Health Education Research Advance Access originally published online on November 13, 2007
Health Education Research 2008 23(3):392-401; doi:10.1093/her/cym056
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Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana
1 Environmental Health Group
2 Hygiene Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
3 Community Water and Sanitation Agency
4 Business Interactive ConsultinG, Accra, Ghana
* Correspondence to: B. E. Scott. E-mail: beth.scott{at}lshtm.ac.uk
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Abstract |
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In 2003—04, a National Handwashing Campaign utilizing mass media and community events took place in Ghana. This article describes the results of the evaluation of the campaign in a sample of 497 women with children <5 years. The unifying message across all communication channels was that hands were not ‘truly’ clean unless washed with soap. The campaign reached 82% of the study population. Sixty-two per cent of women knew the campaign song, 44% were exposed to one channel and 36% to two or more. Overall, TV and radio had greater reach and impact on reported handwashing than community events, while exposure to both a mass media channel and an event yielded the greatest effect, resulting in a 30% increase in reported handwashing with soap after visiting the toilet or cleaning a child's bottom. Our evaluation questions wide-held belief that community events are more effective agents of behaviour change than mass media commercials, at least in the case of hygiene promotion. However, failure of mass media to reach the entire target audience, particularly in specific regions and lower socio-economic groups, and the additive effect of exposure, underscores the need to implement integrated communication programmes utilizing a variety of complementary channels.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsConflict of interestAcknowledgementsReferences |
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Diarrhoeal diseases and acute respiratory infections are among the leading causes of childhood mortality in low-income countries [1]. Many of these deaths and infections could be prevented through simple improvements in hygiene behaviours, especially handwashing with soap (HWWS). Results from a meta-analysis suggest that HWWS may reduce the occurrence of diarrhoea by 42–49% [2], while a recent cluster-randomized trial showed a 50% reduction in the occurrence of diarrhoea, respiratory infections and impetigo (skin infection) over a 6-month period of intensive HWWS promotion in the Karachi slums of Pakistan [3, 4].
However, HWWS at key junctures (after contact with faeces and before contact with food) are low both in high and in low-income countries [5]. In Ghana, structured observations revealed that prior to an intervention campaign, only 3% of mothers practised HWWS after defaecation, only 2% after wiping their infants’ bottom and <1% before feeding them [6].
Thus, a major challenge in public health is to promote the regular practice of HWWS at key junctures at large scale. However, behaviour change is complex and the evidence for a positive effect of traditional hygiene education in developing countries is limited [7, 8]. Increased knowledge may not necessarily transfer into safe practice [9]. While some small-scale programmes have succeeded in effectively changing behaviour, effecting behaviour change at scale remains a struggle.
In recent decades, health promotion programmes have explored the use of marketing techniques, an approach which appears to have met with more success, particularly in reaching large population groups [10]. In Ghana, we have been implementing a national handwashing promotion campaign utilizing a commercial marketing approach, focussed upon increasing awareness and motivation to HWWS through appealing messages promoted via a combination of mass media and interpersonal channels. Ghana is the first of a series of countries to implement such an approach. Other countries are at various stages of the programme development and implementation process, but Ghana is the only country at the evaluation stage. Other countries utilizing this approach include Peru, Senegal, Nepal, Vietnam, Columbia and Tanzania (see www.globalhandwashing.org).
While Pinfold [11] has reported an analysis of the effect of different communication channels (excluding mass media) on hygiene behaviours, few researchers to date have reported a comparison of the effect of mass media and community-based activity within a single hygiene promotion intervention. In this paper, we present results from our evaluation of activities of the Ghana Hohoro Wonsa/‘Truly Clean’ campaign. The aim was to investigate which communication channels (alone or in combination) were most effective in reaching mothers of children <5 years of age and which had the strongest impact on self-reported HWWS.
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Methods |
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Description of the ‘Truly Clean Hands’ campaign
In December 2003, the National Truly Clean Hands campaign began in Ghana utilizing mass media channels across the entire country and community events to reach audiences in 5 of Ghana's 12 regions. Activities ran for 6 months and included the promotion across three major communication channels (TV, radio and community events) of the single key message that ‘without soap your hands are not truly clean’. Print materials such as posters, billboards and stickers were also used.
The campaign strategy was developed in partnership with the professional advertising agency Lintas, Ghana (part of Lowe Worldwide), through a thorough process of in-depth, qualitative consumer research, creative development and pilot testing of materials with the target audience (mothers with children under 5 years).
The consumer research consisted of a cross-sectional survey of 536 randomly selected mothers and an extensive qualitative component comprising 10 focus groups, 30 in-depth interviews and 50 behavioural trials with mothers of children <5 years. This research, which is discussed in more detail elsewhere [6], revealed that mothers’ hygiene behaviours were largely driven by a fear of contamination (disgust), a desire to care for their children (nurture) and to belong within society and respond to social norms (social acceptance). Health issues were not found to be strong motivators for hygiene behaviour. Knowledge of the optimal junctures for handwashing (from a public health perspective) was high. The lack of regular HWWS at key junctures appeared to be predominantly due to habit, the failure to perceive a sense of contamination in the absence of sensory cues of dirt on the hands and a belief that water alone was good enough to clean them [6]. These same hygiene motivations have been reported in other settings and are forming the basis of large-scale hygiene promotion campaigns in other low-income countries [5].
Accordingly, the creative development and subsequent campaign focussed on strategies, not to increase hygiene knowledge but to make contamination after contact with faeces ‘real’. In the radio adverts, women talked about people eating ‘something’ and ‘more than just rice’ when they visited the toilet and did not handwash with soap. The TV commercials showed a purple glow on the hands of mothers and children after toilet visits which was not removed through handwashing without soap, and in one advert was transferred to food about to be eaten by a child. The radio and TV commercials contained no reference to germs. They aimed at evoking feelings of disgust and the desire for cleanliness, instead of providing an educational message.
In community events, mothers pressed their hands onto bright white towels after handwashing with just water and then with soap, hands leaving traces of dirt on the towels unless they were washed with soap. Again, no explicit mentions of germs, disease or health were made, unless raised by the participants themselves during accompanying question and answer sessions.
The different communication channels were linked by a common slogan and a specifically composed handwash song (‘hororo wonsa’—truly clean) which was played in the background of TV and radio adverts and was sung by participants at community events (the mass media commercials can be viewed at www.globalhandwashing.org). Thus, there was a common message across all communication channels that after visiting the toilet or cleaning a child's bottom there remained things on your hands that could be removed unless the hands are washed with soap. All messages and materials were tested with focus groups before final production.
The main campaign took place from December 2003 to the end of May 2004. Television adverts were aired at prime time in English and Twi six times daily across three major TV networks. Radio adverts were broadcast at prime time six times daily, in 10 local languages across 18 stations. One hundred and thirty-two professional direct consumer contact (DCC) events were held in strategic community centres across 5 of Ghana's 12 regions. The Community Water and Sanitation Agency (GCWSA) complemented these with launch activities across all 12 regions and in 120 of the 138 districts before the evaluation. Thirty-two billboards were placed nationally and posters and stickers distributed at events and via schools and GCWSA extension services.
The evaluation commenced in late July 2004, fieldwork being completed by the end of September.
Campaign evaluation
The campaign was evaluated using a structured questionnaire developed in collaboration with GCWSA and the market research agency (Business Interactive Ghana) and covering issues of reach, message recall, interpretation and reported behaviour. The questionnaire was piloted among a convenience sample of 60 women, to test it for ease of execution by the fieldworker and comprehension by the respondent. Adjustments were made accordingly before final execution. Where translations were used, the questionnaire was both translated into local language and back translated.
The questions on reported handwashing behaviour were identical to those used in the consumer research cross-sectional survey prior to the campaign [6]. Women were asked to name occasions when they wash their hands with soap. The questionnaire can be accessed at www.globalhandwashing.org.
The questionnaire was administered during face-to-face interviews with a random sample of 497 mothers of children <5 of age living within the same five regions in which the pre-campaign survey had been conducted and living in districts in which DCCs had taken place. The regions were chosen to represent the five major socio-geographic zones in Ghana. Within the districts, participants were chosen using the random walk method. Sampling was stratified by region. Within each region, the sample of households selected was proportional to the population size of the region. Household heads were asked for permission to carry out interviews.
This questionnaire survey was complemented by a qualitative study consisting of 12 focus group discussions and 24 in-depth interviews conducted within the same sample frame as the structured questionnaires. The qualitative component was designed to gain insight into likes and dislikes relating to campaign components and the reported behaviour change.
Data analysis
Associations between demographic characteristics and exposure to different communication channels were compared using the chi-square test. The main outcome of the study was the difference in the prevalence of reported HWWS at predefined key junctures (i) between the pre-campaign and the post-campaign surveys and (ii) between women of the post-campaign survey exposed to different communication channels. The prevalence proportions were compared using the chi-square test. The prevalence differences were then adjusted using a generalized linear model (binomial family, identity link function). The adjusted effect of different communication channels on reported HWWS was tested using the likelihood ratio test.
The population attributable fraction (PAF), i.e. the proportion of reported hygiene behaviour at key junctures in the total population attributable to exposure to a channel in the absence of bias, was calculated as PAF = prevalenceexposure x (prevalence ratio – 1)/[prevalenceexposure x (prevalence ratio – 1) + 1] [12]. As the multivariable analysis showed only limited confounding by education and water supply, the unadjusted effects were used for the calculation of the PAFs. Since survey participants were only sampled in districts where community events had taken place, the reference population for the PAFs is the population of these districts. STATA 8.1 was used for all calculations.
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Results |
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The socio-demographics of the sample are shown in Table I. This shows that around half the women were between 26 and 35 yrs old, only had primary education and had three to four children. Over half of them relied on public water pipes or hand dug wells as water supply.
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Communication reach
Seventy-one per cent of women reported to have heard of the Hohoro Wonsa campaign. However, the answers given to interview questions on campaign details revealed that an additional 11% had been exposed to the campaign resulting in a total exposure of 82% (Table II). Sixty-nine per cent of all women knew the Hohoro Wonsa song, and 48% could sing it spontaneously. Figure 1 shows the percentages of single and multiple exposure to different campaign channels. Forty-four per cent of women were exposed only to one channel, whereas 36% were exposed to at least two channels. Table II shows that the TV campaign reached over half of the study population. Radio also achieved widespread coverage. As expected, exposure to community events was less common. Exposure to print materials (posters and stickers) was very low (<3%).
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Exposure to the TV and radio campaigns was associated with higher education and improved water supply indicating a higher socio-economic status among those reached by mass media channels. In contrast, exposure to community events was not associated with education and water supply, suggesting that DCCs succeeded in reaching mothers of lower socio-economic status.
There were significant regional differences in coverage for all communication channels. The differences were especially pronounced for community events and TV.
Impact of the campaign on reported HWWS behaviour
In the interviews of 536 mothers during the consumer research phase prior to the campaign, mothers had been asked ‘at what times do you wash your hands with soap’. Mothers interviewed in this evaluation were asked the same (unfortunately the pre-campaign survey did not include the option ‘before preparing food’ and ‘after cleaning child bottom’). Table III shows that compared with the pre-campaign survey, reported HWWS was higher after the campaign in the entire study population including the unexposed group.
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The analysis of joint exposure effects showed that for nearly all key junctures, there was a significant interaction between the different combinations of communication channels. The combined effect of two communication channels on reported behaviour was consistently lower than would have been expected assuming the effects to be additive. Thus, in Tables IV and V all effects are presented stratified by single or multiple exposure.
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Table IV shows that single exposure to each of the three communication channels increased reported HWWS at most junctures. Exposure to the radio advert was associated with increase of >10% of reported HWWS after all junctures. Exposure to the TV advert strongly increased reported HWWS after visiting the toilet and before preparing food, but did not increase reported HWWS related to childcare. Attendance of DCC markedly increased reported HWWS related to childcare, but had little effect on the other occasions. Adjusting for level of education and type of water supply slightly decreased the effect of the communication channels on HWWS at most junctures.
In general, the PAFs of exposure to TV and radio are much higher than those for DCCs, despite purposive sampling to cover only those districts where DCC events had been implemented. However, the PAFs of DCCs for infrequently reported key junctures like HWWS before child feeding (15%) and after cleaning a child's bottom (30%) indicate that DCCs may have had some impact on HWWS behaviour at the population level.
Combined exposure to both mass media channels (radio and TV) did not result in a further increase of reported HWWS compared with single exposure to radio or TV (Table V). Since there was a little difference between those exposed to DCC and radio or TV, and those exposed to all three channels, these combinations were collapsed into one group (i.e. any combination of channels that includes DCC) (Table V).
In contrast to the combined effect of radio and TV, combined exposure to DCC and either radio or TV or both was associated with strong and statistically significant increases in reported HWWS after all key junctures that persisted after adjustment for level of education and type of water supply.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsConflict of interestAcknowledgementsReferences |
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Our analysis suggests that the Truly Clean National Handwashing Campaign strongly increased awareness of the importance of HWWS in Ghana and may have contributed to establish HWWS as a social norm. Surprisingly, the impact of promoting HWWS through single mass media channels was similar, if not greater, than that of community events. The greatest effect on reported HWWS was achieved in those individuals exposed to community events and at least one mass media channel. It is possible that the additional benefit of such a dual exposure was due to the staggering of the campaign activities, whereby events were not hosted until 3 months into the campaign, allowing for an initial increase in awareness via mass media before interpersonal activities took place. Alternatively, it may simply result from the additive effect of exposure to increasing numbers of channels as reported in other studies such as evaluation by Kim et al. of a contraceptive campaign targeting men in Zimbabwe. Kim et al. [13] found a clear increase in reported behaviour change with exposure to increasing numbers of communication channels (29% men exposed to four channels reported change compared with 16% of those exposed to two to three and just 2% of those exposed to a single channel). However, there was no enhanced effect of dual exposure to TV and radio.
While few hygiene promotion studies have investigated the impact of different (combinations of) channels, many past studies in the area of sexual and reproductive health have found interpersonal communications such as community events to be significantly more impacting on reported behaviour change than mass media (e.g. [14]). However, our study suggests that mass media was equally as effective as community events at influencing reported behaviour in the case of a hygiene promotion campaign. Further, the reach of mass media is far greater than that of community events (see PAFs in Table IV), strongly supporting the central role of mass media in national hygiene promotion campaigns. Indeed, the limited ability of interpersonal communications to achieve a high reach has frequently been cited by health promotion programmes [13, 14]). It is also notable that while adverts can be costly to develop, the cost per head reached of mass media campaigns tends to be lower than for events due to the low population coverage achieved via community events. This suggests that the use of mass media in hygiene promotion campaigns, providing the materials, have been carefully developed and tested with the target audience at multiple stages in their development and that messages are aired at the peak viewing time of the target audience (in order to achieve reach) may be more cost-effective than community events. This likely holds true for a wider range of health promotion campaigns, though in sexual health the subject matter may be too sensitive for reliance on mass media alone.
Nevertheless, community events appeared to be useful in reaching communities of low socio-economic status and in remote regions (Table II). Even within mass media the reach of the two major channels is variable. Ashanti region showed relatively low exposure to radio and Western and Volta relatively low exposure to TV. Further, we currently cannot be sure of the sustainability of the impact achieved by mass media. The five-country study by Cairncross and Shordt represents the only documented example of sustained behaviour change following a hygiene promotion intervention and relied on interpersonal, community-based channels [15].
Community events may achieve their effect by building a sense of peer pressure/support among those who share the experience. On the other hand, TV is often watched communally in Ghana (ownership is much lower than viewership) giving the opportunity for social interactions while watching. Our qualitative data suggest that the commercials stimulated discussions among women.
Thus, as advocated by other authors (e.g. [11]), a fully integrated multichannel approach remains important for ensuring widespread reach. In terms of longer-term sustainability of message delivery, it is also important to incorporate messages into the existing government channels such as schools, community health worker networks and women's groups. Such institutionalization has been an integral part of the Ghana programme to date and the second phase is scheduled to focus on the development of a district-level hygiene promotion package that can be delivered via local community networks and shares the same unifying messages as the other programme components.
Generally, the varying results for the impact of each channel, particularly in the case of TV and radio on the reported occurrence of handwashing at the five critical junctures, correlate with the key focus of the ‘story’ portrayed by each communication channel, lending support to the importance of spending time, effort and resources on carefully developing materials to clearly portray and promote the desired behaviour change. For example, the strong effect of TV commercials on HWWS before preparing food and after visiting the toilet is likely explained by the use of a powerful visual image of a child about to eat food with a purple stain on it carried on the mother's hands from the toilet into the food in one advert. Likewise, the failure of TV to elicit marked effects on handwashing after cleaning a child's bottom and before feeding a child, while radio and events succeeded are likely due to the absence of an infant in the TV advert, whereas the radio storyline talked of a mother failing to wash her hands after cleaning her infant's behind and the emphasis events was placed on all the critical times to HWWS.
While this analysis provides strong evidence that the campaign increased awareness about the importance of HWWS at critical occasions, its impact on actual behaviour remains uncertain. Quantifying the change in hygiene behaviour is difficult and presents with many methodological problems. The best method available so far is structured observation of household members [9], but observation by trained staff on its own is likely to affect the hygiene behaviour observed [16]. Prior to the campaign, we conducted a study on handwashing behaviour in Ghana using structured observation. Following the second phase of communications scheduled for 2006, designed to promote ‘sustained’ behaviour change, we have planned to measure observed HWWS behaviour. This will allow us to investigate observed rather than reported behaviour change rates. However, there are some indications from the qualitative component of the evaluation that the campaign may have changed actual handwashing behaviour, as exemplified by the following two quotes:
I like the handwashing advert with soap because it easily comes to mind and it's a constant reminder (Woman, Greater Accra).Prior to our campaign, handwashing was largely a social norm, but the inclusion of soap in the ritual was not [6]. Many respondents reported that they were left deeply impressed by the campaign content, previously believing that water alone was enough to clean hands after visiting the toilet and before eating. Having not known the importance of soap, many said that they felt uncomfortable when exposed to the campaign materials which now make them realise that they must use soap.I felt uneasy and it reminds me to wash my hands with soap anytime I visit the toilet (Woman, Volta Region).
While other studies (e.g. [15 18]) have highlighted that correlations between exposure to and impact of communications may not only be due to the influence of messaging on behaviour, but due to a tendency for the highly motivated to seek out, listen and recall campaign messages, our qualitative work did not support the presence of this bias.
A limitation of our study is that the evaluation took place within 3 months of the termination of communication activities. Thus, while we may detect some immediate effect on behaviour, we cannot be sure that this effect will be sustained. Other studies such as the ‘1% or Less Campaign’ promoting conversion from full- to low-fat milk consumption in West Virginia, USA, have found that the positive impact of mass media campaigns have not been sustained when commercials no longer continued to air [19]. Future studies should attempt to map the erosion of programme impact over time and it is certainly hoped that in this case further evaluations will be made.
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Conclusions |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsConflict of interestAcknowledgementsReferences |
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Our analysis suggests that in the case of hygiene promotion, mass media may have a far higher impact at the population level than community events, without being less effective on the individual level. This hypothesis will be tested when changes in actual behaviour are measured following the second phase of the hygiene promotion programme. However, the failure of mass media to reach the entire target audience, particularly in specific regions and socio-economic groups, also leaves us committed to the need to implement fully integrated communication programmes utilizing multiple channels in order to ensure that widespread coverage is achieved.
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Conflict of interest |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsConflict of interestAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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The authors would like to thank Dr Val Curtis for her continuous commitment to the Ghana Handwashing programme and for reviewing drafts of this paper. Further thanks go to the field workers and data processors at BiG for collecting and processing the data.
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References |
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Received on March 29, 2006; accepted on June 28, 2007
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