WaterAid's Hygiene Behaviour Change Response to COVID-19

"As there is currently an unprecedented focus on handwashing and a high uptake in handwashing with soap, we have an opportunity to leverage multiple motives and change behaviours for an entire generation."

The international not-for-profit federation WaterAid is working to prevent the spread of COVID-19 by drawing on its experience in the water, sanitation, and hygiene (WASH) sector to implement at-scale hygiene behaviour change programmes. This document outlines its phased, evidence-based, behaviour-centric approach to hygiene response during COVID-19 - examining the theory of change behind this approach, reflecting on challenges and lessons learned, and offering a series of recommendations. Through this response to COVID-19, WaterAid aims to reach 99 million people in the 28 countries it works in across South Asia, Africa, and Latin America.

The first phase of WaterAid's response focuses on promoting 5 key hygiene behaviours: handwashing with soap, covering the mouth and nose when coughing or sneezing and wearing a mask in public places, maintaining physical distance, cleaning and disinfecting frequently touched surfaces, and staying home if you feel unwell. Using "do no harm" principles, WaterAid is using social, digital, mass media, and non-contact methods to promote hygiene behaviours, in addition to providing handwashing facilities with an effort to reach the most marginalised populations, consistent with a rights-based approach that attends to issues of equity and inclusion. In the second phase, WaterAid will support government-led campaigns for sustained hygiene behaviour change, including community-based activities, while continuing to promote the wider media campaign and installation of handwashing facilities.

WaterAid's hygiene behaviour change intervention package is designed to motivate people to practise the aforementioned 5 key preventative behaviours by changing their thinking on a sub-conscious level, changing the environment where the behaviour happens through the placement of behavioural products - e.g., visual cues and nudges to reinforce behaviours - along with changing social norms linked with specific behaviours for habit formation. WaterAid reviews the existing hygiene interventions in each country and redesigns these based on new insights that emerge from a creative process targeting the key behaviours. The resulting interventions are then implemented, making use of multimedia channels and disseminated in the appropriate spaces, whilst respecting physical distancing guidelines. Where possible, WaterAid considers motives and emotions that will change people's mindset and behaviours in the long term, such as:

• Affiliation: Bringing a sense of belonging and solidarity in the home and in society by practising key behaviours to reduce the spread of COVID-19.
• Fear: Washing hands and cleaning and disinfecting frequently touched areas to remove and kill the virus.
• Social status/pride: Minimising the transmission of COVID-19 by practising key behaviours as collective pride in communities and nations.
• Nurture: Practising key behaviours to protect their family, loved ones, communities, and the nation from COVID-19.
• Disgust (linked only with virus): Cleaning our hands and environment responsibly to eliminate the disgusting virus.

Having outlined the basic tenets of WaterAid's COVID-19 response, the document delves into WaterAid's approach to developing hygiene intervention campaigns. Using a behaviour-centred design (BCD) approach, WaterAid works with a multidisciplinary team, including design experts, social media teams, artists, implementors, and the intended population, as part of the creative process. While the formative research process usually involves spending time learning from each community, COVID-19 called for WaterAid to rely on previous research and rapid assessment surveys in creating a unifying concept under an umbrella brand that accommodates multiple behaviours. WaterAid offers 5 recommendations for programme design; for example: Expose people multiple times to the hygiene intervention, ensuring it reaches a significant number of the intended population (including the marginalised members) and helping create social desire for new behaviours. It is also important to create assets that are progressive and engaging to help avoid campaign fatigue.

The document then breaks down WaterAid's COVID-19 response into the following themes, providing country-specific examples and key recommendations for each:

• Promoting key hygiene behaviours at scale using non-contact methods (mass, digital, and social media): Sample activity: In Rwanda, WaterAid partnered with a group of young people to write and produce a series of radio dramas to motivate listeners about the vital roles handwashing and sanitation play in preventing the spread of COVID-19. Sample recommendation: Use celebrities, comedians, and artists: influential people as WASH ambassadors, whose messaging to promote behaviours will have a wide reach.
• Integrating hygiene promotion into health, immunisation, schools, and the private sector: Sample activity: In South Africa and Zambia, WaterAid is integrating hygiene with gender and women's rights programmes working on fighting domestic violence. Sample recommendation: Identify other organisations in your area where hygiene promotion can be integrated, and partner with the government or private sector to strengthen hand hygiene behaviour change for all.
• Making hygiene inclusive - developing hygiene programmes that are accessible for all genders, disabilities, and ages, and making hygiene relevant for people in different social economic settings: Sample activity: In Nepal, in areas where there is no access to FM radio, WaterAid is "miking" messages with the same jingle used on the radio and using sign language in television adverts. Sample recommendation: Ensure images represent diverse populations in different settings, with varying ages, genders, and abilities to show that handwashing is for everyone, without discrimination.
• Innovating hygiene behaviour change technology (e.g., handwashing facilities) and products (e.g., promotional package materials): Sample activity: In Bangladesh and Nepal, paddle-operated handwashing facilities have been installed in public places/institutions; WaterAid has developed a technical guide to support such installations. Sample recommendation: Make handwashing facilities visually appealing, with cues that appeal to people of all literacy levels to remind them of the steps for handwashing.
• Monitoring and evaluating hygiene programmes and sharing learning: Sample activity: In South Asia, WaterAid conducted a rapid assessment on hand hygiene behaviours to assess how economically poor, marginalised, and vulnerable groups receive and understand messages on handwashing with soap and water. (See Related Summaries, below.)
• Fostering collaboration and networking at country, regional, and global levels: Sample activity: WaterAid is a core partner for the World Health Organization (WHO)/United Nations Children's Fund (UNICEF) "Hand Hygiene for All" initiative, focusing on fostering hygiene behaviour change, advocating for the sustainable financing, and reimagining hand hygiene in society.

The document closes with WaterAid's reflections on making hygiene responses sustainable beyond the current pandemic - responding to challenges the organisation has faced and looking to the future. For example, some countries had difficulties implementing comprehensive response programmes due to political challenges; COVID-19 was not seen as an issue by some leaders, and elections resulted in large gatherings without physical distancing being enforced. Also, the actual sustainability of the overall hygiene behaviour change programme using non-contact delivery methods and durability of the new handwashing facilities is yet to be tested, as WaterAid is still implementing the response.

However, despite these and other challenges outlined, WaterAid concludes: "Now, as we move forward and transition from an initial rapid emergency response to long-term sustained behaviour change initiative, we have opportunities for new partnerships, increased funding, government commitments and a unique moment to make hand hygiene for all a priority."