children washing hands

Simple everyday actions to improve hygiene saves lives

It’s not easy to change the habits of a lifetime. So we came up with our behaviour-change methodology, Five Levers for Change (PDF | 4MB), to make good hygiene habits part of people’s daily routine. We use them in all our behaviour-change programmes: handwashing, toothbrushing and using toilets.

Our handwashing programmes drive handwashing behaviour change and also directly drive sales. When more people use soap regularly and have access to sanitation, the impact on health is significant and their use of soap increases. In fact, if everyone followed ideal handwashing habits – washing with soap before eating and after using the toilet – each person would use approximately 20 bars of soap a year. However, consumption levels are far below this, with 1.5 billion people using less than eight bars of soap per year.

All of our Lifebuoy activities focus on changing handwashing behaviour through a range of approaches: partnership-led on-ground programmes; mobilising support for handwashing across society and innovative new approaches to reach people with hygiene messages, such as our Mobile Doctarni programme.

Five Levers for Change

These five principles are the bedrock of our approach to changing people’s behaviour – and maximise our ability to make good hygiene habits part of people’s daily routine.

We wanted to find ways to encourage people to use soap on the five occasions that have the biggest impact on their health: washing hands after going to the toilet; before breakfast, lunch and dinner; and while having a bath.

Lever 1: Make it understood

Many people believe their hands are clean if they look visibly clean. Unfortunately, that’s not true.

Our ‘glo germ’ demonstration helps people understand that washing hands with water alone is not enough to get rid of germs. Ultraviolet light demonstrates how the germs can be left behind on their hands when they wash with water alone. Hands are washed again with soap and shown as germ-free under the same ultraviolet light.

Lever 2: Make it easy

For a new behaviour to become a habit, it needs to be seen as easy to do and to fit into daily routines.

We make it easy for people to remember when they need to wash their hands through songs, stories, diaries, rewards and daily sticker charts for children. These and other little reminders at home and at school help make handwashing part of children’s – and adults’ – daily routines.

Lever 3: Make it desirable

People don’t usually do something unless they want to. We want children to want to wash their hands. So we make it fun with our School of 5 comic books and stickers.

Studies show that people who commit to a future action in public are more likely to stick to it. Our Lifebuoy school programme uses the classroom soap pledge to foster commitment by asking children to stand up together in class and pledge to wash their hands.

Pledging is also an important part of our mothers’ programme, as it brings the family together to pledge to protect the health of their baby.

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School of 5: Superheroes to the rescue

Our flagship schools programme is a crucial part of Lifebuoy’s handwashing behaviour change programme. Children develop so much of their behaviour during their primary school years and are heavily influenced by their peers. In turn, children also take messages back to their parents and wider communities.

We make Lifebuoy’s School of 5 programme fun, as that’s the best way to get children to do something. And what could be more fun than superheroes?

We teamed up with specialist children’s communication agency, Yoe, to create Lifebuoy’s School of 5 comic book, which aims to make handwashing cool for kids. The five superhero characters – Biff, Pow, Bam, Hairyback and Sparkle – come to life in animations, radio shows, music, games, and school visits. They each have an important message to get across – encouraging children to use soap at the five key moments in the day: after going to the toilet; before breakfast; before lunch; before dinner; while having a bath.

Available in 19 languages, our School of 5 comic book has reached more than 300 million people worldwide. The large scale of the programme and the numbers of people reached have caused a paradigm shift in the programme’s ability to attract external partners, thereby increasing scale as well as connecting with hard-to-reach communities.

Lifebuoy’s School of 5 programme uses our Five Levers for Change (PDF | 4MB) methodology. These five principles focus on awareness, commitment, reinforcement and reward and they encourage making good hygiene habits part of people’s daily routine.

This work contributes to the following UN Sustainable Development Goal

  • Clean Water and Sanitation)

Lever 4: Make it rewarding

We want to make people feel good for improving their hygiene habits, so we reward good behaviour. For example, children get a reward or recognition if they successfully complete their handwashing diary for a full three weeks.

Lever 5: Make it a habit

Habits are created over time through repetition. Practising a habit consistently for at least 21 days helps to make it a permanent habit.1

That’s why we give children and mothers 21 day diaries – with rewards on completion. We also give teachers activities for 21 days so they repeat handwashing until it becomes a routine.

Tracking impact

Monitoring, evaluating results and learning from our programmes is a key focus area.

Measuring a socially desirable, healthy behaviour like handwashing with soap is very difficult. Most people know they should wash hands regularly, so there is a significant risk that people overclaim how much they are washing their hands if you simply ask them directly.

We have therefore had to find innovative ways to track what people actually do – not just what they claim to do.

Having run a series of evaluations of our programmes and partnerships over several years, we know the “gold standard” for measuring handwashing is using motion-sensor soap loggers. However, this method is expensive. And another effective evaluation method, direct observation, may cause people to act differently when they’re being watched. It also often misses important handwashing occasions, such as when children are at school or outside of the limited time people are observed in their homes. So we have tested and validated an alternative method of measuring handwashing with soap, a method that is both unique and robust: sticker diaries.

How do sticker diaries work?

Sticker diaries ask respondents to track a whole range of daily activities in pictorial form, with respondents not knowing which daily behaviour we are specifically interested in. A recent academic study2 confirmed that this methodology was less biased than other conventional methods of self-reporting behaviour.

This provides us with a series of methods that can be used for evaluation:

  • Sticker diaries, that prompt recall of a variety of behaviours and mask the true intention of the study
  • Trackers (or ‘motion-sensor soap loggers’) placed in bars of soap that capture behaviour at exact points in time, at any time of day
  • Weighing soap to provide an objective measure of the amount of soap used by households.

What happened?

Using this methodology we have seen a sustained increase in the frequency of handwashing with soap. In Indonesia for example, it went up from 53% to 75%.3 A clinical study in India showed that there were 25% fewer incidences of diarrhoea, 15% less acute respiratory infections and 46% fewer eye infections.4 Additionally, our on-ground and mobile neonatal programmes deployed in Kenya and India have shown significant improvement in handwashing with soap on key occasions.

In 2017, we teamed up with Oxfam to create a customised handwashing programme to reach mothers in an emergency setting after the Nepal earthquake. Results from a structured observation study showed significant increases in handwashing with soap before eating and preparing food (18% and 17% respectively). The programme also proved to significantly impact habits after using the toilet, with 45% more mothers observed washing their hands with soap.5

As part of the DFID-funded, four-year South Asia WASH (Water, Sanitation and Hygiene) Results Programme, the Lifebuoy School of 5 programme reached more than 17 million people. Six months after the programme ended, reports showed a 33% increase in knowledge of the five critical handwashing occasions and a 43% increase in handwashing with soap before dinner.6

Using the sticker diary methodology we saw a sustained increase in the frequency of handwashing with soap six months after Lifebuoy’s intervention in Indonesia, demonstrating the ability of our programme to deliver at scale and drive sustained behaviour change. Awareness of ‘five key occasions’ messages doubled and soap use increased significantly, even six months after the programme was complete. Before our intervention, 53% used soap at the key handwashing occasions. Immediately after our intervention, this rose to 75%. Six months later, the figure rose again to 78%, showing a lasting impact.

As part of the Millennium Villages Project Partnership with Unilever and the Earth Institute in sub-Saharan Africa, handwashing behaviour change and the effectiveness of Lifebuoy’s School of 5 programme was measured in Kenya and Ghana. Analysis from the study using electronic loggers showed that there was a significant increase of 22% in handwashing with soap among children who experienced the School of 5 programme compared to children in the control group. Sticker diaries corroborated these results. Among children who experienced the intervention also spent 40% more time handwashing each day.7

1 Based on a clinical trial involving 2,000 families in Mumbai, India during 2007 and 2008. Published in: Nicholson, Julie A., et al. An investigation into the effects of handwashing intervention on health outcomes and school absence using a randomised control trial in Indian urban communities - http://onlinelibrary.wiley.com/doi/10.1111/tmi.12254/pdf, Journal of Tropical Medicine and International Health, 2014 19 no.3: 284-292.

2 Schmidt, W.P., et al. Comparison of structured observation and pictorial 24h recall of household activities to measure the prevalence of handwashing with soap in the community, https://www.tandfonline.com/doi/abs/10.1080/09603123.2018.1511772, International Journal of Environmental Health Research, 2018, 71-81.

3 Based on results from a quantitative behaviour measurement study in Indonesia.

4 Based on a clinical trial involving 2,000 families in Mumbai, India during 2007 and 2008. Published in: Nicholson, Julie A., et al. An investigation into the effects of handwashing intervention on health outcomes and school absence using a randomised control trial in Indian urban communities - http://onlinelibrary.wiley.com/doi/10.1111/tmi.12254/pdf, Journal of Tropical Medicine and International Health, 2014 19 no.3: 284-292.

5 Lifebuoy and Unilever’s Chief Sustainability Office partnership with Oxfam, collaborating on a handwashing with soap behaviour change programme for communities affected by flood, earthquake or other type of emergency. The programme was piloted in Nepal following the earthquake in 2015.

6 DFID South Asia WASH Results Programme (SAWRP) 2014-2016.

7 Based on children in Ghana participating in our School of 5 intervention, in contrast to a control group who did not take part. The findings of this study were published in 2013 in the Journal of Tropical Medicine & International Health.

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