1.
Background
Diarrhea kills about 1.8 million children every year (WHO 2004). Human excreta is the source of most diarrheal pathogens and probably the most important moments at which hands should be washed with soap are after contact with human excreta and before handling food. A recent review of all the available evidence suggests that handwashing with soap could reduce diarrhea incidence by 42-46% and save at least one million lives worldwide.
Each year, Lower Respiratory Infections kill almost 4 million children, half of whom are under-five
(WHO 2004). Hands are an important link in the fecal-oral route of disease transmission carrying respiratory micro-organisms from the nose, mouth or anus to the respiratory tract. Studies have shown that handwashing with soap can reduce acute respiratory infections by 23%. A handwashing with soap campaign has particular relevance to Vietnam and Southeast Asia in the context of SARS and Avian Flu.
However, universally rates of hand washing with soap at key junctures are low. Further, research repeatedly finds that health messages are not motivational enough to promote proper hand washing with soap. Rather people appear to be motivated by the existence of sensory cues of contamination on the hands, a desire to be a good mother and/or to be socially accepted.
The World Bank and its Water and Sanitation Program, the London School of Hygiene and Tropical
Medicine (LSHTM), the Academy for Educational Development and the private sector, in collaboration with USAID, UNICEF, and the Bank-Netherlands Water Partnership are implementing a global initiative aimed at promoting the use of handwashing with soap in developing countries. Successful initiatives are ongoing in Ghana, Peru and Senegal with new partnerships emerging in Benin, Ecuador, Nigeria,
Paraguay and Nigeria. Vietnam is the first country in Southeast Asia to launch this exciting initiative.
In Vietnam, the Ministry of Health (MOH), the Water and Sanitation Program (WSP), and the World
Bank mission, in collaboration with other public and private partners, propose to develop a PPPHWI, with the overall objective of improving the health of populations at risk of diarrhea through a publicprivate partnership promoting handwashing with soap.
2. Rationale for handwashing in Vietnam
The rationale for proposing such an initiative in the country is:

Acute Respiratory Infections (ARIs) are the leading cause of childhood illness in Vietnam. The DHS
2002 survey estimates that 20% of children under 3 will show symptoms compatible with ARIs

within the last two weeks. Pneumonia and acute bronchitis accounted for nearly 450,000 hospital cases and caused over 30% of hospital deaths in 1998.

Diarrheal diseases are the second leading cause of childhood illness. According to the DHS 2002 survey, 11 of out 100 children under 5 will have at least 1 episode of diarrhea within the last two weeks. In 1998, diarrhea accounted for roughly 18% of all hospital admissions and over 250,000 hospital cases.
 Reliable data on handwashing with soap after using a toilet or after cleaning up a child are scarce in
Vietnam. However, a Knowledge, Practices and Coverage survey by the American Red Cross revealed that in central Vietnam, only 17% of households having soap used soap for washing hands at least 2 critical times in the last 24 hours. We know that people tend to over-report handwashing practice, so the actual figure is probably closer to the 3% rate observed by AusAID in a small study in
Cuu Long Delta region. During informal discussions with community members, mothers reported using soap when theirs hands were visibly dirty or smelly but did not mention after the toilet or after cleaning up children.
 Furthermore, most hygiene promotion initiatives in Vietnam have in the past focused on the provision of water and sanitation facilities, good storage methods and water treatment but not on hand washing.
Little is therefore known about the availability, affordability and desirability of soap, especially for use after contact with excreta, in rural, semi–urban and mountainous areas. There is a need to make a connection between hygiene promotion/provision of water and sanitation facilities on one hand and the production and distribution of affordable soap on the other hand.
 Little is known about the retail and distribution side of soap especially why and how widely it is stocked in retail outlets and the supporting distribution and supply chains.
 Private commercial firms and the public sector will likely find it mutually beneficial to work in partnership for public health goals.
 Public agencies stand to gain by involving soap manufacturers in their programs through gaining expertise and capacity in the design of effective behavior change programs for health.
 Industry stands to gain by selling more soap through an expansion of their market into more households and by better market penetration towards poorer households.
The objectives of this research are 1) to provide the insights needed to design an effective communication program to promote handwashing with soap and 2) to provide national representative baseline data on rates of handwashing for monitoring and evaluation. The research should focus primarily on behaviors of mothers with children under 5yrs, which will be used for message development and M&E.
The specific objectives of the assignment are:
1.
To record and gain insights into handwashing behaviors among mothers of children under 5yrs;
2.
To record and gain insights into availability of factors such as sanitation, water and soaps in and around the household;
3.
To understand motivating factors and barriers to hand washing with soap at any time and how these might be applied to key junctures (after contact with feces and before contact with food);
4.
To focus on mothers of children under 5 and segment that target audience;
5.
To document current channels of communication, of all kinds, particularly for the types of messages that might motivate hand washing with soap.
4. Methods

The study requires the employment of both quantitative and qualitative research techniques which should include focus group discussions, behavior trials followed by in-depth interviews, and structured observation followed by a questionnaire for data collection (as set out in the table in

section C of the annex), as well as the compilation of available existing data. Subsequently, results from qualitative data analysis will be utilized by others, in designing a communications program and quantitative data results will be used primarily for monitoring and evaluation.

The study will primarily consist of about 500-600 structured observations to establish a handwashing with soap baseline. For mothers/caretakers: handwashing with soap rates after using the toilet, before feeding a child, before eating, before preparing food.

Detailed study designs will be proposed by the Consultants and finalized in collaboration with the
MOH, Department of Preventive Medicine and the technical advisor, Nga Kim Nguyen,
Handwashing Initiative Coordinator.

A potential methodology for formative research techniques is explained in the Handwashing
Handbook, www.globalhandwashing.org



The agency will be responsible for the following:

Detailed study design in collaboration with MOH and WSP (that is, the client) and their technical advisors;
Set up and manage the study;
Logistics arrangements i.e. travel, accommodation, allowances, communications, and stationery;
Developing an appropriate data-base for data entry with the support of the client and their Technical
Advisor;

Assurance of quality of field work/data collection and data entry;

Analysis of the results (In-depth analysis including relationships between variables);

Production of a final report, draft and final versions, in 15 copies.
It is the responsibility of the agency to recruit, train and supervise a suitable team of field workers.
The Global Hand Washing Partnership may choose to provide technical support to the agency at key stages of the assignment which may include: the appraisal of technical submissions; review of proposed detailed study designs and guidance from prior experience; assistance with the training of field workers during piloting of instruments, fine tuning and finalizing of proposal; monitoring of the quality control system to evaluate progress and refocus if necessary; review of first draft report and recommendations for production of the final report.
6. Qualifications and selection of the contracted agency
The Consultant will be a professional consumer or market research organization with track record of at least 5 years of consumer studies in Vietnam. The Consultant’s team will need to demonstrate their experience both in quantitative and qualitative research techniques. Commercial/industry sector experience is essential. Experience working with ethnically diverse populations is also desired.
The qualifications of the proposed study team will make up a part of the Consultant’s technical and financial proposal and should be as follows:
1 Statistician with:
 track record on quantitative surveys and analysis

 familiarity with fast moving consumer goods
 experience in cleaning products
 knowledge of Vietnamese
1 Social Scientist or Anthropologist with:
 track record in using qualitative methods and data analysis
 familiarity with industry
 experience in cleaning products
 knowledge of Vietnamese
Quantitative field workers should

Have at least one year of experience of field work

Be female

Be fluent in Vietnamese
Qualitative field staff should

Have at least two years of experience of field work

Be female

Be fluent in Vietnamese

All qualitative field staff should have significant experience in in-depth interviews and focus group discussions
WSP requests that special attention be given to: 1) the development of a detailed work plan including quick mobilization of field staff, 2) a system for the management and quality assurance of the study, 3) complete CVs of the proposed staffing. All proposed staff must work directly on the Consumer
Research/Baseline Study.
7. Outputs
The final outputs will include:

Cleaned and fully referenced electronic data sets in an agreed format with copies of the original data collection forms in English;

Full transcripts of all in-depth interviews and focus group discussions in an electronic format in


English;
A presentation of main findings and results at stakeholder workshop in Hanoi in English ;
A 50 page document in 15 copies with detailed findings in English and Vietnamese (draft and final
English reports must be edited by a native-English speaker; costs for English Editor must be included in the budget breakdown);

An 8 page illustrated summary document in English and Vietnamese in 15 copies, suitable for general consumption and an electronic version (in English and Vietnamese) of the summary document suitable for posting on websites.
The main report will include the following chapters:
I. Approach
II. Methods
III. Implementation schedule
IV. Results set out using the framework table in the Annex
V. Conclusion and Recommendations
Annexes

The report will contain graphics as will be needed. Annexes will contain all relevant background information for the study that is not necessary in the body of the report.
All Outputs will be presented in both electronic form (programs to be agreed with WSP) and paper copy.
All Outputs will be presented sequentially in framework, draft and final forms, allowing time for MoH and WSP to make comments on each version. The Consultant will incorporate comments to the extent possible or as agreed otherwise with WSP.
It is expected that the work will last a maximum of 11 weeks from appointment of the Consultant to final report. The firm is required to estimate a detailed work schedule for each phase as part of the technical proposal. A suggested schedule for each phase is set out in the table below:
Output

Set up and training

Inception report with refined methodology, and pretested materials

Field survey (3 weeks)

Analysis (2 weeks)

Topline presentation at stakeholder workshop

Draft report

Final report
Duration
Week 1
Week 2
Week 3 to 5
Week 6-7
Week 8
Week 9
Week 11

To help the Consultant develop a proposal, additional details on our requirements are set out below:
1.
While this is a public-sector led program the research should not be considered in this manner.
Rather we would like the Consultant to approach it as a private sector consumer study. Thus we would like the Consultant to utilize staff with experience working for the commercial sector in the areas of laundry and /or personal care and nutrition, if possible. Relevant experiences should also relate to this sector rather than to development.
2.
While seeming mundane, hand washing is not as simple to research as might be expected. It can be very difficult to get a true measure of hand washing behavior and motivations for it by quantitative questionnaire alone. People commonly over-report the practice and attempt to cite rational reasons for washing hands or not. Thus structured observations (see ToR) are necessary to measure actual rather than reported behavior, while projective qualitative methods are needed to really understand consumer motivations for the behavior.
3.
Relating to the above, the study is to have a strong qualitative component to better understand
(potential) motivations for hand washing with soap and thus guide the development of a highly sophisticated and effective creative strategy to promote hand washing with soap among women with children under 5 years across Vietnam. For the qualitative research, we are interested in exploring individual and household as well as community factors that affect mothers’ decisions to wash their hands with soap. For example, Community Total Led Sanitation initiatives establish community norms of disgust to discourage open defection.
1
4.
For the qualitative component, we suggest the inclusion of roughly 50 Behavior Trials followed by interviews, 16 Focus Group Discussions and a few In-Depth Interviews, if needed.
5.
In the quantitative component, we have outlined the key methodologies and recommend between
500-600 structured observations taken from both rural and urban households from the eight regions of Vietnam. The research sample should focus on surveying households of lower socioeconomic status. While we recommend which research tools should be used for the study, your proposal should necessarily include detailed examples of (projective) methods and lines of questioning that will be used in order to adequately achieve each of the individual project objectives.
6.
In the case of the quantitative research we will provide an initial generic structured observation and questionnaire design which we may work with you on, post-negotiation, to adapt, enhance, pilot and finalize it.
A draft of these is included in Annex B in order to indicate the kind of data to be collected. The primary objectives of the M&E tools, as currently designed, are to measure and understand hand washing practice and what determines it, how it changes over time, and relationships between hand washing practice and reported rates of diarrhea and respiratory infections among children under 5 years.
7.
For the above reasons, it is important that the Consultant’s proposal include both qualitative and quantitative personnel and research history.

8.
In order to allow effective negotiations, please ensure that your net and fully-inclusive budget is fully broken down to display all individual costs including salaries, travel, per diem and incentives to informants following the template included in the RFP, and including all taxes and duties.
9.
The MOH will play a significant role throughout the research process including: review of proposal submissions, providing input into the technical design of final tools, attending training of field workers and monitoring data collection. Their active engagement should be included in the Consultant’s proposal, as well as identification of opportunities for MoH on-the-job training and awareness and capacity building.
10.
Results from this research study will provide insight into consumer demand for soap, which will be compatible and interface with the Asian Development Bank’s, Marking Markets Work for the
Poor program’s future research study on the retail supply chain for soap.

Issues
The following sets out the framework for the formative research on handwashing and is intended as guidance for the Consultant in designing and conducting the research.
Notes
1. What are current handwashing practices?
Data Source
/Method
1.1 What are the handwashing practices of child carers (at key junctures)?
1.2 What are handwashing practice of other family members (at key junctures)?
1.3 What soap (laundry v.s. beauty soap) or other agent is being used?
1.4 What is the source of water?
2. What drives and facilitates handwashing?
2.1 Drivers
What motivates domestic hygiene, bathing and handwashing with soap?
When is handwashing practiced? – With/without soap?
Specific cues and occasions for people to wash their hands
Reasons for not using soap at key handwashing junctures? i.e. psycho-social inhibitors to soap use – cost, smell, drying of skin…
How and when was handwashing learnt? Who taught it?
What are the attributes of a good handwashing soap?
Brand ranking of both soaps & their attributes for handwashing (ask why ranked like this) and of handwashing practices
Ranking of hypothesized drivers/concepts (status, nurture, disgust, aesthetics, attractiveness)
Images/beliefs concerning cleanliness/dirtiness, healthy/non healthy person, hygienic/non hygienic…
Rules for soap use within the household
2.2 Environment [why are the next two important here, will this not be assessed in the baseline and impact surveys?]

Water supply: Where, Type, Access (cost, distance, who), Storage

Sanitation facilities: Where, Type & Access
(including for children), Presence of fecal material in the yard?
Handwashing facilities [yes, is important, see comment under 1.]: What is it? (probe) Where is it?/availability - Distance from toilet, Storage place of
Quantitative representativ e sample on handwashing practices using
Structured
Observation
Behavior trials
In Depth
Interviews
FGDs
Household survey
Structured observations
In depth
Interviews
FGDs
Note 1: Refer to Draft Concept Notes on
M & E. To be provided by HW
Coordinator.
Note 2: The specific occasions for handwashing to be recorded depend on the exact objectives of the handwash program.
Note 3: Structured observation needs to be designed to capture all handwashing events at key junctures.
Note 4: A driver is a psycho-social motivator or inhibitor for hygiene behaviors and can be either positive or negative.
Note 5: When noting drivers for hygiene behaviors it is necessary to note motivators for –general hygiene, bathing, handwashing (without soap) and handwashing with soap separately, paying particular attention to handwashing with soap.
Note 6: Probe meaning of ‘clean’ and
‘dirty’ – are these defined visually, by feel, smell, or concepts of moral purity?
The environment refers to the external conditions that facilitate or hinder handwashing with soap. See the annexed note on Handwash Motivation (annex
D).

soap, Status, Access
3. Who are the target audiences?
3.1 Who buys the soap?
3.2 Who decides about soap buying?
3.3 Who influences the buyers and decision makers?
FGDs
In depth interviews
Household survey
4. How target audiences communicate?
Exposure and reach of all channels of communication including modern and traditional
4.1 Time spent and media consumption moments
(quantitative data)
4.2 Reach of all traditional channels of information?
4.3 Reach of government channels of communication?
4.4 What programs do they like and why? what do they remember? (qualitative data)
4.5 Which adverts do they know and like, and why?
4.6 Which communication channels do they find the most credible?
Household survey
FGDs/IDIs
Commerciall y available media data
Households surveys
FGDs/IDIs
Note 7: Allow costs of consulting commercial databases.
Note 8.
Traditional channels may include churches, social organizations, women’s’ groups, markets, local events etc.
Government channels include contact with health services (e.g. vaccination coverage, maternity and post natal care), schools, agricultural extension, local authorities etc.
* EPI: Expanded Program of Immunization
** FGD: Focus Group Discussion, see annex C for a definition.