Hygiene is essential to the public health mission of reducing the transmission and consequences of disease. The sharp decline in deaths from infectious diseases observed in wealthy countries last century could not have been achieved without vastly improved public hygiene. Raising living standards allowed people to become more hygienic once hand washing was experienced in their homes, and soap became cheap enough to put at every sink. Eventually, the collective efforts of both the public health movement and private industry ensured that clean hands, clean homes, and clean lives, became a social norm.

Unfortunately, the story in poor countries could not be more different. By the end of the 20th century, two billion people still had inadequate access to sanitation, and one billion were without enough clean water to drink. Efforts at promoting effective hygiene have been piecemeal and ineffective. Though industry has succeeded in getting soap into almost every home, it has not consistently promoted good hygiene or handwashing to accompany their products.

This is a missed opportunity for public health. The two biggest killers of children in the developing world today are diarrheal disease and respiratory tract infections. The simple act of washing hands with soap can cut diarrhea risk by almost half, and respiratory tract infection by a third. This makes handwashing a better option for disease prevention than any single vaccine.

If developing countries achieved their 2015 millennium development targets for reductions in child mortality, this unfinished agenda of the 20th century would have been completed. Not only must water and sanitation become universal, but so must the habit of handwashing with soap. This requires Ministries of Health, Education, and Water, in addition to non-governmental organizations (NGOs) and community-based groups, to exploit every opportunity to promote handwashing with soap.

Moreover, private industry, which played such a large part in creating standards of good hygiene in rich countries, can do the same as it expands its business to Ghana.

Handwashing with soap can and must become commonplace in developing countries. To do this we have to:

• Make sure everyone knows the importance of handwashing

• Build alliances between the public and the private sectors

• Mobilize the necessary resources and expertise

• Use proven high-impact communications outreach to promote handwashing to a mass audience

• Demonstrate that measurable changes in behavior can be achieved cost-effectively especially in the century of various pandemic outbreak like the COVID-19.

In a world of competing messages aimed at people from all directions, only the most effective, best-designed campaigns will lead to behavioral change of citizens and occupants. ASKIN HANDWASH BUSINESS PLAN seeks to meet this challenge.

It describes a new approach to handwashing promotion in Ghana, building on the pioneering work of the Public-Private Partnership for Handwashing with Soap. It explains how the latest thinking in industrial marketing can be combined with the latest research in public health to provide powerful new insights to drive effective handwashing campaigns. It offers lessons from national programs in Ghana and other countries. Early indicators suggest that this may be the start of an exciting new field in public health in the 21st century

Several members of the Public-Private Partnership for Handwashing Initiative must be acknowledged for making this Business plan possible. We would especially like to thank Mr. Gerard Henk Van of the Netherlands PUM and the country coordinator of Mr. Ansu Samuel at Sunyani in the Bono region. The public sector partners, Mad. Akua Owusu of the Food and Drugs Authority – Sunyani department, Mr. John K. Kuma, CEO of the National Entrepreneurship Innovation Plan, Ministry Of Business Development, National Board For Small Scale Industries (NBSSI), Business Advisory Council (BAC) who provided expertise and technical advice. Finally, we would like to acknowledge the guidance and leadership provided by the Advisory Board of ASKIN SERVICES.

Handwashing is one of the most effective means of preventing diarrheal and communicable diseases. Evidence suggests that improved handwashing can have a major impact on public health in any country and significantly reduce the two leading causes of childhood mortality - diarrheal disease and acute respiratory infection. Because handwashing with soap can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine or hygiene behavior. Promoted broadly enough, handwashing with soap can be viewed as an essential do-it-yourself vaccine. Almost every household in the Ghana, regardless of economic status, must have soap. Handwashing with soap at key times, however, is not widely practiced. If the millennium development targets for reduction in child mortality are to be met, handwashing habits must be improved along with access to safe water and sanitation.

Improper hand washing contributes to more than 5,000 deaths in Ghana each year through the transfer of communicable diseases in restaurants, schools and hospitals (more than AIDS and breast cancer combined). Studies have shown that proper hand washing procedures in these environments could cut down the spread of disease by up to 75%. The greatest contributing factor to this problem stems from the inability of peoples hand washing in home and offices. Our products offer effective and affordable solutions for enforcing and ensuring hand washing compliance. Treatment of preventable diseases costs Ghana over Million cedi’s in direct costs each year.

ASKIN SERVICES is answering this problem and provides indisputable proof every time a person washes his or her hands. After washing occurs, the antimicrobial and antibacterial ingredient in our soap remains on the hands with clean look for some minutes. This allows people to conclusively verify at a glance whether hand washing has taken place. Our product offers a high level of assurance of sanitation compliance. The product is safe and meets all current regulatory requirements for soap.

The Global Public-Private Partnership for Handwashing has brought together various organizations and sectors to promote handwashing with soap on a large scale. The partnership includes:

• governments who, by prioritizing hygiene, enable handwashing to move from piecemeal, village-by-village, efforts to national programs;

• donor organizations who increasingly include handwashing in their water, sanitation, health, and education programs;

• the private sector which has brought state-of-the art marketing knowledge and techniques to the table;

• academic and scientific organizations who are contributing the latest behavior change theory and scientific evidence of the effectiveness of handwashing; and

• non-governmental and community-based organizations who are aiming to integrate handwashing messages into their own work programs.

The Handwashing plan lays out the experiences of this global partnership in a practical guide. While countries are still optimizing and experimenting with approaches, it is important to disseminate what is currently known. This way ASKIN SERVICES has begin programs and contributing to the national body of knowledge and experience in the fight against communicable diseases. Decision makers in ministries and funding agencies will also be of assistance in this plan for implementing these policies and programs to improve public health.

The approach to large-scale handwashing promotion covers the following components:

LAYING THE FOUNDATION FOR A NATIONAL HANDWASHING PROGRAM

To record success, these handwashing programs must address a recognized health need and have the support of key stakeholders. Government, industry, and donors can all offer unique resources which are necessary to ensure the success of a large- scale program in the country. Conducting a situation assessment and, where needed, making the case for handwashing on topics ranging from cost-effectiveness to health impact will give the handwashing program a solid foundation.

Understanding the Consumer

In order to change long-held habits related to behaviors such as handwashing, a firm understanding of the factors the drive and facilitate behaviors in target consumers must be established. This means putting the needs of the target audience - primarily mothers, guardians, teachers and caretakers of children under five years old as well as school-aged children - at the center and having their perspective determine the nature and scope of all promotion activities. Consumer research provides a baseline for measurement and understanding of the target audience by answering four broad questions:

1. What are the risk practices?

2. Who carries out the risk practices?

3. What drivers, habits, and/or environmental factors can change behavior?

4. How do people communicate?

Program Implementation

The results of consumer research drive program implementation including which environmental factors related to handwashing need to be addressed, what is the most appropriate and appealing way to promote handwashing and what is best mix of communication channels to reach the target audience. Implementation also includes the careful monitoring of the program and periodic evaluation and adjustment.

Ghanaians are encouraged to combine their creativity with existing knowledge in order to innovate and optimize approaches to large-scale handwashing promotion.

The Leading Causes of Child Mortality

The World Health Organization (WHO) estimates that diarrhea and respiratory infections are responsible for two-thirds of child deaths. UNICEF estimates that diarrhea alone kills one child every 30 seconds. The vast majority of child mortality occurs among the world's poorest populations in low- and middle-income countries.

Distribution of Global Child Deaths by Cause

Measles 2% AIDS 5% Malaria 13% Acute Respiratory Infections 32%

Source: WHO 2001

Handwashing with Soap

The Most Effective Vaccine against Childhood Infections?

Human feces are the main source of diarrheal pathogens. They are also the source of shigellosis, typhoid, cholera, all other common endemic gastro-enteric infections, and some respiratory infections: just one gram of human feces can contain 10 million viruses and one million bacteria. These pathogens are passed from an infected host to a new one via various routes. While the routes are numerous, they all emanate from one source: feces. While secondary measures (food handling, water purification, and fly control) may have an impact, far more important are the primary barriers - sanitation and handwashing - after fecal contact. These barriers prevent fecal pathogens from reaching the domestic environment in the first place.

Handwashing interrupts the transmission of disease agents and so can significantly reduce diarrhea and respiratory infections, as well as skin infections trachoma and Coronavirus. A recent review (by the WHO 2020 toward the combat of the Global Pandemic which is highly communicable and quickly infectious disease known as COVID-19)

suggests that handwashing with soap, particularly after contact with feces (post-defecation and after handling a child's stool), can reduce these infection incidence by 75-82 percent. Because handwashing can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine. Promoted on a wide-enough scale, handwashing with soap could be thought of as a ‘do-it-yourself' vaccine.

Two key actions isolate fecal material and prevent its reaching the environment and then the four F's. These actions are adequately disposing of adult and child feces and handwashing with soap after touching feces. Such touching occurs after using a toilet or when cleaning a child after defecation.

Some respiratory tract infections, including the SARS and current Coronavirus, are also transmitted via the fecal-oral route or simply on hands and contact with an infected person, so handwashing helps prevent these infections as well.

How should hands be washed? The evidence suggests that soap - any soap - and water adequately remove microbe- containing dirt from hands. Antibacterial soaps or other hand-sanitizing technologies have no additional advantage. Hands have to be fully covered with soap and then rinsed off which will show that the pathogens on the hand are washed away. Cleaning and wiping of hands after washing should be done with a tissue of piece of cloth that can be disposed off after usage.

Making the Case for Handwashing

If a handwashing program is to succeed, advocates will have to sell the idea to stakeholders, including government, industry, and potential funders. A SWOT (strengths, weaknesses, opportunities, and threats) analysis can determine which factors need to be addressed when engaging these stakeholders. First, the SWOT analysis looks at factors that can potentially be controlled by the stakeholders as potential partners in the initiative.

Second, external factors are assessed. These factors are outside the influence of the initiative but may have a positive or negative impact on the target audiences.

Third, stakeholders can be engaged in partnership in order to address weaknesses, build strengths, recognize opportunities, and mitigate threats.

Making the Case to Financiers

Though they technically work through governments, external support agencies often have their own agendas and usually their own funding cycles. As handwashing moves up the international list of priorities, more and more organizations are preparing to invest in handwashing promotion. To obtain donor support, it is important to determine donors’ priorities, where decision-making ability lies, and the mechanisms for obtaining funding.

Decision-making about the use of funds from bilateral agencies, such as the Danish International Development Agency (DANIDA) and the United Kingdom Department for International Development (DFID), is increasingly devolved to the national level, and accessing them may require lobbying at local, government, and international levels. Multilateral agencies, such as the United Nations Children’s Fund (UNICEF), may have programs that can support handwashing in our parts of the country. Lastly, World Bank loans for water and sanitation may specify expenditure on hygiene.

Financing Issues

Initially, funds are needed to cover the costs of a program start-up, which usually entails an individual and/or organization spearheading the initiative and acting as a coordinator. Funds are next needed for consumer research and then to hire a communications agency. The agency needs a budget for mass media, direct consumer

Consumer Research Process

Who carries out risk practices?

Handwashing programs target those groups whose handwashing behavior can have the largest impact on disease reduction: this is usually the caretaker who provides the child's ‘hygiene environment.' In most settings the primary caretaker is the mother of the young child; however, it is important to document who else participates - grandmothers, sisters, fathers, aunts, etc. School-age children may also form a target audience, not so much because they too may provide childcare, but because they are the caretakers of the future. Furthermore, they are more susceptible to behavior change and the uptake of new healthy habits. They can also act as enthusiastic handwashing advocates. Sometimes secondary target audiences (neighbors, fathers in some societies, elder children, extended family) will also be addressed because of their influence on the primary audience. For example, in some societies husbands decide how much to spend on soap or serve as the purchaser of these goods for their household.

What are the risk practices?

As noted, handwashing after contact with feces is usually the best way to reduce the risk of fecal-oral transmission of gastro-enteric pathogens. However, because this practice is unlikely to ever be universal and because sanitation may also be poor, it is also important to wash hands with soap before contacting, eating, or feeding food. This means that handwashing at three junctures is critical: after using the toilet, after cleaning up a child who has defecated, and before handling food. Now before touching any opening of the body requires a habitual washing of hands to be free from deadly viruses. While the important junctures for handwashing to prevent respiratory infection have not

been identified, more frequent handwashing is clearly protective against respiratory illness as well.

It is essential to have reliable data on actual rates of handwashing with soap in any particular setting in order to determine the scale of the problem and set quantitative improvement targets. Such baseline data also provides a point from which to measure change in handwashing habits over the life of a proposed program.

Unfortunately, actual handwashing behavior is very hard to assess reliably. Handwashing habits are generally private and are ‘morally bound': people fear they will be judged harshly if they admit to a weakness in their hygiene practices. Asking people if they wash their hands with soap consistently results in overestimates of actual behavior. For example, in Ghana 75 percent of mothers claimed to wash hands with soap after toilet use when asked, but structured observation showed that only 15 percent did so. The only feasible and reliable way to obtain a valid measure of handwashing practice is through direct observation, which requires a trained observer spending several hours in the wash centers, observing and recording events of interest in some homes as well. Well-trained and supervised fieldworkers are required for consistent and reliable results.

What can change behavior?

Three key forces are involved in behavior change: drivers, habits, and the environment, which can facilitate or hinder behavior change.

Lowering barriers in the environment so as to facilitate change;

Transforming old habits into new ones; and

Finding drivers that can create new habits.

Habits are ingrained and sustained behaviors, often developed in childhood. Research has shown that once people anywhere acquire ingrained and habitual behaviors, they are not easily lost. The task for handwashing promotion is not to achieve a single handwashing event, but to instill a routine and sustained habit that happens automatically with every contaminating event.

While habits are often learned at an early age, there are opportunities for change, especially at life-changing events. A key event for mothers is the birth of a baby. Many mothers report that hand hygiene did not become important to them until a baby was born and that if midwives or others involved with perinatal care recommended handwashing with soap, it would likely take hold. Another life-changing event for many mothers is moving to the husband's home after marriage and learning the habits of the new household.

Habits are best documented using structured observations. Their origins can be explored through in-depth interviews and the process of taking on new habits understood in behavior trials.

Drivers are innate and learned modules in the brain that motivate particular behaviors. They come in the form of emotions and the feelings that people report when carrying out particular behaviors. Discovering drivers is key to successfully promoting handwashing.

How do people communicate? Finally, research has to determine where the target audience obtains information; the reach of different channels of communication, both traditional and modern; which channels are trusted and believed; and the best language(s) to use. The potential effectiveness of different channels will differ among the various segments of the target audiences.

There are two main sources of information on channels of communication. The first source is existing data. In Ghana, commercial entities have already collected detailed profiles of consumption of mass media, possibly even covering mothers' and children's listening.

Ghana Consumers Prefer Multipurpose, Long-Lasting Soaps at Economy Prices like ASKIN Antibacterial Handwash Soaps.

Women in Ghana were asked what features they favored in a handwashing soap for research purposes. In commenting on favored features for soap, they cited a range of attributes - smell, cost, texture, and durability - and its capacity to be used for many purposes.

Smell was the most important attribute. Overall, mild lemon/lime scents were most popular. However, soaps with stronger scents were favored for use after defecation, while as little scent as possible was preferred before eating: women feared a strong scent would affect the enjoyment of eating. One said, “You will not have an appetite for food if the soap lingers in it.”

Cost: Overall, cheaper soaps were preferred, though women were sometimes willing to pay more if the soap was larger or they thought it would last longer.

Texture/durability: Associated with cost, women tended to prefer liquid varieties and harder bar soaps,

as they thought they were longer lasting. The preference for hard soaps was so strong that many stored soap in cold or sunny places to harden them before use: “I cut it into pieces and put it on the floor of a veranda to dry and harden so that it will be long in use.”

Liquid soaps, as well as being economical - only a little is used each time hands are washed - are favored for convenience “with soap in its hard state, you need to ask someone to pour water on your hands, but with this you don't need anyone's help.”

So strong was the desire for the more expensive liquid soaps that some women made their own from bar soap: “I soaked it in water, mashed it, and poured it into an old feeding bottle.”

Multipurpose: Because it is associated with economy, many women preferred laundry bar soaps that could be used for a variety of purposes: “That is the only soap I buy, since I can use it to wash my things and have a bathing soap at the same time.”

On Schools

Because they provide a relatively easy and sustainable route to long-term behavior change, schools are a good focus of handwashing programs. Schools are a key environment, not just for learning about handwashing, but for introducing the habit in practice, so it lasts. Children are often enthusiastic proponents of behavior change, and research questions apply to school-age children, teachers, and administrators as well as they do to other target audiences.

In most countries, schools are the second places of socialization after households. Children can spend up to eight hours a day for more than eight months a year in schools and a substantial amount of time with their peers. Consumer behavior literature shows that children do not react to brands and brand communication in the same way as adults, so a separate communications strategy is needed for schools. The risk practices being carried out at school are also different than at home. Specific tools for researching school children's habits and motives are in development,

Key Points for Contracting Consumer Research

It should be made explicit from the outset and re-iterated often that handwashing promotion programs are not traditional public health projects. Rather, they are consumer-driven programs that need to determine deep consumer motivations for handwashing with soap. Simple interviews are not enough. For example, the contractor must be told that when consumers are asked whether they have washed their hands, the answer is invariably “yes.” People often respond to questionnaires as if they were being tested or judged, so they tell the interviewer what they believe is the “right” answer.

A team with commercial consumer research experience is preferable to one that is accustomed to working on public health programs.

Field workers need to speak local languages.

Once recruited, agencies need detailed briefing and training to ensure that the right questions are asked in adequate detail. For example, many handwashing studies find that consumers wash their hands because they want to be “clean.” However, this is not a useful finding. Understanding what “clean” means in this context and all its ramifications - physical, psychological, and social - is more important.

The research agency must stay focused on the four questions and the specific information that is needed. The agency must probe to the bottom of each question and ensure that findings are sufficiently detailed to allow the development of a sophisticated, creative strategy to promote behavior change among the target audience.

As with all contract work, the quality of work will only be as good as the client demands. The client has to understand all the issues in-depth, know exactly what is wanted, and keep the agency focused on achieving this. Clients must visit the field and make sure that field work is being carried out to specification. Unannounced visits will help ensure rigor in the field team.

Qualitative work (e.g., in-depth interviews) cannot be carried out by field workers but must be executed in the field by qualified and well-trained anthropologists or psychologists. Support from the Ghana Health Service technical team will be needed to ensure effective, quality research.

All data, both quantitative and qualitative, are precious. Qualitative interviews should be recorded on tape, translated, and transcribed; carefully labeled and indexed with date, time, and respondent details; and returned to the client for safekeeping. Quantitative data should be thoroughly cleaned and a copy of the data set given to the client.

1. Systems and infrastructure

IT Infrastructure

ASKIN will grow over the Business Plan 2019-2023. To support this expansion, ASKIN will continue to invest in robust IT infrastructure to support greater connectivity between the various functional teams and business units. ASKIN will continue to develop more effective archiving or data backup systems and will refine and develop its business continuity and disaster recovery plans as a critical contribution to mitigation of organizational risk.

In the build of handwashing centers, there is the need of using modern equipment and technology for this purposes of promoting this washing and hygienic practices. The infrastructural processes will include; Walk in à Soap dispense à Wash under running water à Drying Hands.

These structures needs to be done carefully that they don’t become a germ productive tools since they will be enhanced by the masses. It should be observed that no one comes in the washing facility to have access in touching any of these equipment. It should be disallowed for any touch.

Operational Systems

As a contribution to the development and expansion of the organization, the following six areas have been identified as priorities for systems development over the course of the Business Plan:

Finance;

Knowledge management and sharing;

Programme delivery and management of time, cost and quality;

Contact management;

HR management;

• Donor management.

Investment in the infrastructure and systems described above will be be prioritised over the period of the Business Plan and funded through the new cost recovery policy.

1 Funding model

As ASKIN pursues its programmatic and national goals, the company will simultaneously develop strategic partnerships supporting the increased company budget to match its impact and operations. This will increase its global budget to over GH¢2 million by 2022/2023.

ASKIN's funding model has been developed to deliver sustainable resourcing that responds directly to ASKIN's needs, nurtures existing partnerships and enables expansion into new markets. With this model, ASKIN will prioritise current donors and partnerships while seeking to diversify sources of funding and strategic engagements and to promote opportunities within the sanitation promoters and broader international development sectors.