WASH Marketing Assessment and Strategy Development
MARKET ASSESSMENT
FINAL REPORT – JUNE 2017
Geo-Sys (Lao) Co., Ltd. Lao-Thai Road, km3, Ban Wat Nak, Sisattanak District P.O. Box 8243, Vientiane, Lao PDR Email: [email protected]; Tel: (+856) 30 9286726 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Table of Contents
1. List of Acronyms ...... 4 2. Executive Summary ...... 5 2.1. Background ...... 5 2.2. Methodology ...... 5 2.3. Assessment Findings ...... 6 2.3.1. Consumption of clean drinking water by children aged 6-24 months ...... 6 2.3.2. Hand washing with soap at key points ...... 7 2.3.3. Use of improved sanitation facilities (open defecation free villages) ...... 7 2.3.4. Separating children aged 0 - 24 months from environmental contaminants in the household and outside ...... 8 2.4. Communication Channels ...... 8 2.5. Recommendations ...... 8 3. Introduction ...... 10 3.1. Project Background ...... 10 3.2. Specific Objectives of the Market Assessment ...... 10 4. Methodology ...... 12 4.1. Project Target Area ...... 12 4.2. Study Sites ...... 14 4.2.1. Mahaxay District – Khammouane Province...... 14 4.2.2. Phin District – Savannakhet Province ...... 17 4.3. Data Collection Methods ...... 21 4.3.1. Literature Review...... 21 4.3.2. Key Stakeholder Interviews ...... 21 4.3.3. Village Walks ...... 21 4.3.4. Household Visits ...... 22 4.3.5. Supplier Visits ...... 22 4.3.6. Consumer Focus Groups ...... 23 4.4. Analysis ...... 24 4.4.1. Data compilation, translation and cleaning ...... 24 4.4.2. Analysis and presentation of findings ...... 25 5. Assessment Findings ...... 26 5.1. Consumption of clean drinking water by children aged 6 - 24 months...... 26
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5.1.1. Observed behaviours and risks of contamination through consumption of unclean drinking water ...... 26 5.1.2. Drinking water consumer profiles ...... 31 5.1.3. Drivers and barriers for investment in specific WASH products for consumption of clean drinking water by children aged 6-24 months ...... 32 5.1.4. Recommendations for promotion of products to encourage consumption of clean drinking water by children aged 6-24 months ...... 37 5.2. Hand washing with soap at key points...... 38 5.2.1. Observed behaviours and risks through lack of hand washing with soap ...... 38 5.2.2. Hand washing consumer profiles ...... 42 5.2.3. Drivers and barriers towards investment in products promoting hand washing with soap at key points ...... 42 5.2.4. Recommendations for promotion of products to encourage hand washing with soap at key points ...... 47 5.3. Use of improved sanitation facilities (open defecation free villages) ...... 48 5.3.1. Observed behaviours and risk of contamination from poor sanitation ...... 48 5.3.2. Sanitation consumer profiles ...... 53 5.3.3. Drivers and barriers for investment in improved sanitation ...... 54 5.3.4. Recommendations for promotion of products for latrine construction ...... 55 5.4. Separating children aged 0-24 months from environmental contaminants in the household and outside ...... 56 5.4.1. Observed behaviours and risk of contamination from environmental contaminants ...... 56 5.4.2. Consumer profiles - separating children from contaminants ...... 57 5.4.3. Drivers and barriers towards investment in products that separate children aged 0-24 months from environmental contaminants in the household and outside ...... 58 5.4.4. Recommendations for promotion of products that separate children aged 0-24 months from environmental contaminants in the household and outside ...... 59 6. Willingness to Pay ...... 60 6.1. Household buying power ...... 60 6.2. Willingness to pay ...... 61 7. Communication Channels ...... 63 7.1. Community based communication channels ...... 63 7.2. Multi Media, Internet and mobile usage ...... 64 8. Summary of Recommendations ...... 66 9. References ...... 68
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Appendices1
Appendix A: Village Walk Data Tables Appendix B: Household Visit Data Tables Appendix C: Supplier Visit Data Tables Appendix D: Consumer Focus Group Data Tables Appendix E: Assessment Protocol Appendix E.1: Key Stakeholder Interviews Appendix E.2: Village Walk Form Appendix E.3: Household Visit Form Appendix E.4: Supplier Visit Form Appendix E.5: Focus Group Facilitation Guide
1 Appendices are attached as separate reports with each a frontpage. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 3 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
1. List of Acronyms
ASEAN Association of Southeast Asian Nations CLTS Community Led Total Sanitation EE Intestine Infections HH Households MCH Mother and Child Health Care Department PRF Poverty Reduction Fund SCI Save the Children International WASH Water, Sanitation and Hygiene
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2. Executive Summary
This Market Assessment Report completed by Geo-Sys (Lao) Co., Ltd has been commissioned by Save the Children International (SCI) under the USAID Nurture Project. The objective of the Market Assessment is to determine how best to introduce and/or scale up the supply and demand of selected WASH products and services in target villages to support households’ adoption of the project’s targeted WASH behaviours that will contribute to the reduction of rates of stunting. Products assessed in this assessment aim to improve practices associated with the following identified WASH behaviours: - 1. Consumption of clean drinking water by children aged 6 - 24 months; 2. Hand washing with soap at key points; 3. Use of improved sanitation facilities (open defecation free villages); and 4. Separating children aged 0-24 months from environmental contaminants in the household and outside.
2.1. Background Lao PDR experiences some of the highest levels of malnutrition in the ASEAN region with the national prevalence of stunting being 35.6%.2 Stunting is most prevalent amongst the poor, with rural communities particularly affected.3 Malnutrition is particularly damaging during the first 1000 days of life – from conception to the child’s second birthday. The effects of malnutrition throughout this period are lifelong and irreversible. The underlying causes of malnutrition and stunting are a combination of poor-quality diets, poor-quality health and care, the environment and behaviours. Inadequate Water, Sanitation and Hygiene (WASH), including open defecation or use of unimproved sanitation, lack of hand washing with soap, consumption of untreated water and overall high levels of exposure to environmental contaminants, can cause diarrheal infections and environmental enteropathy in children reducing the absorption of nutrients from food and thereby have a significant impact on stunting.4 Marketing strategies have been successfully used by the private sector to create demand for products and changes in consumer behaviours. A marketing approach can be utilized to improve WASH behaviours within target communities. The development of an effective marketing campaign will both increase the supply of and demand for identified WASH products and create emotional drivers that encourage long term, sustainable behavioural change.
2.2. Methodology The target area of the Nurture Project covers a total of 6 districts, including Mahaxay, Nhommalath and Xayboutathong in Khammouane Province and Phin, Xonnabouly and Atsaphangthong in Savannakhet Province. The Project takes a district-wide approach and therefore aims to cover all villages in the six target districts.
2 2015 Lao Child Anthropometry Assessment Survey (LCAAS). 3 2012 Ministry of Health and Lao Statistics Bureau, Lao Social Indicator Survey (LSIS) 2011-12, Vientiane, Lao PDR. 4 2014 WHO: http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 5 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
The study sites of the Market Assessment included a total of six villages; three villages in Mahaxay District, Khammouane and three villages in Phin District Savannakhet. These two districts have both been approved as ‘Phase 1 districts’ of the Nurture Project. The data collection for the Market Assessment included a review of secondary data and the collection of primary data using a variety of methods including observations and stakeholder interviews with Government and Development partners, village walks, household visits, supplier visits and consumer focus groups.
2.3. Assessment Findings 2.3.1. Consumption of clean drinking water by children aged 6-24 months The risk of contamination through consumption of unclean drinking water is considered to be very high for children aged 6-24 months in the Nurture Project Areas, especially in the more remote areas of Phin district. In the surveyed households, the types of water consumed are: a) Factory treated bottled water: - Primarily consumed by households located in Phonsaat, Mahaxay, and Nonsaat, Phin, which are both located close to main roads and have easy access to their respective district capitals. b) Filtered water using TerraClear system: - In 2012 World Vision distributed TerraClear water filtration systems to households in Xangphok and Phanang villages, Mahaxay, at a subsidized rate of 100,000 LAK per unit (full purchase price 1,000,000 LAK per unit). A limited number of households in these two villages continue to utilize the systems to filter water before consumption. c) Boiled water: - Largely consumed in Xangphok and Phanang villages, Mahaxay. Water is collected from private/communal wells or in a few cases directly from the stream and boiled before consumption. After boiling water is stored in containers with lids including kettles, pots, plastic bottles or jugs. d) Untreated water: - Consumed largely by households in Tadhai Xe and Gang Mai, Phin District, untreated water is collected from private/communal boreholes or in some cases a stream or pond. Water is stored in pots or buckets with lids. The key risk factors identified in the assessment are: - consumption of untreated, contaminated water directly from source, drinking utensils are rarely washed and shared by household members and water stored in container without spout or tap and is transferred by “dipping” unclean utensil recontaminating treated water. Products that were assessed that could reduce these risk factors were: - Bottled water (various sizes), water filter systems (TerraClear and Abundant Water), various types of water storage solutions, cups and glasses, special cup for child and dishwashing soap. To promote the consumption of treated water and appropriate storage to avoid re-contamination and/or improve hygiene of drinking utensils, the following is recommended: -
Promotion of a cheaper water filter system – this filter system could be household based or community based, if a local entrepreneur could be trained to become the Village Water Maker in line with the proposed Village Soap Makers; Promotion of special water storage and drinking utensil for child as for example a water bottle. This bottle should be large enough to contain the water consumed by the child in one day, but not too big for the child to hold and drink from. A special child friendly water bottle would combine the functions of clean storage and separate drinking; and
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Promotion of dish wash soap and frequent washing of child’s drinking utensil. This soap could be produced and marketed specifically as child friendly dish wash, by locally trained Soap Makers.
2.3.2. Hand washing with soap at key points The risk of contamination through soiled hands is assumed to be very high in the Nurture Project Areas. The assessment found a high open defecation rate as well as a high prevalence of animal faeces in all of the surveyed villages. Further to this, hand washing practices were assessed to be very poor in majority of surveyed households. Whilst a majority of households surveyed were aware of most of the project defined key points for adult hand washing, soap is rarely available at key locations, including the kitchen and bathroom and hand washing among small children is rare. The key risk factors identified in the assessment are: - households not washing hands with soap at key points, soap not available to wash hands at keys points and households not washing hands of small children. Products that were assessed that could reduce these risk factors were: - Soap produced by women trained by Soap4Life, Commercial block soap, Happy Tap and Tippy Tap hand washing stations, container with tap and plastic buckets. Hand washing with soap can be increased by expanding the use of soap within communities and by encouraging more hand washing (i.e. hand washing with soap at all key points). Soap is available in most villages at low cost. Improved hand hygiene requires a product and a behaviour change based on motivations and practicality. Recommendations include:
That the Soap4Life soap is specifically marketed as a child friendly soap and as a hand washing soap; That the packaging style and branding be redesigned to reflect the soap as a child friendly soap and as a hand washing soap, while avoiding marketing as an aid product which carries the connotation of being a soap for the poor; That Soap makers are equipped and trained to produce soaps in child friendly shapes and colours that will encourage children to use the soap, while clearly signalling to mothers and other caregivers that this soap is particularly good for their children; and Investigation of additional low-cost hand washing station options or designs.
2.3.3. Use of improved sanitation facilities (open defecation free villages) The practice of open defecation is considered to be a significant contributor to the environmental contamination in the project target areas. Some of the surveyed households across all of the assessed villages, including households with access to a latrine, were thus found to practice open defecation. Just under half of the surveyed households did not have access to a latrine, however, approximately two thirds reported to defecate in the open. Whilst households without a latrine reported to openly defecate exclusively, households with latrines reported to defecate in the open when they were working away from the home in the field or forest. Whilst latrine use was favoured by almost all households due to it being a cleaner, safer option to open defecation barriers to households installing latrines include inability to afford materials to construct a latrine, materials to construct a latrine are hard to find or unavailable in their village and that they did not know how to install/construct a latrine. Products that were assessed to reduce the rates of open defecation were: - material package “all in one” for different types of latrines and buckets with lid (to be stored near toilet for use with pour flush toilets).
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Community Led Total Sanitation (CLTS) is the main strategy for promotion of improved sanitation chosen by the Nurture Project. Based on the findings of this Market Assessment it is recommended:
To assist households with access to full package of materials needed for construction of in-ground latrine and over-ground shelter; To assist households with technical knowhow; and To explore opportunities for setting up a 1-2-year credit scheme for monthly payments of instalments of 100,000LAK/month.
2.3.4. Separating children aged 0 - 24 months from environmental contaminants in the household and outside Small children play on the ground indoors as well as outdoors, touch the ground and objects with their hands, put their hands and objects in their mouths and are therefore potentially at high risk of contamination from environmental contaminants. The risk of contamination from environmental contaminants is particularly high in areas, such as those targeted by the Nurture Project, where the population practice open defecation, rear livestock within or close to living areas and practice poor home hygiene. Products that were assessed to reduce children’s contact with environmental contaminants whilst playing on the floor or ground were: - cleaning material including floor cleaner, brooms and mop, play mats and fencing materials. Based on the assessment findings, children in the Project target areas are assumed to be at high risk of environmental contaminants when playing indoors as well as on the ground outdoors, however products that could separating children from contamination, including play mats and floor cleaner are not currently available. In order to encourage separation of children from environmental contaminants, it is recommended:
To promote whether liquid soap, produced by local soap makers that can be used for floor washing; and To investigate further the production of a specialised play mat suitable for Lao children (with Lao letters and culturally relevant pictures).
2.4. Communication Channels Evidence suggests that the most effective way to promote behavioural change is to utilise multiple channels and methods of communication, generating a unified, wide reaching message. Information can be communicated in various ways including advertising, direct marketing, social media, popular culture, word of mouth and demonstrations/events. Currently, target villages primarily utilise traditional forms of communication including television, radio, print media, notice boards, village meetings and village based broadcast. However, it is also important to consider and incorporate new communication channels which result from the implementation of new community based communication techniques in WASH programs and the rapid growth of new technologies, the expansion of broadband coverage.
2.5. Recommendations
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Based on the assessment findings, it is recommended to select a group of WASH products that strengthen uptake of each other. These products could include: Community water filters; Child specific water container; Dish wash soap produced by Project trained Soap Makers; Child friendly soap produced by Project trained Soap Makers; Low cost hand washing station; Special designed play mat; and Floor cleaner produced by Project trained Soap Makers. Furthermore, it is recommended to use the same ‘strong-child’ reference (cartoon/logo) to brand all products and on other health, nutrition and WASH messaging, and to use multiple communication channels, specifically chosen for context, while phasing/prioritising marketing in accordance with local situation.
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3. Introduction
3.1. Project Background Lao PDR has one of the fastest growing economies in the ASEAN, with an annual growth rate of close to 8% over recent years. Despite this, children in Lao PDR still experience some of the highest levels of malnutrition in the region with a national prevalence of stunting at 35.6%, underweight at 25.5% and wasting at 9.6%.5 Stunting is more prevalent amongst the poor with 61% of children in the poorest quintile stunted compared to 20% in the wealthiest.6 Rural areas are particularly affected with every fifth child considered severely stunted.7 The underlying causes of malnutrition and stunting are a combination of poor-quality diets, poor-quality health and care, the environment and behaviours. Inadequate Water, Sanitation and Hygiene (WASH), including open defecation or use of unimproved sanitation, lack of hand washing with soap, consumption of untreated water and overall high levels of exposure to environmental contaminants, can cause diarrheal infections and environmental enteropathy in children reducing the absorption of nutrients from food and thereby have a significant impact on stunting. 8 Malnutrition is particularly damaging for the child throughout the first 1000 days of life – from conception to the child’s second birthday. The effects of malnutrition throughout this period are lifelong and irreversible. Marketing campaigns have been successfully used by the private sector to create demand for products and changes in consumer behaviours. A marketing approach can be utilized to improve WASH behaviours within target communities. The development of an effective marketing campaign will both increase the supply of and demand for identified WASH products and create emotional drivers that encourage long term, sustainable behavioural change. In this context, Save the Children International (SCI) in Lao PDR has commissioned Geo-Sys (Lao) Co., Ltd under the USAID Nurture Project to design and conduct a Market Assessment for targeted WASH products and services in targeted districts of Khammouane and Savannakhet provinces.
3.2. Specific Objectives of the Market Assessment As per the terms of references for the assignment, the specific objective of the Market Assessment is to determine how best to introduce and/or scale up the supply and demand of selected WASH products and services in target villages to support households’ adoption of the project’s targeted WASH behaviours that will contribute to the reduction of rates of stunting. More specifically these behaviours are defined by the Project as:
1. Consumption of clean drinking water by children aged 6-24 months Children between the ages of 6-24 months who drink faecal bacteria and germ-contaminated water have an increased risk of intestine infections (EE) that hinders the child’s absorption of nutrients and thereby leads to malnutrition and stunting.9 The infection usually occurs either when untreated water is consumed or when treated water is recontaminated before consumption due
5 2015 Lao Child Anthropometry Assessment Survey (LCAAS). 6 2012 Ministry of Health and Lao Statistics Bureau, Lao Social Indicator Survey (LSIS) 2011-12, Vientiane, Lao PDR. 7 2017 WFP: https://www.wfp.org/countries/lao 8 2014 WHO: http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf 9 Lao Statistics Bureau, December 2012, Lao Social Indicator Survey (LSIS) 2011-12, UNFPA UNICEF Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 10 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
to unsafe storing solutions or unsafe drinking practices. The risk of ingestion of faecal bacteria and germs through drinking water is especially high in areas with high levels of environmental contamination. 2. Hand washing with soap at key points Soiled hands are identified as one of the major sources of contamination with faecal bacteria and germs that lead to infections of the intestine (EE) and compromise the body’s ability to absorb micronutrients and therefore cause malnutrition. The contamination from soiled hands is transferred to the human body indirectly through hands contact with drinking water and/or food, as well as directly from hand to mouth contact. Main risk behaviours causing contamination include 1) lack of hand washing at key points;10 2) hand washing at key points without soap; and 3) drying hands after washing at key points using a dirty towel. Risk of contamination is particular high in communities where the environmental contamination levels are high due to poor sanitation facilities, practice of open defecation and the presence of livestock within the boundaries of the village.11 3. Use of improved sanitation facilities (open defecation free villages) Exposure of infant and young children to human faeces – both adult and child faeces - is a main source of environmental contamination. This exposure can lead to infection of the gut (EE), a key contributor to child malnutrition and mortality. This contamination, which stems from open defecation and a failure to properly manage child faeces, is transferred to the human body indirectly through the contamination of drinking water, foods and hands as well as the dust and dirt in the environment around the villages. Elimination of open defecation and appropriate management of child faeces can significantly lower these sources of contamination. 4. Separating children aged 0-24 months from environmental contaminants in the household and outside Small children are at higher risk of contamination from the environment than adults. They play on the ground indoors as well as outdoors, touch the ground and objects with their hands and put their hands and objects in their mouths and are therefore potentially at high risk of contamination from environmental contaminants.12 Sources of environmental contamination include animal faeces, dirt, and unclean objects, such as toys, etc.
In order to provide evidence-based product/service recommendations for a marketing strategy to increase the supply and demand of WASH products that will impact targeted WASH behaviours in Project communities, the market assessment aimed to understand current household and community WASH behaviours, identify key actors, products available and opportunities in the supply chain. The analysis integrates secondary data identified in the literature review and primary data gathered with the aim of filling any information gaps, focusing specifically on communities within the target areas of the Project. As malnutrition has the greatest impact on children from the time of conception to 24 months of age particular emphasis is placed on marketing the use of the identified WASH products to “first 1000-day households” – defined as households where pregnant women and/or children under 2 years reside.
10 Key Points for hand washing are defined by the Project as: after adult defecation, after handling child’s faeces, before food preparation or food handling, before eating, before feeding and before breast feeding 11 2014 WHO: http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf 12 2017 WHO: http://www.who.int/ceh/risks/en/ Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 11 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
4. Methodology
A detailed description of data collection methods is provided in the Assessment Protocol, where data collection forms, questionnaires and discussion guides are attached. This section of the report mainly provides a description of the included study sites and sample of the study participants.
4.1. Project Target Area The target area of the Nurture Project covers a total of 6 districts, including Mahaxay, Nhommalath and Xayboutathong in Khammouane Province and Phin, Xonnabouly and Atsaphangthong in Savannakhet Province. The Project takes a district-wide approach and therefore aims to cover all villages in the six target districts. Adjacently located in the centre of Lao PDR, Khammouane and Savannakhet provinces both have a high prevalence of stunting, low participation rates in key WASH behaviours and are preferred development target areas of the Government of Lao PDR (GoL). Both provinces have large rural populations of various ethnic backgrounds. Khammouane province shares borders with Bolikhamxay province to the north, Savannakhet to the south, Thailand to the west and Vietnam to the east. The province has a population of 337,000 people, with 40% of children under 5 years being stunted. 13.4% of children are exclusively breastfed during the first 6 months of life, which is significantly below the national average of 40.4%.13 There are a number of ethnic groups in the province with 94% of the population coming from one of three main groups, Lao, Phouthay and Brou and the remaining 6% of the population are made up of other minor ethnic minority groups.14 Savannakhet province has a much larger population of over 800,000 people, but a similar stunting rate to Khammouane of 40.8%. The exclusive breastfeeding rate is slightly higher than in Khammouane at 16.5%, but still significantly below the national average. Households with improved sanitation facilities make up 39% of total households compared with the national average of 57%. The most prevalent ethnic groups in Savannakhet are Lao, Phouthay and Katang.15 As in most other parts of the country, access to improved sources of drinking water is increasing in both Khammouane and Savannakhet, however, still approximately half of the population in the two provinces is without an improved source of water. In 2012 the percentage of households using an improved water source was 56.9% in Khammouane and 48.4% in Savannakhet.16 Boiling water is currently the main solution used for treatment of drinking water. This is practiced by roughly 60% of households in Savannakhet and 57% of households in Khammouane, in both provinces mainly in rural areas.17
13 2014 WHO: http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf 14 http://dpikhammouane.gov.la/documents/Khammouane%20province.pdf 15 http://dpisavannakhet.gov.la/documents/Savannakhetprovince 16 Lao Statistics Bureau, December 2012, Lao Social Indicator Survey (LSIS) 2011-12, UNFPA UNICEF 17 Ibid. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 12 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Sites
Study
Assessment
Market
indicating
Area
Target
Project
of
Map
: 1
Map
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4.2. Study Sites The study sites of the Market Assessment included a total of six villages; three villages in Mahaxay District, Khammouane and three villages in Phin District Savannakhet. These two districts have both been approved as ‘Phase 1 districts’ of the Nurture Project. The map in Figure 1 illustrates the location of the study sites within the Project target area. The selection of the study sites was based on their difference in access to water, sanitation and markets. Mahaxay is thus located in the western part of Khammouane relatively closer to Thailand and therefore assumed to be influenced to a higher degree by Thai markets, while Phin district is located in the eastern part of Savannakhet, relatively closer to the Vietnamese border and therefore assumed to be influenced by Vietnamese markets. Within each of the two selected districts, 3 villages were selected in consultation with Project staff and local Government counterparts. The criteria for selection were, one urban/semi-urban village on the main road, one rural village with relatively good road access and one rural village with very poor road access. Furthermore, the sampling aimed to include, where possible, villages with prior exposure to Community Led Total Sanitation (CLTS) or other sanitation projects as well as villages with different sources of water supply. In five of the six selected villages, the population is of ethnic Lao background. Only in one surveyed village, Gang Mai in Phin, is the population of other ethnic background; Katang.
4.2.1. Mahaxay District – Khammouane Province Mahaxay is located east of Thakhek, the provincial capital of Khammouane, located by the Mekong River with access by bridge to Thailand. National Road 12, connecting Thakhek to the Vietnamese border in Na Phao, cuts through the district. The district capital, Mahaxay town, is located just off this road approximately 50km from Thakhek and 100km before the Vietnamese border. The district has already received support for reproductive health and WASH related activities from various organizations. Interviews with the provincial Mother and Child Health Care Department (MCH) and Nam Saat in Thakhek, thus informed that both UNICEF and WFP have previously provided support to WASH related projects in Mahaxay District, and that both the Poverty Reduction Fund (PRF) and World Vision are currently doing so. The Mahaxay district MCH and Nam Saat, furthermore informed that the Japanese Volunteer Corporation has just finished implementing WASH related activities in the district. Further to these, other organizations have supported additional sectors in the district, including CIDSE (agriculture), LuxDevelopment (village development planning and livestock training), French Red Cross (disaster risk management). Finally, a number of villages impacted by the Nam Theun 2 Hydropower Project (NT2) received support from this company. Access to markets is relatively good in Mahaxay. Villages located along Road 12 have markets with stalls selling clothes, food and other normal household items. These villages also have at least one shop selling construction materials and a shop selling slabs, concrete rings and concrete bricks. Villages along good dirt roads within the district also often have markets however with a smaller selection of goods. Finally, villages with poor road access, or even no access by car in the rainy season, usually only have a couple of small shops selling soap, sodas and various kinds of snacks.
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Table 1: Study sites in Mahaxay District, Khammouane Province
Phonsaat Xangphok Phanang
No of Households: 570 115 66 Ethnicity: Ethnic Lao Ethnic Lao Ethnic Lao Access in dry season: Paved road Dirt road Poor dirt road Access in wet season: Paved road Dirt road Only by foot/boat Distance to district capital: 5km 30km 10km Water Sources Nampapa 2 public wells 4 public wells Main source of household water: 8 private wells 1 private well
Well Gravity Fed System River Other water sources: Streams Bottled water Wells Wells Main Source of Drinking Water:
Other Sources of Drinking Nampapa Gravity fed system None Water: Streams Sanitation Private latrines 165 47 53 Public latrines 0 0 0 Project support for latrines No Yes Yes Development Aid Support Currently supported by Aid No CIDSE NT2
World Vision World Vision Previously supported by Aid No LuxDevelopment French Red Cross
Markets and Shops No of shops 97 5 4 Soap retailed in village Yes Yes Yes
Kitchen utensils retailed in village Yes Yes Yes
Mobile retailers selling WASH No Yes No products Source: Observation and conversation with Village Chiefs during Village Walks.
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Phonsaat The semi-urban village, Phonsaat, is located 5 kilometres from the district capital, Mahaxay, and accessible year-round by paved road. There are 570 households in the village of which 75 are ‘first 1000-day- households’ according to the village chief’s records. The village has a higher percentage of brick/concrete dwellings than any other village surveyed, with approximately 30% of houses constructed of these materials. All other houses are wooden houses on stilts. Most households in Phonsaat buy their drinking water (bottled water), some drink water from the public water supply system (Nampapa). All households in the village are connected to the Nampapa system. This is supplied by water from the Xe Bang Fai River. There is also a well in the village. This source is used by some households and mainly for washing clothes. Approximately one third of the households have private latrines. According to the village chief, households without latrine use the latrines of their neighbours or other family members. However, some people still practice open defecation, mainly those living on the outskirts of the village and those working in the forest or field away from the village. A private company, according to the village chief, services the latrines, however only once in 8 years. The village has never received any support from development aid projects. There is a market in the village and a total of 97 retail shops, some of them selling a variety of WASH products, including construction materials needed for building latrines.
Xangphok The rural village Xangphok is located 30 kilometres from the district capital, accessed all year by car via a dirt road. There are 115 households in the village of which the village chief estimates, 25 are ‘first 1000- days-households’. A vast majority of houses are wooden constructions on stilts, with only a few being enclosed with concrete/brick downstairs.
Plate 1: Village shop selling snacks, soap, drinking water and various other drinks. This type of shop was found in most surveyed villages.
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Drinking water is sourced mainly from wells or boreholes. However, drinking water may also be sourced from the gravity fed system during the wet season, the only time of year this system is working. In the wet season households may also source their drinking water from the streams when they reside in their huts in the rice fields. 22 households pump water from the public wells into their households using private electric pumps. Remaining households must collect the water from the community well. Just under half of the households have private latrines. The construction of these was supported by a development project approximately 20 years ago. The latrines are not serviced. Most households without a latrine defecate in the open. Besides support for latrine construction, the village has received aid from World Vision (WASH) and LuxDevelopment (community planning and livestock) and is currently supported by CIDSE (agriculture). Soap and a small selection of kitchen utensils are available for purchase in Xangphok’s 5 retail shops. Further to this, mobile retailers selling kitchen utensils including cups occasionally visit the village. The Village Walk further noted that there were a lot of animal faeces located throughout the village and no fencing of animals.
Phanang The rural village Phanang is located only 9 kilometres from the district capital, however, has very poor access, particularly in the wet season where the village is only accessible by foot or boat. There are 66 households in Phanang. The chief does not know how many of these are ‘first 1000-days-households’. As in Xangphok, the vast majority of houses in Phanang are wooden constructions on stilts with only a few households having enclosed the downstairs area with concrete/bricks. Drinking water is sourced from wells or boreholes. There are 4 community wells in the village, which are all working, and one household has a private well. Households also use water from the river nearby, but mainly for showering, washing of clothes and dishes, with 4 households pumping water directly from the river to their bathrooms (latrines). 53 households have private latrines constructed with support by NT2 in 2008. In addition to NT2, the village has received support from World Vision (WASH and agriculture) and French Red Cross (disaster risk management). There are 4 retail shops in Phanang, selling soap and a very small selection of kitchen utensils. The Village Walks noted that there were animal faeces located throughout the village and limited fencing of animals.
4.2.2. Phin District – Savannakhet Province Whilst located centrally in the province, Phin District is closer to the Vietnamese border than to the provincial capital of Savannakhet. The relatively busy Road 10 connecting Seno (intersection with Road 13 South) with the Vietnamese border, cuts through the province, as well as Phin district. The district capital, Phin, is located on this road approximately 130km from Seno and 30km from the Dansavanh border crossing. According to the provincial MCH, Phin District has received development aid support from both UNICEF and NT2, and the district hospital is currently implementing WASH related activities. The district MCH and Nam Saat furthermore informed that World Vision, LuxDevelopment and Red Cross Luxembourg currently support WASH related activities in the district. Finally, the Poverty Reduction Fund (village planning and small infrastructure development) and the Japanese Volunteer Cooperation (agriculture) supports selected communities in the district.
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Plate 2: Temporary road-side stall set up by Vietnamese mobile trader
The access to markets is good in Phin. The areas close proximity to the Vietnamese border means that trucks from Vietnam selling goods pass through the district daily. These mobile traders often set up temporary stalls selling their goods to local retailers or directly to consumers. According to shop owners in the local market, people can buy goods off the trucks cheaper than from the market. Most villages located along Road 10 have markets with stalls selling clothes, food and other household items. There are also shops selling construction materials including cement and concrete rings needed for latrines. However, in villages with limited road access hardly any retailers sell products other than and soap, drinks and snacks. As illustrated in Table 2: study sites in Phin district included: 1) Nonsaat village with 187 households, located on the main road approximately 7 km from the district capital, 2) Tadhai Xe village with 153 households, located approximately 30 km from the district capital with year-round road access, and finally 3) Gang Mai village with 51 households, located approximately 20 km from the district capital, only accessible by road in the dry season. While all assessed households in Mahaxay district were ethnic Lao, in Phin district households of various ethnic backgrounds were assessed, including ethnic Lao and Phuthai in Nonsaat and Tadhai Xe villages, and Katang in Gang Mai.
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Table 2: Study sites in Phin District, Savannakhet Province Nonsaat Tadhai Xe Gang Mai No of Households: 187 153 51 Ethnic Lao Ethnic Lao Ethnicity Katang Phuthai Phuthai Access in dry season: Paved road Dirt road Poor dirt road Access in wet season: Paved road Dirt road Only by foot Distance to district capital: 7km 30km 20km Water Sources 187 private household 5 public wells 6 public wells boreholes with electric Main source of household water: pumps 2 public wells Stream (used for River Stream Other water sources: agriculture) Pond Rain water
Main Source of Drinking Water: Bottled Water Wells Wells Borehole Bottled water None River Other Sources of Drinking Water: Pond Rain water
Sanitation Private latrines 170 29 4 Public latrines 0 0 0 Project support for latrines No No Yes Development Aid Support Currently supported by Aid No PRF No Japanese Volunteer Previously supported by Aid No PRF Cooperation Markets and Shops No of shops 20 14 3 Soap retailed in village Yes Yes Yes Kitchen utensils retailed in village No Yes No Mobile retailers selling WASH Yes Yes No products Source: Observation and conversation with Village Chiefs during Village Walks.
Nonsaat
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Nonsaat is the largest of the three villages surveyed in Phin District, and with its location relative close to the district capital on the main road, it is considered a semi-urban village. Comprised of 187 households, a majority are of Phuthai ethnicity, while some are Ethnic Lao and some are a mix of Phuthai and Ethnic Lao. The village chief does not know how many of these are ‘first 1000-days-households’. There are approximately 20 brick/concrete houses and approximately 30 wooden constructions on stilts with a brick/concrete enclosed area downstairs, while the vast of houses in the villages are wooden constructions on stilts with open downstairs. The main source of drinking water is bottled water. Some households may also get their drinking water from community wells. There are six wells in the village, however, only 2 of them are currently working. All households have access to latrines, either their own or a shared latrine, however, some households still practice open defecation, mainly when working in the forest or fields away from the village. There are approximately 20 retail shops in the village that sell soap, kitchen utensils and a variety of WASH products and construction materials. The village has never received support from development aid organizations or projects.
Tadhai Xe Located 30km from the district capital, Tadhai Xe is accessible year-round via a dirt road. There are 153 households in the village, comprised of Ethnic Lao, Phuthai, Khmu and mixed ethnicity households. A total of 90 households are identified as ‘first 1000-days-households’ by the village chief. A majority of houses are wooden constructions on stilts. Approximately 30 houses are wooden on stilts with a brick/concrete enclosed downstairs area and approximately 10 houses are brick/concrete constructions. Drinking water is primarily sourced from community wells, with some households buying bottled water. In the dry season, some households may use water from the river near the village or from a pond near the rice fields for drinking. In the wet season, they may use collected rainwater. There are 10 community wells in the village, constructed with support from PRF, however only 5 of them are currently working. Approximately 20% of the 153 households in the village have access to a private latrine. Remaining households practice open defecation. Village Walks furthermore noted that there were a large amount of animal faeces located throughout the village and no fencing of animals. Tadhai Xe is currently supported by the Poverty Reduction Fund, and has requested the fund support to construct additional boreholes as well as a kindergarten. The village has 14 retail shops selling soap and a small selection of kitchen utensils.
Gang Mai The rural village Gang Mai is located approximately 20 km from Phin district capital. The entire population is of Katang ethnic background. The village is accessible by car only in the dry season via a dirt road. In the wet season, the road is only passable by foot or motorbike. There are 51 households in the village. The village chief identifies 18 of these households as ‘first 1000-days-households’. There are 6 public wells in Gang Mai, all working year round. These are the main source of drinking water used by villagers. In addition, villagers use water from a stream, approximately 50m from the village, for bathing and washing of clothes. Less than 10% of households have access to a latrine with only 4 out of 51 households having their own latrine. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 20 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
A development project implemented by CIDSE, constructed 10 public latrines in the village a while ago, however, did not provide the village funding to construct sheds around the latrines for privacy. While villages have built sheds around 4 of these latrines, the remaining 6 latrines can be seen in the village still uncovered and therefore unused. The village is currently not supported by any aid projects, but have previously received support from the Japanese Volunteer Cooperation, who helped the village make rice banks. There are 3 retail shops in Gang Mai selling a few soap types. Kitchen utensils and other WASH related products are unavailable. Village walks noted that there were a lot of animal faeces located throughout the village and no fencing of animals.
4.3. Data Collection Methods The data collection for the Market Assessment included a review of secondary data and the collection of primary data using a variety of methods as outlined below.
4.3.1. Literature Review A review of literature was carried out to identify relevant information and data about WASH behaviours and to propose WASH products most likely to have a significant impact on child nutrition and the reduction of stunting rates in Lao PDR. The review included data and documents provided by SCI and its partner organisations, as well as information sought by the consultants.
4.3.2. Key Stakeholder Interviews A total of 28 key stakeholder interviews were carried out with government, development partners and commercial entities including: Ministry of Health, Department for Hygiene and Health Promotion; Provincial Health Departments (MCHC and Nam Saat) in two target provinces; District Health Departments (MCHC and Nam Saat) in two targeted districts; 17 development organisations working in the Nutrition and/or WASH sectors; 3 commercial enterprises. The aim of the interviews was to gather information about existing programmes, lessons learnt, potential communication channels and other opportunities and barriers for promotion of specific WASH behaviours. The interviews were carried out using open-ended questions to facilitate discussion. Minutes were drafted after each interview. A list of key stakeholder interviews is attached in the Appendix E: Assessment Protocol.
4.3.3. Village Walks
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Village Walks were undertaken in each of the 6 surveyed villages. The Walks consisted of a tour around the village with the Village Chief and/or other authority to make observations of and discuss infrastructure and local behaviours. During the Walk, observations and information provided by the Village Chief was recorded on the designed Village Walk Form. Pictures were taken to document the situation. Upon return from the field, data collected was compiled in an Excel sheet.
4.3.4. Household Visits Household Visits were conducted in a total of 90 ‘first 1000-days’ households (15 households in each of the 6 surveyed villages), to provide an insight into current drinking water management and hygiene and sanitation practices at a household level. Each visit combined observations of household structures and features and interviews with male and female household members. Observations and information collected were recorded on the designed Household Visit Form. Pictures were taken to document the situation. As illustrated in Table 3, the total sample included 14 households with pregnant women (16%) and 72 households with a child aged 0-24 months (80%). 23 of these households had a child under 6 months of age (26%), while 61 households had a child or children aged 6-24 months (68%). A total of 8 households had more than one child under 24 months (9%). The composition of surveyed households with pregnant women, child under 6 months and child 6-24 months varied little between villages, with the exception of Mahaxay, where a slightly higher percentage of households with pregnant women were sampled and Phin where a slightly higher percentage of households with children under 6 months were sampled.
Table 3: Sampled households in the 6 surveyed villages Village HH with HH with HH with HH with Total HH pregnant child 0-6 child 6-24 child 0-24 woman months months months Mahaxay, Khammouane 8 (18%) 9 (20%) 30 (67%) 37 (82%) 45 (100%) Phonsaat 1 (7%) 5 (33%) 10 (67%) 14 (93%) 15 (100%) Xangphok 2 (13%) 1 (7%) 12 (18%) 13 (87%) 15 (100%) Phanang 5 (33%) 3 (20%) 8 (53%) 10 (67%) 15 (100%) Phin, Savannakhet 6 (13%) 14 (31%) 31 (69%) 35 (78%) 45 (100%) Nonsaat 2 (13%) 7 (47%) 8 (53%) 13 (87%) 15 (100%) Tadhai Xe 2 (13%) 2 (13%) 12 (80%) 12 (80%) 15 (100%) Gang Mai 2 (13%) 5 (33%) 12 (73%) 10 (67%) 15 (100%) Total 14 (16%) 23 (26%) 61 (68%) 72 (80%) 90 (100%) Note: Categories not exclusive - some households have both pregnant woman and child age 0-6 month and/or 6-24 months.
4.3.5. Supplier Visits
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A total of 28 Supplier Visits were conducted to identified suppliers in the market area nearest to the sampled villages in order to provide an insight into the availability, cost levels and current demand of the assessed WASH products. Visits were mainly made to retailers of construction materials, including materials for latrine construction and fencing; retailers of kitchen utensils and plastic items, including water buckets, tin kettles, cups and glasses and village ‘khanom’ shops selling smaller items including drinks, snacks, soap, candles, etc. Observations and information collected was recorded on the designed Supplier Visit Form. Pictures were taken to document the situation.
Table 4: Number of Retailers surveyed per study site Village Retailers of Retailers of Retailers of Retailers of Total construction kitchen soap drinking Retailers materials / utensils / water Surveyed interior plastic items Mahaxay, Khammouane 4 4 7 8* 13 Phonsaat 2 0 1 2* 3 Xangphok 2 2 2 2 4 Phanang 0 2 4 4 5 Phin, Savannakhet 5 6 6 4* 15 Nonsaat 3 2 2 2* 6 Tadhai Xe 2 2 2 2 4 Gang Mai 0 2 2 0 4 Total 9 11 13 12* 28 Note: Categories are not exclusive. Some retailers sell products from more than one category. *Including two factories producing drinking water (20L bottles), one in each district.
4.3.6. Consumer Focus Groups A number of in-depth Consumer Focus Groups with product testing were designed in order to provide information about general aspirations, as well as specific product preferences and motivations related to the selected WASH products. The Consumer Focus Groups were carried out in two of the surveyed villages, Xangphok in Mahaxay District and Gang Mai in Phin District. In each village 4 sessions were completed examining the following products: 1) Soap for hand washing and dish washing with women from the previously surveyed households – including feedback on Soap4Life block and liquid soap samples provided to the households during Household Visits and presentation of new products including, block soap in different ‘child-friendly’ colours and shapes and block soap on rope. 2) Hand washing station - Happy Tap - presentation for women and men from ‘first 1000-days households’ – including practical testing of the Happy Tap by participating women, men and children washing hands with soap and water from the hand washing station. Furthermore, the Happy Tap was left with a selected ‘first 1000-days household’ overnight and feedback sought on their use of it during an interview with the family on the following day. In Gang Mai village, the team also built a Tippy Tap for the presentation and asked participants to compare the two hand washing stations.
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3) Water Filter presentation for women from ‘first 1000-days households’ – including presentation of TerraClear and Abundant Water filter systems, practical water drinking testing by participating women, and discussion of drinking practices and presentation of a special cup for the child. In Xangphok village, this session also sought their feedback on participant’s previous experiences of having a TerraClear water filter. 4) Water Filter presentation for men from ‘first 1000-days households’ – including presentation of TerraClear and Abundant Water filter systems, practical water drinking testing by participating men, and discussion of drinking practices and presentation of a special cup for the child. In Xangphok village, this session also sought their feedback on participant’s experiences of having a TerraClear water filter. In all of the group discussions feedback was sought on the usage and practicality of the product, preferences of different versions of the same products, preferences of design as well as willingness to pay.
Table 5: Number of participants in focus group sessions
Xangphok, Mahaxay Gang Mai, Phin
1) Soap 13 women, 13 children 13 women, 1 man, 12 children - Women’s Group
2) Hand Washing Station 10 men, 2 women, 12 children 6 women, 7 men, 4 children - Mixed Group
3) Water Filters and Cups 42 women, 6 children 12 women, 8 children - Women’s Group
4) Water Filters 31 men 19 men, 3 children - Men’s Group
4.4. Analysis 4.4.1. Data compilation, translation and cleaning During Village Walks, Household Visits and Supplier Visits, data was collected on printed paper-format questionnaires, to make it easy for surveyors to quickly note long answers to open ended questions. In the evening after each day of surveying, each surveyor translated the data they had collected during the Household Visits and entered it into an Excel database using mobile devices ensuring that the interviews were fresh in their memory. Data collected in Village Walks was likewise translated, entered directly into an Excel sheet on the day of the survey, while data collected during Supplier Visits was entered into an Excel sheet on the team’s return from the field. Consumer Focus Groups were facilitated by two team members, a facilitator and note taker. During the group session, the note taker assisted members of the focus group to complete the printed paper- questionnaires and took notes of the discussion. Audio recordings made of each session were also utilised to serve as back up. Upon return from the field, the facilitator listened to the audio recording, expanded on the notes, collated printed-paper questionnaires and translated the information to English. The data was further cleaned during the data analysis process where odd data was identified and missing data investigated by referring to the paper-format questionnaires.
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Photos taken during the interviews were labelled with IDs and categorized based on where the photo was taken (i.e. “soap by household toilet” or “soap in road-side shop”).
4.4.2. Analysis and presentation of findings Analysis of quantitative data was carried out on the final dataset in Excel, while qualitative data was integrated into the analysis to contextualize and provide more details about findings. Data from Village Walks was primarily used to give an overview of the situation at the different study sites. An overview of findings is presented in Appendix A. Details on the availability and cost levels of the assessed products were summarized in tables for each product type. These are attached in Appendix C. This information informed the analysis of access and barriers to uptake and behaviour change. Data from Household Visits further informed the analysis of risk behaviours and drivers and barriers for behavioural change. Basic tables were produced to illustrate findings. These tables are attached in Appendix B, while graphs were produced to illustrate selected findings in this report. Finally, information gathered in the Consumer Focus Groups was integrated into the analysis of barriers and drivers for product uptake and willingness to pay. Notes from the focus groups are attached in Appendix D.
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5. Assessment Findings
This section of the report provides a summary of findings. It consists of four sub-sections, each one addressing practices and products related to one of the four desired behaviour changes. Observed and reported behaviours are described and analysed in order to understand levels of risk and what products could have the greatest impact on prevention of stunting. The demand and barriers for uptake of the products are discussed considering the availability of products and the supply chain before recommendations for product promotion is presented. Detailed tables of findings are attached in the Appendices.
5.1. Consumption of clean drinking water by children aged 6 - 24 months 5.1.1. Observed behaviours and risks of contamination through consumption of unclean drinking water
Treatment of drinking water The risk of contamination through consumption of unclean drinking water is considered to be very high for children aged 6-24 months in the Nurture Project Areas, especially in the more remote areas of Phin district. The Assessment thus found that while majority of households in the surveyed villages located close to district centres, Phonsaat in Mahaxay and Nonsaat in Phin, consume mainly factory treated ‘bottled’ drinking water, one third of all surveyed households, drink untreated water directly from the source, mainly wells or boreholes.
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Untreated Water 9 Boiled and Filtered Water 6 Boiled Water Filtered Water 3 Bottled Water
0 Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 1: Main source of drinking water by number of households per village
While majority of households drinking untreated water are located in Gang Mai and Tadhai Xe, Phin, a few households in Xangphok, Phanang and Nonsaat also reported to be drinking untreated water. Generally, these households do not stand out as having less valuable household assets than other households in their village. In Gang Mai and Tadhai Xe, on the other hand, one of the assessed households stands out by drinking bottled water. Despite bottled drinking water being a significant household expense, only the one household in Tadhai Xe may be considered wealthier than other households in the village, based on
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Plate 3 and 4: Water filter and communal well observed in Phanang village, Mahaxay
All of the filters observed were of the brand TerraClear. While the two households in Nonsaat reported to have purchased their water filters on their own initiative, the households in Xangphok and Phanang had been encouraged to do so by World Vision, who distributed partly subsidized water filters in the villages in 2012. In 2012, the normal price of the TerraClear filter system was thus 199,000 LAK, however the households in Xangphok and Phanang reported to have paid 100,000 LAK for their filters. The two households in Nonsaat village that use filters may be considered relatively wealthier than other households in the two villages. These two households both have more of the assessed household assets than the average in their village and they both have their own toilet, which they have paid for fully by themselves.
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Despite having purchased a water filter in 2012, many of the surveyed households in both Xangphok and Phanang reported to be boiling their water at the time of this assessment. Feedback provided during the Consumer Focus Groups suggests that this is a result of the ceramic filters needing replacement after a few years use. Broken ceramic filters were indeed observed in a few of the visited households.18 Interestingly, two surveyed households (1 in Xangphok and 1 in Phanang, Mahaxay) reported to be boiling their drinking water after filtering it. This could suggest that they do not entirely trust the filtering method.
Storing of drinking water Experts consider both filtering and boiling safe methods of removing contaminants from drinking water, however after treatment, the water must be stored safely in a clean container under lid and preferably with a spout for pouring, to avoid recontamination before consumption. 19
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No treatment 9 Only bottled water 6 Spout, no lid Lid, no spout 3 Both lid and spout
0 Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 2: Water storage after treatment by boiling or filtering (number of all surveyed households)
Overall, the assessment found a high risk of recontamination of treated water due to unsafe storage. In the assessed households using boiling as treatment, the most common way of water storage observed was in some kind of container with lid, including a kettle, cooking pot or plastic bottle. However, less than one in four of these households reported to be cleaning this container every day, and very few to be using any kind of soap (mainly liquid dish wash) when they do clean the container. Approximately one third said they clean the container a few times per week and another third that they clean the container only once per week. Of the 10 households who reported to filter their drinking water only one household stored the clean water in a container without a lid. However, none of the households reported to be cleaning the container every day. Only 3 households reported to be cleaning the container more than once per week and only one of the 10 households reported to be using soap for cleaning the container.
18 TerraClear water filters are normally sold with a 4-year warranty also on the ceramic filters. It is the company’s experience that the ceramic filter may need replacement after 2-3 years. It is company policy to provide these replacements at no cost to the consumer within the 4-year warranty period. That households in Xangphok and Phanang villages have not had their filters replaced may be linked to the fact that the filters were distributed by another project and not directly by TerraClear and within TerraClear’s normal distribution scheme (Source: Stakeholder Interview with Nathan Cole, TerraClear - see more about this distribution scheme below). 19 2015 WHO: http://www.dwi.gov.uk/stakeholders/guidance-and-codes-of-practice/Boiling-water01-15.pdf Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 28 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
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No treatment 9 Only bottled water 6 No soap Powder Soap 3 Liquid Soap
- Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 3: Households treating water and using soap for washing water container (number of all surveyed households) Drinking practices Transferring the drinking water from the container to drinking cup or glass, by dipping the cup or other utensil directly into the drinking water poses a high risk of recontamination. This practice was particularly found to be an issue in the two more remote villages in Phin district, Tadhai Xe and Gang Mai. While most surveyed households in the Mahaxay district pour their drinking water into the cup, only half of surveyed households in Phin district pour the water. Of the remaining households in Phin, the majority dip the drinking cup or a special serving bowl (plastic) directly into the drinking water. Some of these households did not have cups or glasses and would therefore drink the water directly from the serving bowl. The assessment found no correlation between how many cups/glasses the household owns and the practice of ‘dipping’. However, in Tadhai Xe the 7 households that reported to be dipping generally own less of the other assessed household assets compared to other households in the same village. In Gang Mai, it was found that there was no difference in assets owned by households that ‘dip’ and households that ‘pour’.
Plate 5: Storage of drinking water observed in Tadhai Xe, Phin. In this household water is transferred to the cup by dipping it into the water container. Subsequently the cup is put back unwashed for the next user
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Children’s drinking practices Of the 90 households surveyed 61 reported to have a child aged 6-24 months. Almost all of these children were reported to drink water20 and most of them the same drinking water as other household members, including factory treated bottled water, home-treated by boiling or filtering or untreated water. Thus, the assessment found that in two out of five of households with children aged 6-24 months, the water consumed by the young child is untreated, while approximately half of the remaining children drink factory- treated ‘bottled’ water and one-half home-treated water.
15
12
9 Bottled Water 6 Treated Household Water Untreated Water 3
- Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 4: Type of drinking water consumed by children aged 6-24 months (of 59 children)
Again, the situation is worst in the two more remote villages in Phin district, Gang Mai and Tadhai Xe, where almost all the surveyed children aged 6-24 months, were reported to be drinking untreated water. Nine of the 61 households with children aged 6-24 months reported to give their child breast milk substitutes in form of milk-powder (nom phong/nom feun). These 9 households are spread across the 6 surveyed villages, and may all be considered relatively wealthier than other households in their villages based on the amount of observed household assets. Eight of them reported to use boiled water to mix the powder while only one household (located in Gang Mai, Phin) reported to be using untreated water directly from the source (well).
Cups and glasses The vast majority of the children aged 6-24 months drink water from a communal cup shared with other household members without cleaning between uses by different users. Only one child (in Phonsaat, Mahaxay) was reported to be using his/her own personal cup for drinking water. This child lives in a household quite similar to other surveyed households in the village, in terms of assets and access to infrastructure. The average number of glasses/cups observed in surveyed households was 13, however the number is high because of a few households owned many glasses/cups. The highest number of glasses/cups owned
20 A total of 23 of the surveyed households had a child younger than 6 months . Nine of these households reported that their child drinks water. However, one of these 9 households also have a child aged 6-24 months and may be referring to the older child when taking about drinking practices. It should be noted, that not all households with children aged 0-6 months reported on this question. Still, a total of 8 households reported that their child aged 0-6 consumes water, suggesting that exclusive breastfeeding is still not always practiced. Five of these households were located in Phin district and 3 in Mahaxay district. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 30 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
was thus 200 in Mahaxay and 30 in Phin, while two in five surveyed households had fewer glasses than household members. Seven households, all located in Gang Mai village, Phin, did not have any glasses or cups at all. These households drink water directly from the plastic bowl used to transfer the water from the container. Generally, a correlation is seen between how many cups, appliances and larger assets a household has. Thus, in Gang Mai of the 7 households that do not have any cups or glasses, 5 have none of the assessed kitchen appliances or larger assets. The two other households in Gang Mai have none of the assessed appliances or assets; these households own only 1 or 2 cups each.
Cleaning of child’s cups, glasses and bottles Communal drinking cups are rarely cleaned with more than a third of surveyed households with children aged 6-24 months drinking water, reporting to be cleaning the cup used by the child once per day and almost half once per week. Only very few of these households reported to clean the child’s cup every time it has been used. Baby bottles for drinking water are only used in 5 of the surveyed households with children aged 6-24 months. These bottles are commonly reported to be cleaned with use of boiled or hot water. Only one household reported to be using soap for washing the bottles. In 39 of the 90 visited households there was no soap observed in the kitchen. Soap was found in approximately 3/4 of kitchens in Mahaxay, while only in 1/3 of kitchens in Phin. Only one household in Phin, located in Nonsaat village, had dish washing soap in the kitchen while 7 of the 45 visited households in Mahaxay – mainly in Phonsaat - had dish washing soap in their kitchens.
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Every time after use 9 Once per day 6 Once per week 1-2 times per month 3 Never
- Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 5: Frequency of cleaning glass used for drinking by child aged 6-24 months by number of children reported to drink from a cup/glass per village
5.1.2. Drinking water consumer profiles The observed behaviours for various groups of drinking water consumers are summarised into four consumer profiles described below.
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Consumer Profile 1.1: Consumption of bottled water Consumer Profile 1.1 households are generally located in Phonsaat, Mahaxay, and Nonsaat, Phin, which are both located close to main roads and have easy access to their respective district capitals. Households consume factory treated bottled water which is purchased in a local shop or delivered directly to the house by a district based water producer. Water is stored in a bottle with lid and poured into the drinking utensil. Water is priced at 4,000 LAK per 20L bottle with households on average reporting to spend 23,000LAK per week on bottled water equating to 1,180,000 LAK per year. The key risk behaviour identified in Consumer 1.1 households is: Drinking utensils are rarely washed after each use and are shared by different household members.
Consumer Profile 1.2: Consumption of filtered water In 2012 World Vision distributed TerraClear water filtration systems to households in Xangphok and Phanang villages, Mahaxay, at a subsidised rate of 100,000 LAK per unit (full purchase price 1,000,000 LAK per unit). A limited number of households in these two villages continue to utilise the systems to filter water before consumption. The key risk factors identified in Consumer 1.2 households are: Drinking utensils are rarely washed after each use and are shared by different household members. Ceramic filters and tap break over time and are not replaced.
Consumer Profile 1.3: Consumption of boiled water Consumer Profile 1.3 households are largely located in Xangphok and Phanang villages, Mahaxay. Water is collected from private/communal wells or in a few cases directly from the stream and boiled before consumption. After boiling water is stored in containers with lids including kettles, pots, plastic bottles or jugs. The key risk factors identified in consumer 1.3 households are: When water is stored in a pot or container without spout or tap, water is usually transferred to drinking utensils by “dipping”. Drinking utensils are rarely washed after each use and are shared by different household members.
Consumer Profile 1.4: Consumption of untreated water Comprised largely of households in Tadhai Xe and Gang Mai, Phin District, consumer profile 1.4 households drink untreated water largely collected from private/communal boreholes or in some cases a stream or pond. Water is stored in pots or buckets with lids. The key risk factors identified in consumer 1.4 households are: The consumption of untreated, contaminated water. When water is stored in a pot or container without spout or tap water is usually transferred to drinking utensils by “dipping”. Drinking utensils are rarely washed after each use and are shared by different household members.
5.1.3. Drivers and barriers for investment in specific WASH products for consumption of clean drinking water by children aged 6-24 months
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Various products, assumed to potentially affect behaviours related to the consumption of clean drinking water by children aged 6-24 months, were identified in the Literature Review and assessed in the studied communities. These products are all listed in Table 6 below. While most of these products were found to be available in local markets and at relatively low cost, certain products, including water filters and special cups for children, were not available in the studied communities. A summary of findings for each product is attached in Appendix B, while this section of the report provides a discussion of potential drivers and barriers for each of the products, in consideration of consumer demands as well as local availability and cost for the consumer.
Table 6: Products for promotion of consumption of clean drinking Proposed products Objective of product introduction 1.1) Bottled water (various sizes) Water treatment to remove contamination 1.2) Water filters 1.3) Buckets with lid (various sizes of plastic buckets used for water filter system) 1.4) PVC pipe and connection bits (specific for construction of water filter system) 1.5) Container with tap (e.g. 20L water bottle with Safe storage of water to avoid re-contamination tap) 1.6) Tin kettle with lid and spout 1.7) Drinking glasses/cups Utensils to avoid recontamination by cup 1.8) Special cup for small children sharing 1.9) Dish wash soap To clean cups and water containers to avoid recontamination of drinking water
Bottled Water Reflecting an urban, modern lifestyle, factory treated ‘bottled water’ may be seen as an aspirational product that reduces household labour as water does not need to be treated by the household before consumption. Introduction of bottled water not only eliminates the risk of contamination from drinking untreated water, but also from recontamination due to poor storing. Bottled water is usually stored in the bottle it is purchased in, with a lid, and is poured directly from the bottle eliminating recontamination of the water from contact with unclean cups, utensils and other environmental contaminants. Bottled water is primarily utilised in the two of the surveyed villages located close to district centres and markets. The water is delivered to households in 20L bottles made of heavy duty plastic. The bottles are collected and refilled by the local water supply company. Small sized factory bottled water is also available in some of the more remote villages (200ml - 1500ml bottles), however not in those with no or very poor road access. Purchase of small bottles is significantly more expensive than the 20L bottles and not used as the main source of drinking water in any of the surveyed households. Thus, the litre price by purchase of smaller bottles was found to be between 3,333 LAK – 8,000 LAK in Mahaxay and between 3,333 LAK and 16,500 LAK in Phin, while the litre price by purchase of 20L bottles is 150 LAK in Mahaxay and 250 LAK in Phin.
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Besides availability and general lack of awareness of the risks of drinking untreated water, the main barrier to consumption of bottled water is assessed to be the high on-going cost. The introduction of bottled water thus poses an additional on-going expense to the household. A 20L bottle has a retail cost of 4,000 LAK. With households reporting an average weekly spending of 23,000 LAK/week, over a year this equates to an expense of more than 1,000,000 LAK, which is equal to the cost of purchasing the more expensive water filtration system from for example TerraClear. Households who are drinking untreated water as well as those who are boiling their drinking water are not used to have any expenses related to their water consumption. Although time consuming, boiling is cost free, as households mainly use firewood as fuel. As in most areas of the country, wood is available in the target districts and easily collected in the forest at no additional cost to the household.
Water filter systems: TerraClear & Abundant Water Ceramic water filters are an effective, cost efficient and environmentally friendly way to treat water. Water collected from a contaminated source can be put directly into the filter system removing bacteria, protozoa, helminths, turbidity and other suspended solids. Two water filtration system manufacturers were identified, including the commercial enterprise ‘TerraClear’ and the NGO ‘Abundant Water’. The ceramic filters, used in both systems, are produced in Lao PDR contributing to the local economy, while reducing the need to use firewood to boil drinking water and store water effectively avoiding recontamination. However, the design of the two filter systems varies significantly as does the retail price levels. The TerraClear system, consists of a square water container made of blue see-through plastic. The ceramic filter is placed within the square container. The untreated water is stored in a blue 20L water bottle, sitting on the top of the square container. Clean drinking water is accessed from the tap on the square container. The whole system is retailed as a ‘set’ at a retail price of 1,000,000 LAK. The Abundant Water system on the other hand, utilises locally available materials, including a black 35L plastic bucket for storage of the untreated water and a blue water bottle with tap for storage of the treated water, the two are connected by blue pvc pipes. The filter itself is placed inside the black plastic bucket. Consumers can choose to purchase the whole system at a total retail price of 170,000 LAK or just the filter itself, retailed at a price of 70,000 LAK. Potential barriers to the use of water filters are assessed to be the initial expense to purchase the filtration system, lack of awareness of the risks of drinking untreated water and lack of desirability of water filters to households using commercially bottled water. Barriers related to the effectiveness of water filters are the decreased use of product overtime due to lack of availability or access to replacement filters, incorrect cleaning, lack of maintenance of the filter and mistrust in the filters effectiveness. In households surveyed that were distributed TerraClear filters by World Vision in 2012, the use of the filter had decreased over time. This can be attributed to distrust of the products effectiveness and lack of replacement of filters when braking, perhaps because households had not made any investment in the filters. A study conducted in Cambodia by WSP and UNICEF on the use of ceramic filters thus concluded that households who contributed to the cost of purchasing the filter were more likely to continue to use the water filter over time than households that did not contribute financially to the cost of the product. To ensure sustained use of the product, filter parts and replacements must be readily available and accessible. Filter maintenance and reliability depends on the user, the ceramic filter surface requires regular cleaning to reduce surface deposits, which slow filtration rates. The TerraClear system includes a (nail)-brush to be used when cleaning the filter as well as printed maintenance instructions, while the Abundant Water
Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 34 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR system only includes instructions of cleaning but no specific cleaning tool. Incorrect cleaning methods such as cleaning with a soiled cloth could recontaminate the filtered water. Product education by suppliers is essential to reduce this problem. In stakeholder interviews TerraClear representatives noted that a challenge and potential deterrent to the use of water filters is that households currently using commercially treated bottled water often see filtration as a retrograde solution. The company addresses this point by highlighting the financial benefit during product demonstrations. The product is more expensive than the Abundant Water filter system, however, has a payment scheme that allows users to pay the system off in 10 monthly instalments with 90% of purchasers opting to utilise this option. Abundant Water likewise provides a credit scheme in which consumers pay a total of 280,000 LAK for the system over 4 monthly instalments of 70,000 LAK. Benefits of the Abundant Water filter system are affordability, effectiveness, the filter has a two-year guarantee and the user can construct and change the structure of the product components, and while TerraClear has its own distribution system, Abundant Water are working through local retailers and entrepreneurs, who receive training in system construction and maintenance. However, its design is not as attractive as the TerraClear system, it is not freestanding needing to be held upright by a structure and currently is only produced in small quantities. Whilst the TerraClear product is more expensive than the Abundant Water system, low-price is not always the primary motivator. Research of how best to market nutrition shows that people, despite low levels of resources, often will pay more for a product that is aspirational and can be deterred from using products that are seen as products for low socio-economic status households. Both filter systems were demonstrated to focus groups in target communities, acquiring feedback on the products. When not informed about the price of the products, both male and female participants noted that they preferred the TerraClear filter due to its more ‘modern’ and ‘urban’ design and the ‘clean’ taste of the water. It was mainly the black plastic bucket of the Abundant Water system that the participants did not like the look off as well as the taste it gave the water. When told about the price difference of the two filters, male participants changed their preference to the Abundant Water system, highlighting that they could build this filter system themselves, while the majority of the female participants still preferred the TerraClear filter.
Water storing containers The majority of surveyed households store home-treated drinking water in a container with a lid, which reduces environmental contamination. However, containers are not regularly cleaned and treated water can be recontaminated when unclean cups and utensils are placed directly into the container. To reduce the risk of recontamination of home-treated water, water storage containers with taps or spouts could be used allowing water to be poured directly from the container and into the cup. Tin kettles with lid and spout, suitable for boiling and storing of water after boiling, are widely available at district markets and in villages with good road access at a cost of 25,000 LAK - 30,000 LAK, however, not available in remote hard to access villages. Plastic water containers with tap, produced in Vietnam, can be found at the district market in Phin and retail for 25,000 LAK. Currently, there is limited availability of tapped plastic containers in villages surveyed with no availability in villages with poor road access.
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While the introduction of better storing options, and particularly options with taps or spout for pouring, could improve the consumption of drinking water in households that currently filter or boil their water, this approach would not have an impact on the households drinking untreated water (in the assessment found to be 33% of households). Furthermore, the risk of recontamination by the child drinking from an unsafe drinking utensil remains. Introduction of a child’s only water bottle may illuminate some of these risks, if the behaviour is supplemented with improved hygiene. Local availability of such bottles was, however, not directly assessed in this assessment.
Cups and glasses Seven households, all located in Gang Mai village, Phin, did not have any glasses or cups, and more than one third of the 90 surveyed households have fewer glasses than household members. Households who had drinking utensils preferred glasses. Of the 1175 glasses and cups observed 3/4 were made of glass, while approximately 1/4 were made of plastic and only very few were made of iron/steel. A serious risk issue is hygiene of drinking utensils. Cups and glasses are rarely washed after each use, with very few households reporting washing the cup used by a child after every use, increasing the spread of bacteria and germs from person to person. Additionally, close to one third of households reported placing unclean cups and utensils directly into the treated water risking recontamination. Cups and glasses are available for purchase in retail stores in district markets however limited supplies are available in villages with poor road access. The retail price of cups varied depending on type with glasses ranging from 30,000 LAK to 40,000 LAK for 12 glasses, and plastic cups retailed for 25,000 LAK for 12 cups. A single plastic cup cost about 2,500 LAK, while a single glass cost 3,000 LAK. As washing cups and glasses after each use is uncommon, increasing the number of cups or glasses per household allowing for each household member to have their own personalised cup or glass, or to leave cups and glasses aside for washing every time they have been used, could reduce the need for cup sharing. The benefits of increasing the number of cups per household would be increased if introduced in conjunction with a water storage solution with a tap (container with tap, water filtration system or 20L bottled water supply) reducing water recontamination by pouring water directly into cups and utensils.
Special cup for child Introducing an individual cup for each child in the household that is only used by the child can further reduce the spread of bacteria and germs to the child from cup sharing. The cup could be brightly coloured and aesthetically designed for children. Such cups were not observed in any of the surveyed households. Specially designed cups for children were also not available for purchase in any of the surveyed districts. Coloured plastic cups are available at the district markets and in villages located by main roads. The retail price is 25,000 LAK for 12 cups or 3,000 LAK if only one cup is bought. Examples of personalized coloured plastic cups for children were introduced to consumer focus groups in target villages for feedback. This included a cup with cartoon print and a cup with flower print. The cup with flower print had a handle. While consumers liked the idea of a special drinking utensil for the child, they expressed their concern of whether household members, in particular the small child, would be able to remember which cup to drink from. They did however note that having a handle on the utensil would make it user-friendlier for the small child.
Dishwashing soap
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Washing cups, glasses and water storing container with dishwashing soap after use removes bacteria and germs reducing their spread from person to person. Whilst dishwashing soap is available to purchase from retail stores in villages close to the main road for 10,000 LAK for 1 litre or 12,000 -16,000 LAK for 1.5 litre, it is not available in villages with poor road access. Of the surveyed households, almost half did not have soap in their kitchens. This can be attributed to dishwashing soap not being available to purchase in villages and/or lack of awareness of the need for using dishwashing soap to clean cups and utensils after each use. As part of the assessment, samples of Soap4Life dishwashing soap were distributed in target villages. Each visited household was thus given a 35ml sample of the soap provided in a small blue plastic water bottle. Households were given instructions on what to use the product for and product feedback was sought during focus group discussions with female consumers. While consumers liked that the dish soap did not contain chemicals, they disliked that the soap did not produce foam and that it did not have a strong smell. They did not find the soap durable and some of the participants found that it did not clean very well.
5.1.4. Recommendations for promotion of products to encourage consumption of clean drinking water by children aged 6-24 months The assessment concludes that overall, the risk of contamination through consumption of unclean drinking water is very high for children aged 6-24 months in the Nurture Project Areas, especially in the rural areas outside of district centres. While all of the assessed products potentially could help mitigate this risk, it is recommended to choose one or a combination of the below options for future marketing, that will promote consumption of treated water and appropriate storage to avoid recontamination and/or improve hygiene of drinking utensils:
1. Promotion of a cheaper water filter system – this filter system could be household based or community based, if a local entrepreneur could be trained to become the Village Water Maker in line with the proposed Village Soap Makers. Abundant Water has produced filter systems with larger capacity to be used mainly in schools. A partnership with Abundant Water could be sought to develop a more attractive household filter system (by finding a replacement for the black plastic bucket) or a community filter system with larger capacity. 2. Promotion of special water storage and drinking utensil for children for example a water bottle. This bottle should be large enough to contain the water consumed by the child in one day, but not too big for the child to hold and drink from. A special child friendly water bottle would combine the functions of clean storage and separate drinking. The marketing should promote that special water for the child is treated (boiled or filtered) every day and stored in the clean bottle, which only the child drinks from. The design should take easy hygiene and durability into consideration e.g. by avoiding sippy snout, straws and rubber nipples that are hard to clean while easy to break. 3. Promotion of dish wash soap and frequent washing of child’s drinking utensil. This soap could be produced and marketed specifically as child friendly dish wash, by locally trained Soap Makers. However, the soap should have a slightly stronger ‘fresh’ smell, if possible make bubbles or foam21 and should be provided in a user-friendly container, e.g. a strong 1L bottle with push pump, which
21 It was suggested by another soap maker in Vientiane, that adding coconut oil to the soap will increase the amount of foam. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 37 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
could be refilled by the Soap Maker. This soap bottle could be subsidised as part of the marketing strategy.
5.2. Hand washing with soap at key points 5.2.1. Observed behaviours and risks of contamination through lack of hand washing with soap Overall, the risk of contamination through soiled hands is assumed to be very high in the Nurture Project Areas. As discussed above, the assessment found high open defecation rates as well as high prevalence of animal presence in all of the surveyed villages. Further to this, hand washing practices were assessed to be very poor in majority of surveyed households.
Hand washing with soap at key points The level of awareness about key points of hand washing was found to be relatively good. When asked openly when they wash hands close half of the respondents mentioned 4 or more of the six Project defined key points key points. 10 respondents mentioned all of them, and only 3 respondents did not mention any of the key points. The key points mentioned by most respondents were ‘before eating’ (by almost all respondents); ‘after handling child’s faeces’ (by 3/4 of households with children aged 0-24 months); ‘after adult defecation’ (by app. 3/4 of respondents) and ‘before preparing food’ (by more than half of respondents).
45 40 35 30 25 20 15 10 5 - After toilet use After cleaning Before Before eating Before giving Before Never (adult child’s faeces preparing food child food breastfeeding defecation)
Mahaxay - Khammouane Phin - Savannakhet
Figure 6: Number of households claiming to wash hands at key points per district (Note: 10 of the 90 surveyed households did not have any children aged 0-24 months. Of the 80 households with children aged 0-24 months, 39 households are in Mahaxay and 41 households are in Phin). Relatively fewer respondents mentioned ‘before feeding child’ and ‘before breastfeeding ‘. Thus, only half of surveyed households with children aged 0-24 months claimed to be washing hands ‘before feeding child’ and 1 in 5 ‘before breastfeeding child.’ Rates were significantly lower in the villages located in Phin, and particularly low in Gang Mai and Tadhai Xe, where the team even came across 1 or 2 households that claimed to never wash their hands.
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45 40 35 30 25 20 15 10 5 - After adult After cleaning Before eating Before Before feeding Before Never defecation child's faeces preparing food child aged 0-24 breastfeeding months child aged 0-24 months
Mahaxay - Khammouane Phin - Savannakhet
Figure 7: Number of households reporting to be using soap to wash their hands at key points (Note: 10 of the 90 surveyed households did not have any children aged 0-24 months. Of the 80 households with children aged 0-24 months, 39 households are in Mahaxay and 41 households are in Phin).
When asked specifically about use of soap for hand washing at the various key points (as leading question) less than half of respondents confirmed to be using soap when washing ‘after adult defecation’, approximately 1/5 ‘before food handling’ and likewise 1/5 ‘before eating.’ Of the 61 surveyed households with children aged 0-24 months, more than half claimed to use soap for hand washing ‘after handling child’s faeces’, while only 6 said they used soap ‘before feeding child’ and 2 ‘before breast feeding child.’ Generally, there is a correlation between households washing hands with soap and how many of the assessed household assets they have. Although the sample size is not big enough to make final conclusions based on statistical analysis, it is still evident that there is a correlation: the more assets a household has, the more key points they claim to use soap for hand washing. The poorest hand washing behaviours were reported by respondents in Gang Mai, Phin. With regards to gender, there is a slight difference in interviews with male respondents and female respondents, with male respondents generally claiming to be using soap for hand washing at more key points than female respondents. The main type of soap used for hand washing is ‘block soap’, while a few respondents used other kinds of soap including dish wash, detergent and shampoo.
Hand washing of children aged 0-24 months Hand washing rates was found to be even lower for small children than for adults. When asked openly when they wash the hands on their child aged 0-24 months, 33 of the 80 surveyed households with children aged 0-24 months, mentioned ‘after helping child to toilet’, 47 mentioned ‘before the child is eating or being fed’, while 17 said ‘never’. Finally, more than half said that they never use soap when washing the hands of their child aged 0-24 months. Similar to adult hand washing, rates of hand washing of small children are generally lower in the more remote villages of Phin district, Tadhai Xe and Gang Mai, than in other surveyed villages.
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45 40 35 30 25 20 15 10 5 - After helping child Before child is After child has After child has After child has Never to toilet eating / feeding been playing been playing on touched animals child outside the floor
Mahaxay - Khammouane Phin - Savannakhet
Figure 8: Number of households claiming to help children aged 0-24 months wash hands at key points (Note: Of the 80 households with children aged 0-24 months, 39 households are in Mahaxay and 41 households are in Phin).
Less than half of surveyed households with children aged 0-24 months report to wash the hands of their child with soap. These households generally have more of the assessed household assets than the households who do not wash their child’s hands with soap. With regards to gender, similarly to adult hand washing, relatively fewer male respondents claim to wash child’s hands with soap than female respondents. When asked from what age a child’s hands need to be washed with soap the most common age noted by households was 12 months of age, however, responses ranged from 2 months to as high as 24 months. The reasons noted for not washing children’s hands with soap were that they were not old enough to play in dirt so therefore their hands were not dirty, or that they only washed children’s hands with water, as soap was not available in the household.
Availability of water and soap at key locations for hand washing Lack of availability of water and soap at key locations, including toilets and kitchens, are potential barriers for hand washing with soap at the defined key points. It is suggested that having a ‘special hand washing place’ in the household may have a positive impact on hand washing practices.22 Of the 90 surveyed households, only 28 reported to have a special place for hand washing, though more households than this actually had hand-washing stations by their toilet and/or kitchen. Of the households who considered themselves to have a special place for hand washing, this was mainly located within or near the kitchen (25 households), while only two households said that their special hand washing place was located outside the toilet and one household had a hand washing place in front of the house. Overall, a majority of households had stations for hand washing at the kitchen and/or toilet. 48 of the 90 surveyed households had access to a toilet – their own or shared with other households. The assessment found that water was available in 42 of these toilets, mainly stored in a ceramic jar, concrete tub or plastic bucket. Only two toilets had water stored under lid. Soap for hand washing was available in more than half of the toilets (not including detergent and toilet cleaner).
22 Availability of a ‘special place’ for hand washing is thus a USAID indicator for this project. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 40 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Figure 9: Households defining a ‘special place’ place for hand washing
All surveyed households had kitchens. Water was available in majority of kitchens, mainly stored in plastic buckets without lid or concrete tub without lid. Only 6 of the surveyed households had a tap in the kitchen. Five of these were located in Phonsaat, Mahaxay, and one in Nonsaat, Phin – both villages located close to district centres. 51 of the 90 households had some kind of soap in their kitchens, mainly block soap (more than half), while only 8 of the households had dish wash in their kitchens, and 11% detergent. Households with soap in their toilet and/or kitchen generally have more of the assessed household assets compared to households, who do not have soap in these key locations for hand washing. The worst cases are found in Gang Mai, which is also the most remote of the surveyed villages, and the only village where all surveyed households are of other ethnic background (Katang). Observations from household visits noted that soap, when available, was most often stored in a multi-use plastic basket or bucket together with other toiletries such as toothbrush, toothpaste, washcloth, scrubbing brush and shampoo (in 31 of 41 observed cases). Other storage options observed were plastic bags (in 2 of 41 observed cases) or other container (in 4 of 41 observed cases). Only 4 of the 41 observed cases have soap lying by itself near the water source. These households all had a sink with tap and the soap was stored on the sink.
Plate 6 & 7: Most common storage of soap observed in all surveyed villages
Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 41 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
5.2.2. Hand washing consumer profiles
Consumer Profile 2.1: Aware of key points, have water but no soap at key locations A majority of households surveyed across all villages fall into the consumer profile 2.1 category. Households in this category can list most of the project defined key points for adult hand washing. Water is available in both the kitchen and bathroom however soap is not available at either location, and hand washing among small children is rare. The key risk factors identified in consumer 2.1 households are: Household members do not use soap for hand washing; Most households do not wash the hands of children less than 1-year old.
Consumer Profile 2.2: Aware of key points, have water and soap at key locations These households are aware of most of the key points when adults should wash their hands. Soap and water are available both in the kitchen and bathroom however; soap is primarily used for washing clothes and showering. A few profile 2.2 households are located across all surveyed villages. The key risk factors identified in consumer 2.2 households are: Household members mainly use soap for showering and washing clothes; Most households do not wash the hands of children less than 1-year old.
5.2.3. Drivers and barriers towards investment in products promoting hand washing with soap at key points The products, assumed to potentially affect behaviours related to hand washing with soap at key points are listed in Table 7. Some of these products were found to be available in local markets. Block soap of various brands was thus observed to be available at a relatively low cost in all of the surveyed villages, while plastic products including materials needed for construction of a ‘Tippy Tap’ and basket for toiletries were sold in most villages with good road access. A summary of findings for each product is attached in Appendix B part 2, while the sections below describe current household behaviours, related to each of these products and potential drivers and barriers for uptake of the products desired behaviour change.
Table 7: Products for promotion of hand washing with soap at key points Proposed products Objective of product introduction 2.1) Soap produced by women trained by Soap4Life Increase access to soap / introduce ‘new’ special 2.2) Commercial block soap product for hand washing 2.3) Happy Tap 2.4) ‘Tippy tap’ materials Storage of water at key locations for hand washing (e.g. toilet, kitchen) 2.5) Container with tap (e.g. 20L water bottle with tap) 2.6) Plastic baskets Storage of soap at key locations for hand washing (e.g. dedicated hand washing place, toilet, kitchen)
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Soap Hand washing with soap and water at key points is a highly effective way to remove contaminants from hands reducing the ingestion of bacteria and germs. Soap is widely available for purchase in all surveyed villages with block soap being the most common type of soap found in households, however soap is rarely used for hand washing. The least expensive soap available retails for 2,000 LAK - 4,000 LAK per 100g block, with various brands, sizes and fragrances available at both district and village levels. Liquid soap was available in villages close to the main road, however, was not widely used for hand washing in households surveyed. Whilst soap was observed in a majority of surveyed households, it was primarily used for showering with almost 3/4 of households using block soap for this purpose. While close to 3/4 of household respondents reported washing hands after using the toilet, less than half reported using soap. Households reported that the main reasons they did not wash their hands with soap at key points were that soap was not available at key points, that they were unfamiliar with the need to, that they could not afford soap and that their hands were not dirty. Households who reported that they do wash hands with soap did so because of health concerns and because it made their hands clean. Soap4life is a local, non-profit organisation dedicated to improving hygiene, developing and supporting economic opportunities for critically impoverished families and developing a path for women to attain empowerment among their peers. The organization trains women to make natural soap products in their villages and provides basic sales training to soap makers, which includes door-to-door sales. Soap4life has been identified as a partner of the SCI Nurture project, which plans to train one woman from each target village to become a Soap Maker, as well as two Community Facilitators who will be responsible for engaging 1000-day households on infant and young child feeding and hygiene messages both by making household visits on a monthly basis and by facilitating peer support groups in the villages. Female household members are primarily responsible for purchasing soap and soap products. Of surveyed households, approximately 3/4 reported that the wife is responsible for buying soap. Few households mentioned a daughter or other female household member. These findings support Soap4Life’s strategy of training women to make and sell soap in villages. The block soap sample produced by Soap4Life for this Project is uncoloured and unscented and made with local and organic raw materials however natural colours and fragrances can be added. The 80g soap bar comes in Soap4Life, USAID and SCI branded cardboard package with a slogan highlighting that it is a natural product without chemicals. While Soap4Life has observed that the strong fragrance of other commercial soaps is a common barrier to the use of soap as it spoils the taste of food, the smell of soap was reported by some of the assessed households to be a motivator for hand washing as they liked the smell of their hands after washing with the soap. In consumer focus groups, it was also noted that the smell of the soap is important, however, while the group participants in Gang Mai, Phin, preferred the soft smell of the Soap4Life soap, participants in Xangphok, Mahaxay, said that they preferred soap with stronger smell. In addition to the smell, consumers further noted that soap should emit foam, something group participants in both Gang Mai and Xangphok noted to miss in the Soap4Life samples. To encourage soap use for hand washing and hand washing of small children, soap could be produced in various ‘child-friendly’ shapes and colours. It was further noted by group participants, that the packaging should be clear with pictures of children washing hands.
Storage of soap Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 43 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Not having soap available at key locations makes hand washing with soap at key points unpractical for the consumer. More than 1/3 of households did not have soap at key points for hand washing (in kitchens and toilets). Soap was found to be stored in the basket or other container used when showering. Improving the storing of soap at key locations could encourage use of soap for hand washing at key points. Promotion of hand washing in WASH programs is often focused on teaching people proper hand washing techniques and increasing awareness about key points of hand washing. Marketing of products that helps ensure availability of water and soap at key locations could further enable people to wash hands at key points and therefore support the desired behaviour change. Soap storage products could be packaged with Soap4Life soap or with products ensuring water availability (see below). Plastic baskets are available in retail stores in villages near the main road with limited or no access in villages with poor road access. Retailing for 5,000 LAK, they are an inexpensive way to store soap to reduce the risk of environmental and animal contamination. However, they are commonly associated with showering rather than hand washing. Soap on a rope is an alternate way to store soap at key points, the product is currently not sold in the target villages, however, product samples were demonstrated in two target villages during consumer focus group sessions. The response was very positive. Most consumers could immediately see the advantage of being able to access the soap easily at points of usage.
Containers for storing water at key locations A majority of surveyed households had water available at key locations for hand washing, including in kitchens and near toilets. This water was largely stored in plastic containers without a lid or in a tub without a lid. Plastic containers for water storage are cost effective, widely available, and portable and can be placed at key points to act as a physical reminder to wash hands. Plastic containers in various sizes are available for purchase in most villages with limited or no availability in villages with poor road access. Prices of containers range from 25,000LAK to 135,000LAK, depending on size (12L - 180L) and quality. However, whilst storage of water in containers is useful for flushing toilets, the water can become contaminated when soiled hands or contaminated pouring utensils are placed directly into the stored water, reducing the effectiveness of hand washing. Furthermore, this way of storing is known to the household, however does not encourage hand washing, particularly not hand washing for small children.
The ‘Happy Tap’ The Happy Tap (also called LaBobo) developed by WaterSHED Asia as part of a USAID funded grant, is a brightly coloured, purpose designed, portable hand washing device. The product does not require running water, has a place to store soap and can be placed at any height allowing easy access for children. WaterSHED report the product “reflects the right mix of aesthetic appeal, functionality, durability, and affordability.” WaterSHED is currently working with the private sector in Vietnam to help develop a sustainable, profitable commercial market for the product and aim to introduce 70,000 Happy Taps to the Vietnamese market reaching 280,000 people. In addition to household use the hand washing device has also been used in health clinics and schools with success.
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The purpose of the Happy Tap is to provide households with a convenient, specialized place for hand washing with soap and help reinforce good hygiene behaviour by acting as a physical reminder enabling hand washing at key locations. The product is attractively designed and the bright colour and green sticker are designed to make hand washing more fun for children.
Plate 8: Happy Tap in Vietnamese kitchen (http://www.watershedasia.org/handwashing)
The Happy Tap is not currently available in Lao PDR; however, the product has been launched in both Cambodia and Bangladesh besides Vietnam, showing that import may be an option. The product costs 15.00 USD in Vietnam, transport and retail costs would most likely increase the retail price in Lao PDR to an estimated 200,000 LAK - 250,000 LAK per unit. Similarly, priced household appliances that were noted in surveyed villages included electric rice cookers (in more than 1/3 of households), frying pans (in app. 1/4 of households)) and kettles (in app. 1/3 of households), suggesting that households may purchase products at this price point if the product is desirable enough to them. The Happy Tap was demonstrated in target villages during focus group sessions seeking feedback on product desirability, the price point households would be willing to pay for the product and where and when they would use the product. Here it was found that households were very interested in having a Happy Tap and could immediately see the advantages of it, especially in terms of encouraging children to wash hands. Group participants were attracted to the looks of it, however, were unlikely to be willing to pay 200,000 LAK for it (see further discussion of willingness to pay below).
The ‘Tippy Tap’ Providing a cheap alternative to the Happy Tap, the Tippy Tap is a hands-free hand washing device that can be constructed by households using low cost, readily available materials found in villages. Developed in Zimbabwe, the Tippy Tap is designed to be used in rural areas that do not have access to running water.23
23 2017 http://www.tippytap.org/the-tippy-tap Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 45 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
The system is operated by a foot lever requiring users hands to only come into contact with the soap, reducing product contamination from soiled hands. Constructed at the right height and decorated with stickers the product could be an easy and fun way for adults and children to wash their hands.
Plate 9 & 10: Tippy Tap (http://www.tippytap.org)
A reported deterrent to washing hands is that household water consumption increases requiring additional household labour to collect water. This is exacerbated the further households need to go to collect water. The Tippy Tap should only use 40ml of water for each hand wash, which is considerably less than the 500ml required to wash hands by pouring water on hands with a bowl or other utensils from water storage containers. Waste water from the Tippy Tap can be recycled and used on plants or it can go back into the water table.24 Materials for construction of Tippy Taps are available locally and the system can be set up at a total cost of 25,000 LAK. In Lao PDR, a few stakeholders including LuxDevelopment and UNICEF have promoted the Tippy Tap mainly as part of WASH in Schools programs, where the Tippy Tap has been built on school’s grounds.25 Less information is available on the success of promoting Tippy Taps in homes. Cambodian households surveyed in a WaterSHED Asia hand wash initiative reported that the main disadvantages of the Tippy Tap were difficulty of using the foot mechanisms, high frequency of refilling if the water container is not large enough, the durability and that children often needed help to operate the Tippy tap.26 Other potential barriers to use could be the unattractiveness of the product and the product being linked to low socio-economic household use.
24 ibid. 25 2017 LuxDevelopment: https://vte.luxdev.lu/en/activities/project/LAO/024 26 2009 WaterSHED Asia: Hand wash Initiative in Cambodia, Summary of Progress and Initial finding, http://www.watershedasia.org/wp-content/watershed_resources/Research_and_TA_Docs/WaterSHED _Handwash_Study_Cambodia_Overview.pdf Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 46 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Plate 11: Tippy Taps in Lao schools supported by Lux- Development (https://vte.luxdev.lu/en/activities/project/LAO/024)
Consumer feedback on the Tippy Tap was also sought during consumer focus groups in Project target areas, where consumers were asked to compare it to the Happy Tap (see below). While male consumers were very excited about the opportunity to construct something cheap by themselves, female consumers preferred the Happy Tap. They did not find the Tippy Tap as attractive, they found it too common, and thought it was not suitable for use by small children.
5.2.4. Recommendations for promotion of products to encourage hand washing with soap at key points Hand washing with soap can be increased by expanding the use of soap within communities and by encouraging more hand washing (i.e. hand washing with soap at all key points). Soap is available in most villages at low cost. Improved hand hygiene requires a product and a behaviour change based on motivations and practicality.27 Soap4Life has marketed their product in other contexts, by initially offering potential customers free soap in an effort to create product demand. However, as block soap is widely available and is currently already in a majority of surveyed households, it is considered important that the Soap4Life product is launched with a point of difference and that it is adapted to specifically target hand washing at key points. 1. Initial product recommendations include: That the Soap4Life soap is specifically marketed as a child friendly soap and as a hand washing soap;
27 UNICEF 2008: “More than soap and water: Taking hand washing with soap to scale”, Hand washing training manual. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 47 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
That the packaging style and branding be redesigned to reflect the soap as a child friendly soap and as a hand washing soap, while avoiding marketing as an ‘aid product’ which carries the connotation of being a ‘soap for the poor’; That Soap makers are equipped and trained to produce soaps in child friendly shapes and colours that will encourage children to use the soap, while clearly signalling to mothers and other caregivers that this soap is particularly good for their children. 2. It is further recommended to investigate other low-cost hand washing station options or designs. An example of such is the ‘Blue Tap’, made from a water container with tap and decorated with stickers.
Plate 12: ‘Blue Tap’
5.3. Use of improved sanitation facilities (open defecation free villages) 5.3.1. Observed behaviours and risk of contamination from poor sanitation
Latrine access and practices of open defecation The practice of open defecation is considered to be a significant contributor to the environmental contamination in the project target areas. Some of the surveyed households across all of the assessed villages, including households with access to a latrine, were thus found to practice open defecation. Of the 90 surveyed households, just over half (48 households) had access to a latrine. A majority of these households (38 households) had their own latrine, while the remaining 10 households had access to a shared latrine. Only in one of the assessed villages, Phonsaat in Mahaxay, did all surveyed households have access to a latrine.
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15
12
9 No access to toilet 6 Own toilet Shared toilet 3
0 Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 10: Number of surveyed households per village with access to own latrine, shared latrine or no latrine
15
12
9 OD Exclusively
6 OD occasionally Latrine Exclusively 3
0 Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai
Mahaxay - Khammouane Phin - Savannakhet
Figure 11: Number of surveyed households per village defecating in the open exclusively, occasionally or never
Just under half of the surveyed households (43 households) did not have access to a latrine, however, approximately two thirds (61 households) reported to defecate in the open. While the 43 households without access reported to be defecating in the open exclusively, 18 households reported to be defecating in the open occasionally and explained that this was mainly when working in fields or forest away from the village. The total open defecation rate was significantly higher in Phin district where almost all (41 of 45) surveyed households reported to be defecating in the open, compared to less than half (20 of 45) in Mahaxay district. The nearest open defecation occurred to a household dwelling was 4 meters, the maximum distance 6,000 meters and the average 358 meters. The average distance is relatively high because of the households mainly defecating in the open when working in the fields or forest away from the village. It was thus found that a total of 24 of the households who defecate in the open do so less than 50 meters from their household dwelling, and another 13 households within 51-100 meters from their household dwelling. A majority of these households are located in Gang Mai and Tadhai Xe villages, Phin.
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When asked what they like about their latrine, compared to defecating in the open, most respondents explained that the latrine is more convenient, especially in the rainy season. It is also clean and close to the house. They explained that they consider open defecation dirty, inconvenient during the rainy season and expressed their concern about the risk of snakes, mosquitos and other insects as well as the transfer of diseases. Only two of the surveyed households reported to prefer to defecate in the open, as water and toilet paper are not necessary. Both of these households were located Phin district, one in Gang Mai and one in Nonsaat.
12
10
8
< 50 m 6 51-100 m
4 101-500 m >500 m 2
0 Phonsaat Xangphok Phanang Nonsaat Tadhai Xe Gang Mai Mahaxay - Khammouane Phin - Savannakhet
Figure 12: Reported distance to place of open defecation in intervals by number of households
Latrine designs Latrines were observed in all of the 6 surveyed villages. Very little variation of design of the actual in-
ground latrine was found. All latrines were wet pits, the majority pour flush (47 households of 48). They all had slab and majority squatting pans.
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The design and materials used to construct the walls and flooring around latrines – the ‘bathrooms’ - however varied largely. More expensive structures utilized concrete to construct both the walls and flooring, a small number had tiles. Most commonly structures were enclosed with timber walls and concrete flooring.
Latrine acquisition Surveyed households reported that latrines were either purchased by the household or provided to the household by a project. Of the 48 surveyed households that had access to a latrine, almost half across Phanang and Xangphok, Mahaxay District and Gang Mai, Phin District were subsidized by aid projects. All households in Phanang, had received full support for latrines by Nam Theun 2. In Plate 13: Typical latrine Plate 14: Best Latrine Plate 15: Worst latrine (Phonsaat, Mahaxay) (Phonsaat, Mahaxay) (Xangphok, Mahaxay) Xangphok some households had received support for latrine construction many years ago (most likely when the village was smaller). Here just under half of the surveyed households had access to a latrine. Finally, Gang Mai village, Phin, received support for latrine construction from a CIDSE project that installed 10 latrines in the village in year 2000. These latrines were however built, without support for construction of the surrounding structures/ shed/shelters. Thus, it was left to the villagers themselves to make such structures, resulting in only 4 of these latrines being in use. These 4 latrines all have a privacy shelter (floor, walls and roof), built by individual villagers/ households. The remaining 6 toilets still lay bare in the village and are therefore not in use.
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Plate 16: Latrine, Gang Mai, Phin
Household funded latrines accounted for more than half (28 latrines) of the latrines in households interviewed. In a majority of these households it had been the household head’s decision to invest in a latrine, while it had been a joint decision between more household members in approximately one third of the households.
Cost of latrine Of the 48 households with sanitation access, 40 households reported to have invested fully or partly in the latrine. 9 of these households reported to have paid between 40,000 LAK and 300,000 LAK for the latrine, mainly as payment for transportation of materials. A further 3 households reported to have paid partly for the investment, 2 of them 1,000,000 LAK and one 1,500,000 LAK, mainly for construction of the bathroom around the latrine. 28 households reported to have paid fully for the latrine. Amounts paid varied between 1,000,000 LAK and 16,000,000 LAK, with 14 households reporting to have paid less than 5,000,000 LAK and 13 households between 5,000,000 LAK and 10,000,000 LAK, while only one household had paid more than 10,000,000 LAK (this was the household with two latrines). The average investment made by the households reporting to have paid for the latrine in full was 5,107,500 LAK. There seems to be a correlation between how many of the assessed household assets the households own and the investment in a latrine. Households with non-subsidized latrines thus generally owned more of the assessed household assets than household who had a partially or fully subsidized latrine or no latrine.
Difficulties of latrine construction Of the 19 households that have project-funded toilets, 6 said nothing was difficult. They had received the materials by the project and it had been easy for them to build the latrine and bathroom by themselves. The remaining 13 households said it was difficult or expensive to find sand and gravel and to pay for the transport of materials.
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Of the 28 households who had fully paid for the latrine, the most common difficulty met was that they had no experience in building a toilet and that it was difficult to get hold of the materials needed. Some of them furthermore said that it had been difficult to find enough money for the investment.
Latrine aspirations Latrine aspirations are assessed based on what respondents with access to a latrine would like to improve about their current latrine. 41 of the 48 households with access to a latrine thus reported a desire to improve their latrine, while only 7 households were content with the conditions of their current latrine. Most of the respondent explained that they would like their latrine/bathroom to look nicer, with tiled floors and walls. Some would like their bathroom to be bigger and some would like to have an extra bathroom. As described above most commonly bathrooms were enclosed with timber walls and concrete flooring. Only one household had more than one latrine.
5.3.2. Sanitation consumer profiles
Consumer Profile 3.1: Exclusive usage of privately funded latrine Mainly found in Phonsaat, Mahaxay, consumer profile 3.1 households have constructed and paid for latrines through their own initiative. The average household expenditure on installing the latrine was 5,000,000 LAK, with reported costs ranging between 1,000,000 LAK and 16,000,000 LAK. Most households have their own latrine with very few households reporting to share latrines. A large percentage of latrines are wet pit, pour flush with slabs and squatting pans, surrounded by wooden walls, concrete floors and tin roofs. Most households would like to improve their latrine by tiling the walls and floors. The reasons for having a latrine identified by consumer 3.1 households are: Open defecation is dirty, inconvenient when it rains and exposes them to snakes, mosquitos and disease transfer; Households consider their latrine clean and convenient as it is close to their house.
Consumer Profile 3.2: Exclusive usage of project subsidised latrine Consumer profile 3.2 households are largely found in Xangphok and Phanang villages in Mahaxay district. Aid projects have provided subsidies for households to construct latrines with some households contributing between 40,000 LAK - 300,000LAK for the transportation of materials and some households funding the construction of the shelter around the latrine contributing between 1,000,000 and 1,500,000 LAK. As among consumer profile 3.1 households the latrines are primarily wet pit, pour flush with slabs and squatting pans surrounded by wooden walls, concrete floors and tin roofs. Households in this profile group would also like to improve their latrines by adding tiles to the floors and walls. The reasons for having a latrine identified by consumer 3.2 households are similar to those defined by profile 3.1 households, including: Open defecation is dirty, inconvenient when it rains and exposes them to snakes, mosquitos and disease transfer. Households consider their latrine clean and convenient as it is close to their house.
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Consumer Profile 3.3: - Latrine access - occasional open defecation Found in 5 of the 6 surveyed villages, most commonly in Phanang in Mahaxay district and Nonsaat in Phin district, consumer profile 3.3 households have access to a private or shared latrine either fully household funded or subsidized by a project. As in consumer 3.1 and 3.2 households, latrines are primarily wet pit, pour flush with slabs and squatting pans surrounded by wooden walls, concrete floors and tin roofs. Households reported to practice open defecation when working away from the village in the field or forest with very few reporting to practice open defecation when in the village. The reasons for having a latrine identified by consumer 3.3 households are: Open defecation is dirty, inconvenient when it rains and exposes them to snakes, mosquitos and disease transfer.
Consumer Profile 3.4: - No latrine access/exclusive open defecation Profile 3.4 consumers were found in 5 of the 6 villages surveyed, however primarily in the Katang ethnic village, Gang Mai, Phin district. Profile 3.4 Households do not have access to a latrine and therefore practice open defecation exclusively. One third of households defecate less than 50 meters from their dwelling. The nearest open defecation occurred to a household dwelling was 4 meters, with the maximum distance reported being 6,000 meters. The reasons consumer 3.4 households desire a latrine are: Open defecation is dirty, inconvenient when it rains and exposes them to snakes, mosquitos and disease transfer. Few households reported to prefer open defecation, as there is no need for water or toilet paper.
5.3.3. Drivers and barriers for investment in improved sanitation Community Led Total Sanitation (CLTS) is the main strategy for promotion of improved sanitation currently implemented in Lao PDR. This is also the strategy chosen by the Nurture Project, who had entered into a partnership with Rural Development Association (RDA) for implementation of this approach, prior to this Market Assessment. The Assessment, in relation to improved sanitation, therefore focused on opportunities for making materials for latrine construction and water storage in bathrooms easily accessed by target population as listed in Table 8. All of these products were found to be available in local markets. A summary of findings for each product is attached in Appendix B part 3.
Table 8: Products for promotion of improved sanitation Proposed products Objective of product introduction 3.1) Material package ‘all-in-one’ for different types Make materials for latrine construction easy of latrines accessible for target population 3.2) Buckets with lid (various sizes of plastic Storage of water near pour flush latrine buckets) or other water storage
Self-constructed latrine
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A pour flush latrine with slab is considered a basic sanitation facility by the Joint Monitoring Programme (JMP) as it hygienically separates human excreta from human contact. A majority of households surveyed who had latrines utilised this system type. Whilst a majority of surveyed households reported they prefer to use a latrine and more than half have access to a private or shared latrine, only one third of households reported to use a latrine exclusively, with higher much rates in Mahaxay (25 of 45 interviewed households) than Phin (4 of 45 interviewed households). Almost half of the households surveyed reported to practice open defecation exclusively and more than two thirds reported to openly defecate at some point during the day largely when in the field or forest. Households reported that they openly defecate, as they do not have a latrine, that their latrine is broken and that they work in the field or forest and it is not convenient to return to their household during the day. A majority of households reported that they did not like open defecation reporting it was unclean with risk of disease, mosquitoes, insect and snakes were present, inconvenient and unsafe. Households reported that using a latrine was clean and convenient particularly during rainy season. Households were motivated to install latrines to increase comfort of family, as they have been advised by a public health officer to use a latrine, they wanted a latrine as other households had one, it is convenient and as they were able to afford to purchase at the time. Whilst households prefer to use a latrine reported barriers to investment and use of latrines were that households could not afford to purchase the materials, that materials were hard to find and that they did not know how to construct a latrine. Only one surveyed retail store located between Phin and Nonsaat stocked all the materials required to construct a latrine, while the store did offer a delivery service within 30km for 300,000LAK this added expense, which is a disincentive for low income households to install a latrine. Limited construction materials were available in other villages, with materials not available in hard to access villages. Gang Mai, had the highest reported levels of open defecation with all surveyed households reporting to practice open defecation exclusively. In 2000 CIDSE provided 10 latrines to the community, however, only 4 are currently in use as households were required to build the shelter around the latrine themselves and did not have enough money. In addition, there is a latrine at the school, however, it is not currently in use with a reported barrier being the need to collect water to flush with. Of the households who received latrines through projects reported, 6 reported no difficulties or barriers to the installation difficulties Reported barriers to installing household latrines were that construction materials were difficult to acquire, that households did not have experience building latrines and latrines were too expensive.
5.3.4. Recommendations for promotion of products for latrine construction Community Led Total Sanitation (CLTS) is the main strategy for promotion of improved sanitation chosen by the Nurture Project. Based on the findings of this Market Assessment it is recommended: 1. To assist households with access to a full package of materials needed for construction of in- ground latrine and over-ground shelter; 2. To assist households with technical knowhow; 3. To explore opportunities for setting up a 1-2-year credit scheme for monthly payments of instalments of 100,000LAK/month
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5.4. Separating children aged 0-24 months from environmental contaminants in the household and outside 5.4.1. Observed behaviours and risk of contamination from environmental contaminants
Child exposure to environmental contaminants Small children play on the ground indoors as well as outdoors, touch the ground and objects with their hands, put their hands and objects in their mouths and are therefore potentially at high risk of contamination from environmental contaminants. The risk of contamination from environmental contaminants is particularly high in areas, such as those targeted by the Nurture Project, where the population practice open defecation, rear livestock within or close to living areas and practice poor home hygiene. As mentioned above, the assessment found households practicing open defecation in all surveyed villages and a presence of livestock on the property of the vast majority of surveyed households, while hands of children aged 0-24 months were rarely washed with soap, if washed at all. However, the real risk of contamination is also dependent on the level of the child’s exposure to the environmental contamination. Observations and questions related to the time spent by children aged 0-24 months playing directly on the floor indoors or on the ground outdoors were therefore part of this assessment. A total of 80 surveyed households had children aged 0-24 months. In majority of these households (71 households), a child aged 0-24 months was present during the interview. Close to half of these children (32 children) were held or carried by a family member during the interview, while close to one quarter (18 children) were sleeping in a hanging basket/ crib/hammock, and another quarter (17 children) were observed playing on the floor inside the house. Only 3 children were observed playing on the ground outside and 1 child on the raised platform/rest under the house. Only two of the children playing on the floor indoors were doing so on a mat during the interview. In both cases this mat was made from plastic.
14 12 10
8 6 4 Hours pr 24 hours 2
- Sleeping in bed Sleeping in Carried by mother Playing on the Playing on the On a platform hanging basket / other family floor ground outside outside member
Mahaxay - Khammouane Phin - Savannakhet
Figure 13: Estimated average time spent per 24 hours on different locations by child aged 0-24 months
In Lao communities, it is common for small children to be carried in a sling on the hip or back of a parent. The relative high incidence of children being carried during the interview may however also be a result of the child being nervous about the presence of the unknown interviewer and wanting to be close to the parent. When asked to estimate average time spent by children aged 0-24 months in various locations during an average day, all households reported that their child would spend time being carried by a family member with the average estimated time carried being 3.4 hours/day.
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Most children were reported to play on the floor indoors or ground outdoors. A majority of households (74 of 80 households with children aged 0-24 months) thus reported that their child would play on the floor inside. The average estimated time spent, by the child playing on the floor indoors was 2.2 hours/day. 30 households reported that their child aged 0-24 months would play daily on the ground outside and the average estimated time spent by the child there was 1.5 hours/day.
Floor hygiene More than three quarters of surveyed households reported that animals, including cats, dogs and chickens, occasionally would enter their house. While majority of households reported to be cleaning their floor at least once per day, the main method of cleaning is to sweep the floor with a grass broom with only 8 of the 90 surveyed households washing their floor with water and soap. It is therefore very likely that children aged 0-24 months are in contact with germs and bacteria from animals when playing on the floor inside the house.
Use of mats Only 2 households with children aged 0-24 months reported to be using mats outside for their child’s play. Both mats were of natural material (e.g. grass or bamboo). A total of 17 households reported to be using mats when their child aged 0-24 months is playing on the floor inside. Mats are mainly made of plastic (by 15 households). These mats were however not special play mats for children, they were the normal mats often used when sitting on the floor inside, including during meals. In some households, such mats are laid out on the floor all day, in some they are removed when people are not sitting on them. While half of the mat users claimed to wash the mat occasionally, only 3 of them reported using soap.
5.4.2. Consumer profiles - separating children from contaminants
Consumer Profile 4.1: Young children play on bare floor Consumer profile 4.1 households were found in all surveyed villages with higher levels in Xangphok, Mahaxay district and Tadhai Xe, Phin district. Children between the ages of 0 - 24 months play directly on the floor, the average age being 14 months with very few children below 6 months playing directly on the floor. The average time children spent playing on the floor was 3.4 hours per day. Floors are primarily wooden and cleaned daily by sweeping, few household floors are regularly washed using soap and water.
Consumer Profile 4.2: - Young children play on a mat Profile 4.2 households were found in all surveyed villages, with higher percentages found in Phonsaat and Nonsaat, which are both located close to the main road with easy access to markets and their respective district capitals. Children between the age of 0 - 24 months play on the mat an average of 2.8 hours a day. The average age of these children was 12 months old with very few children below 6 months being left on the mat. Mats are largely made from plastic, with some households washing the mat regularly with water, very few washing the mat with water and soap and some reporting not to wash the mat at all.
Consumer Profile 4.3: - Young children do not play on floor Distributed evenly throughout all villages, consumer profile 4.3 households reported that children between the ages of 0 - 24 months do not play on the floor or a mat within the household.
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With an average age of 5 months old these children spend 1 - 2 hours more sleeping and being carried then children in consumer profile group 4.1 and 4.2 households. Older children in this group are reported to play on the ground outside.
5.4.3. Drivers and barriers towards investment in products that separate children aged 0-24 months from environmental contaminants in the household and outside The products, assumed to potentially affect behaviours related to the separation of children aged 0-24 months form environmental contaminants in the household and outside are listed in Table 9. These include products to remove the contamination as well as products that will separate the child from the contamination.
Table 9: Products for separation of children aged 0-24 months from environmental contaminants Proposed products Objective of product introduction 4.1) Cleaning materials including floor cleaner, Remove contamination from environment brooms and mops. 4.2) Play mats Remove child from direct contact with environment 4.3) Fencing materials Keep livestock away from children and/or play spaces While cleaning and fencing materials were found in the surveyed areas, actual play mats were not available, only mats normally used for household members to sit on. A summary of findings for each product is attached in Appendix A part 4, while the sections below describe current household behaviours, related to children aged 0-24 month’s exposure to environmental contaminants and potential drivers and barriers for uptake of the products desired behaviour change.
Brooms, mops and floor cleaner Cleaning the floor will remove contamination from the environment and since more than half of the households reported that their children spend time on the floor during the day and few of them use mats, the quality and frequency of cleaning floors have an impact on child health. Natural brooms made from grass are available in most areas of Lao PDR as they are often produced locally. Brooms were thus observed in various shops in both target districts. Prices range from 7-13,000 LAK. As almost all households already sweep their floors with this natural broom at least once per day, an improvement could be to change the behaviour towards washing the floors with water and soap as few practice this. Mops were however only observed in Phin district and only in one shop. A mop without a bucket costs 30,000 or 60,000 LAK. All-purpose cleaner or other soap meant to clean floors were not observed in any shops in the two target districts, they were however observed in households during household interviews. In Vientiane, the price was observed to be 15-16.000 LAK.
Play mats The introduction of ‘play mats’ could theoretically separate a child from the environmental contamination on the floor and ground. However, the mats must be kept clean and not pose a contamination vector in households where poor hygiene behaviours are practiced. Of the 18 households who reported that children played inside on a multi-use plastic mat, only 3 reported that the mat was washed with soap. Concentrating a child’s play area can increase bacteria and germs and
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if not sterilized properly could increase illness. Of particular concern is an increased risk of faecal contamination of the mat as children in target areas often observed not wearing nappies or underwear. Whilst specialized children’s play mats are not currently available to purchase in target villages, they could be imported. Play mats designed for children vary significantly in quality and price, retailing for approximately 5 USD to 150 USD per mat. The mats are generally constructed of washable plastic, foam, rubber, soft synthetic or cotton materials. Products purchased in bulk are significantly cheaper. Examples of mats available include an educational, brightly coloured mat with numbers, letters and pictures, that is easy to clean and made of organic rubber and a similar plastic mat with colourful illustrations advertised as a wipe clean mat. A specialized educational play-mat could be also developed for use in the Lao context.
Fencing As majority of households’ report that animals enter the house and few households wash their floor with water and soap, animal faeces inside the house can cause contamination. Fencing made from either plastic or metal can be bought in both districts in markets close to the main road. The price varies from 5-15,000 LAK per meter depending on the material. Fences can also be made from locally obtainable materials such as bamboo, rattan or wood and is thus a cheap way of keeping animals out of the house. In houses on stilts with an open area downstairs, it was observed in Xangphok that households had tied a rope between the top of the ladder and the rack on the first floor of the house, so the ladder could be tipped away from the house preventing chickens from climbing up.
5.4.4. Recommendations for promotion of products that separate children aged 0-24 months from environmental contaminants in the household and outside Based on the assessment findings, children in the Project target areas are assumed to be at high risk of environmental contaminants when playing indoors as well as on the ground outdoors, however products that could separate children from contamination, including play mats and floor cleaner are not currently available. In order to encourage separation of children from environmental contaminants, it is recommended: 1. To investigate whether liquid soap, produced by local soap makers can be used for floor washing; 2. To investigate further the production of a specialised play mat suitable for Lao children (with Lao letters and culturally relevant pictures).
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6. Willingness to Pay
6.1. Household buying power In order to get an understanding of the buying power and willingness to pay of the targeted population, the Market Assessment asked households about their ownership of certain kitchen appliances, including electric rice cooker, electric frying pan, electric kettle, gas stove, induction cooker, microwave, and refrigerator; as well as a few larger assets including car, motorbike, bicycle, tok-tok (tractor), satellite dish/TV, stereo, smart phone, mobile phone or other larger assets. Overall, many of the surveyed households have invested in smaller household assets. It was thus found that among the 90 surveyed households, the average of number of these specific kitchen appliances owned was 1.5 appliances per household ranging from 0.1 appliances in Gang Mai, Phin district, to 3.3 appliances in Phonsaat, Mahaxay district. More than one third of households reported to have none of the assessed kitchen appliances. The most common appliances were refrigerators, owned by more than half of the surveyed households. Interestingly at a normal purchase price around 2,000,000 LAK, this is also the most expensive of the assessed kitchen appliances. More than one third of surveyed households owned electric rice cookers, usually purchased at a price around 160,000 LAK, while less than one third of surveyed households had electric frying pans and/or electric kettles usually purchased at prices around 160,000 LAK and 140,000 LAK respectively. Very few of the surveyed households owned a gas stove, induction cooker or microwave. The average of specific larger assets owned was 3.5 assets per household ranging from 1.1 assets in Gang Mai, Phin district, to 5.1 asset in both of the more urban villages Phonsaat in Mahaxay and Nonsaat in Phin. Twelve households reported to own none of the assessed larger assets. All of these households are located in Gang Mai and Tadhai Xe, the two more remote villages surveyed in Phin district. A majority of households reported to have one or more of the most valuable assets, including cars. Of the 90 surveyed households, 12 reported to have car, while 52 households owned a tok-tok, a handheld tractor used to plough paddy fields and transport people and/or goods, and two thirds of surveyed households owned a motorbike. Finally, around two thirds of households owned a regular mobile phone and/or a TV, while less than one third owned a bicycle, stereo and/or smart phone. Comparing the two districts, Mahaxay and Phin, overall surveyed households in Mahaxay own more of the assessed kitchen appliances and assets than surveyed households in Phin district. The average number of assessed kitchen appliances in households was thus 1.7 appliances in Mahaxay district and 1.2 appliances in Phin district, and the average number of assessed larger assets was 4.0 assets in Mahaxay and 3.0 assets in Phin. Overall more of the surveyed households in Mahaxay owned some of the assessed appliances and assets, than of the surveyed households in Phin. In Mahaxay, all surveyed households reported to own one or more of the assessed larger assets and two thirds of surveyed households to own any one or more of the assessed kitchen appliances, while in Phin, 11 of the 45 surveyed households did not own any of the larger assets and more than half did not own any of the assessed appliances. Households with none or very few of the assessed kitchen appliances were mainly located in Gang Mai, Phin. Gang Mai is the only village in the sample of Katang ethnic background and is also the most remote and hardest to access of all surveyed villages. The village is connected to the electricity grid, however only
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one of the surveyed households had access to electricity.28 This household reported to own an electric rice cooker and an electric frying pan. Households in Gang Mai also had the lowest average of large assets, at 1.1 assets per household. Seven households reported not to own any of the assessed assets and only 2 reported to have a motorbike, while 5 households reported to have a tok-tok. Two thirds of households reported to have a refrigerator, most of them are located in Phonsaat and Phanang, Mahaxay. Phonsaat is the village in Mahaxay with the highest number of assets, both small and large, per household. All households had at least one kitchen appliance, half of them had 4 and more. 14 reported to have a refrigerator. No households had less than 3 assets and more than two thirds had 5 or more large assets. 1 household had 7 large assets Households in Xangphok have the lowest average of assets, big and small, in Mahaxay district. 11 households report to have no kitchen appliances and the rest of the households have a refrigerator. No households reported more than 2 kitchen appliances. All but one household reported to have 1 or more of the larger assets, most commonly motorbike (all), TV (all) and mobile phone (all). Only one household did not have car, tok-tok or motorbike. In Phanang the average number of kitchen appliances per household was 1.6 and 12 of the household had a refrigerator. Only 2 households reported to not have any kitchen appliances, both of those however having a tok-tok. Two thirds of the households reported to have 4 or more large assets and the most common assets were TV, regular mobile phone and motorbike. 9 households reported to have a tok-tok and 1 household reported to have a car. In Nonsaat no households reported to have 0 kitchen utensils and 13 households reported to have 3 or more. All households reported to have a refrigerator. All households in Nonsaat had 3 or more large assets and all households reported to have one or more of the 3 most valuable assets (4 had a car, 14 had a motorbike and 14 had a tok-tok). In Tadhai Xe 10 households reported to have no kitchen utensils and 4 reported to have 1 (two with a refrigerator, two with a rice cooker). One household had both electric rice cooker, frying pan, kettle and a refrigerator. This household also had 7 large assets whereas the overall average of large assets per household was 2.9. 9 households reported to have car, tok-tok or motorbike and 4 households reported to have no larger assets at all.
6.2. Willingness to pay The household’s willingness to pay for specific WASH products was assessed in consumer focus groups. This is a challenging exercise as it is often very difficult for respondents to decide on a price level for a product they are unfamiliar with. The assessment therefore used product demonstrations and hands-on testing and comparison of known and new products. The products tested in consumer focus groups included: two water filter systems, TerraClear and Abundant Water; special cup for child; the ‘Happy Tap’ and ‘Tippy Tap’; liquid dish wash samples from Soap4Life and hand washing block soap samples from Soap4Life including modified samples made into animal shapes and colours and soap on rope.
28 The Village Chief reported that it cost up to 2,400,000 LAK for a household to connect to the electricity grid. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 61 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
As illustrated in table 10 below, female consumers were willing to pay more for the water filters than male consumers, while none of the groups were close to be willing to pay the real market price for the products. Overall consumers in Mahaxay were willing to pay more for the products than consumers in Gang Mai, Phin, this finding was reflected in general with households in Gang Mai owning less assets than in other villages.
Table 10: Willingness to pay water filters and hand washing stations Group Participants: Water Filter Hand Washing Station TerraClear Abundant Happy Tap Tippy Tap Water 1,000,000 270,000 LAK 300,000 LAK 25,000 LAK LAK Xangphok Female 100,000 LAK 30,000 LAK 100,000 LAK - Mahaxay Male 50,000 LAK 30,000 LAK 100,000 LAK -
Gang Mai Female 60,000 LAK 50,000 LAK 20,000 LAK 2,000 LAK Phin Male 30,000 LAK 30,000 LAK 50,000 LAK 5,000 LAK
With regards to soap, the willingness to pay exercise concluded that consumers in Xangphok, Mahaxay were willing to pay similar or less for the Soap4Life samples than for known products, while consumers in Gang Mai, Phin, were willing to pay more for the Soap4Life block soap, however less for the liquid soap samples.
Table 11: Willingness to pay block soap and liquid dish wash Group Participants: Block Soap Liquid dish wash Soap4Life Commercial Soap4Life Commercial Sample Sample Sample Sample 60 gr 60 gr 350 ml 350 ml
Xangphok Female 3,000 LAK 3,000 LAK 3,000 LAK 5,000 LAK Mahaxay
Gang Mai Female 5,000 LAK 2,500 LAK 3,000 LAK 5,000 LAK Phin
Finally, with regards to a ‘special cup for the child’ the presented products included ‘normal’ shaped plastic cups in various colours that may be purchased locally for 2-3,000 LAK. While both male and female focus group participants in Xangphok, Mahaxay, found investment in such cups financially durable, they also noted that it would be difficult to ensure that only the child uses the cup. Focus group participants in Gang Mai, Phin, particularly the female participants, were much more positive towards the idea of a separate cup for the child, however worried about the cost, as they do not even have cups/glasses for adults to use and therefore mainly drink from a communal coconut shell or other bowl.
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7. Communication Channels
This section of the report provides a summary of current and emerging communication channels that may be utilised to reinforce product use and behavioural change within the Marketing Strategy. To determine the most effective way to introduce and market new WASH products to target communities it is important to understand the way information is disseminated within the communities. Information can be communicated in various ways including advertising, direct marketing, social media, popular culture, word of mouth and demonstrations/events. Currently, the target villages primarily utilise traditional forms of communication including television, radio, print media, notice boards, village meetings and village based broadcast. However, it is also important to incorporate and consider new communication channels which result from the rapid growth of new technologies, the expansion of broadband coverage and the implementation of new community based communication techniques in WASH programs. Evidence suggests that the most effective way to promote behavioural change is by utilising multiple channels and methods of communication, generating a unified, wide reaching message.29 Communication must be tailored to meet the needs of the community. Semi-urban communities surveyed that are located close to the main road and have access to WASH products may have different needs compared to remote communities with poor road access and limited availability of WASH products. The marketing strategy will consider the various communication channels and assess which will be most effective for each site within the project target area.
7.1. Community based communication channels Meetings, announcements, notice boards, temples and health centres are common communication channels used in villages to disseminate information to the community. Only two villages surveyed made announcements over a loud speaker, however, all surveyed villages reported to conduct community meetings (between 1-5 times a month) to disseminate information. Information was also displayed on community notice boards. All surveyed communities, excluding Nonsaat, reported that they held health outreach days between 1-2 times per year, which included communication of messages about WASH, vaccinations and malaria. The outreach meetings could provide an opportunity for WASH products to be demonstrated and/or sold. The Nurture Project will implement CLTS as detailed in the iNuW field guide (2016), which is a community wide approach raising awareness of the connection between malnutrition and open defecation and poor hygiene practices. The pre-triggering, triggering and post triggering phases present opportunities for village leaders and trained community facilitators to engage with “1000 day” households to help the adoption of positive behaviours around infant and young children feeding and hygiene. The complimentary community based communication channels detailed in the iNuW field guide provides an avenue to inform the community about, demonstrate and sell identified WASH products, particularly soap for hand washing at key points, hand washing stations and latrine packages to target communities. The private sector also provides information to communities through product promotion and training. An example of this is TerraClear promoting the benefits of using a water filtration system in communities
29 B Scott et al, Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana, Health Educ Res (2008) 23 (3): 392-401. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 63 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
and delivering water filtration systems direct to users and sales staff demonstrating how to correctly use the product. While surveyed villages do not currently hold market days or product fairs, villages located on the main road or with easy road access did report mobile suppliers periodically visiting their villages. Partnerships could be further developed with private sector suppliers to promote, demonstrate and sell identified WASH products and services to target communities at health outreach days, district market days and other community events. Demonstrations should be interactive and encourage households to purchase or sign up for the product on the day.30
7.2. Multi Media, Internet and mobile usage The most popular way to consume media in Lao PDR is via television. Television ownership is lower in rural areas than urban areas. In target villages 38% of households surveyed had a television and satellite dish. Village leaders reported that users watched television both for entertainment and for information purposes. Whilst print media, in the form of newspapers and magazines, is consumed in urban areas, village leaders reported that print media was not utilized in their communities. Radio was available in all villages and village leaders reported that it is used both for entertainment and as an information source. Radio listenership is highest in the central part of the country (25%), with only 8% in the northern part and 14% in the southern part reporting radio use.31 Limited studies have been conducted on the use of mobile technology and internet usage in Lao PDR. However, general trends have been established, which are similar across the SEA region. World Bank statistics thus showed that there were 53 mobile phone subscriptions per 100 people in Lao PDR in 2015, this number has decreased from 84 subscriptions per 100 people in 2011, though increased from 2% in 2000. 32 Of the households surveyed 71% had access to a mobile phone, though household members shared this phone. Whilst internet standards in Lao PDR lag behind neighbouring countries of Thailand (excluding North- Eastern Thailand) and China, mobile broadband services are continuing to expand throughout the country, with the expansion of broadband into rural areas being a priority of the Lao Government.33 IMF statistics (2016) show that 19.9% of the Lao population have access to the internet with a majority of users accessing via smart phone technology.34 Younger users access the internet more frequently than older users, with 15-24 year olds being the largest consumers.35 Of the households surveyed, 22% had access to a smart phone with internet access capabilities, however, data was not collected on internet usage.
30 PSI Vietnam: Social Marketing for Improved Water, Sanitation, and Hygiene, http://www.psi.org/publication/psi-vietnam- social-marketing-for-improved-water-sanitation-and-hygiene/ 31 “Consumer research in inform rural sanitation behaviour change and marketing communication for Lao PDR” EMC for WSP, 2014 32 http://data.worldbank.org/indicator/IT.CEL.SETS.P2?contextual=default&end=2015&locations=LA&name_desc =true&start=2000&view=chart 33 Harpur, P, Laos - Telecoms, Mobile, Broadband and Digital Media - Statistics and Analyses, 2016. 34 International Monetary Fund Statistics, http://www.imf.org/external/data.htm 35 Harpur, P, Laos - Telecoms, Mobile, Broadband and Digital Media - Statistics and Analyses, 2016. Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 64 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
Social media usage is growing across the region with Facebook reporting that the ASEAN market is one of their fastest growing markets in the world.36 Facebook is the most used social media site in Lao PDR (more than 95% of social media users) and is utilised for both social and business purposes.37 Instant messaging sites such as Snapchat, WhatsApp and Line are also widely used in Lao PDR, however no current data on usage is available. With mobile and internet usage, higher in urban areas than rural areas, use of these technologies to market WASH products in target areas may not currently be effective, however, it is important to monitor the growth of emerging technologies in rural areas for future utilisation.
36 Facebook, Presentation at ASEAN Private Sector Forum 37 Facebook, Presentation at ASEAN Private Sector Forum Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 65 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
8. Summary of Recommendations
Households surveyed in the Nurture Project Areas were found to be at high risk of contamination in all of the identified WASH behavior areas. The risk of contamination through consumption of unclean drinking water is considered to be very high for children aged 6-24 months. Consumption of untreated, contaminated water directly from source, consumption of water from shared, unwashed drinking utensils and inadequate water storage requiring water to be transferred by “dipping” unclean utensils, were the key risk factors identified. The risk of contamination through soiled hands is assumed to be very high in the Nurture Project Areas. The assessment identified households not washing hands with soap at key points and not washing the hands of small children as primary risk factors. In addition, Nurture Project Areas were found to have high levels of environmental contamination through the practice of open defecation and presence of animal faeces. In conjunction with poor home hygiene, children playing on the ground both indoors and outdoors are therefore potentially at high risk of contamination from environmental contaminants. Based on the risk factors identified in the assessment findings, it is recommended to select a group of WASH products that strengthen uptake of each other. These products could include: - 1. Household based and Community water filters Promotion of a cheaper water filter system – this filter system could be household based or community based, if a local entrepreneur could be trained to become the Village Water Maker in line with the proposed Village Soap Makers. Abundant Water has produced filter systems with larger capacity to be used mainly in schools. A partnership with Abundant Water could be sought to develop a more attractive household filter system (by finding a replacement of the black plastic bucket) or a community filter system with larger capacity. 2. Child specific water containers Promotion of special water storage and drinking utensil for child as for example a water bottle. This bottle should be large enough to contain the water consumed by the child in one day, but not too big for the child to hold and drink from. A special child friendly water bottle would combine the functions of clean storage and separate drinking. The marketing should promote that special water for the child is treated (boiled or filtered) every day and stored in the clean bottle, which only the child drinks from. The design should take easy hygiene and durability into consideration e.g. by avoiding sippy snout, straws and rubber nipples that are hard to clean while easy to break. 3. Dish wash soap produced by trained Soap Makers Promotion of dish wash soap and frequent washing of child’s drinking utensil. This soap could be produced and marketed specifically as child friendly dish wash, by locally trained Soap Makers. However, the soap should have a slightly stronger fresh smell, if possible make bobbles or foam, and should be provided in a user-friendly container, e.g. a strong 1L bottle with push pump, which could be refilled by the Soap Maker. This soap bottle could be subsidised as part of the marketing strategy. 4. Child friendly soap produced by Project trained Soap Makers That the Soap4Life soap is specifically marketed as a child friendly soap and as a hand washing soap. The packaging style and branding of the soap should be redesigned to demonstrate the product is a child friendly soap and as a hand washing soap, while avoiding marketing as an aid product which carries the connotation of being a soap for the poor. Soap makers are equipped Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 66 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
and trained to produce soaps in child friendly shapes and colours that will encourage children to use the soap, while clearly signalling to mothers and other caregivers that this soap is particularly good for their children. 5. Low cost hand washing station Investigate other low-cost hand washing station options or designs. An example of such is the Blue Tap made from a water container with tap and decorated with stickers. 6. Special designed play mat To investigate further the production of a specialised play mat suitable for Lao children (with Lao letters and culturally relevant pictures). 7. Floor cleaner produced by Project trained Soap Makers To investigate further if liquid soap, produced by local soap makers can be promoted for floor washing. 8. Full package of materials to construct latrines To assist households with access to a full package of materials needed for construction of in- ground latrine and over-ground shelter; assist households with technical know-how and explore opportunities for setting up a 1-2 year credit scheme for monthly payments of instalments of 100,000LAK/month. Furthermore, it is recommended that: - A ‘strong-child’ reference (cartoon/logo) be developed to brand all WASH products and other health, nutrition and WASH messaging. The private sector has long used cartoon’s and logo’s to successfully market products, particularly food to children.38 Studies show that marketing healthy behaviours to children using cartoons results in a more successful result then marketing without a cartoon.39 Associating the identified WASH products and behaviours with a purpose designed character will increase children’s engagement with the product and thus encourage positive WASH behaviours. It will also allow both adults and children to connect the ‘strong-child’ branded WASH products with good health. The branding can be used across a variety of communication channels including product packaging, advertisements, visual media, social media, games, toys and health programs and can be adapted as new technologies emerge. Multiple communication channels are utilised, specifically chosen for context, while phasing/prioritising marketing tools in accordance with local situation. Communication channels utilised by a village that is easily accessible by road may differ from channels utilised by a remote, difficult to access village. Partnerships be developed with private sector suppliers to promote, demonstrate and sell identified WASH products and services to target communities at health outreach days, district market fairs and other community events.
38 Calvert, S, Children as Consumers: Marketing and Advertising, http://files.eric.ed.gov/fulltext/EJ795864.pdf 39 Kraak, V et al, Influence of food companies' brand mascots and entertainment companies' cartoon media characters on children's diet and health: a systematic review and research needs, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359675/ Geo-Sys (Lao) Co., Ltd. Lao-Thai Road km3, Ban Wat Nak, Sisattanak, Vientiane, Lao PDR Email: [email protected]; Phone: +856 30 9286726 p.. 67 / 68 WASH Marketing Assessment and Strategy Development – Market Assessment Save the Children International – Lao PDR
9. References
Calvert, S, Children as Consumers: Marketing and Advertising, accessed 2017 http://files.eric.ed.gov/fulltext/EJ795864.pdf, 2008. Department for Planning and Investment, Khammouane Province, accessed 2017, http://dpikhammouane.gov.la/documents/Khammouaneprovince.pdf Department for Planning and Investment, Savannakhet Province, accessed 2017 http://dpisavannakhet.gov.la/documents/Savannakhetprovince.pdf Gap, K, Facebook, Presentation at ASEAN Private Sector Forum, 2016. Harpur, P, Laos - Telecoms, Mobile, Broadband and Digital Media - Statistics and Analyses, 2016. International Monetary Fund Statistics, accessed 2017, http://www.imf.org/external/data.htm Kraak, V et al, Influence of food companies' brand mascots and entertainment companies' cartoon media characters on children's diet and health: a systematic review and research needs, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359675/,2015. Lao Child Anthropometry Assessment Survey (LCAAS), 2015. Lux Development, https://vte.luxdev.lu/en/activities/project/LAO/024, 2017. Ministry of Health and Lao Statistics Bureau, Lao Social Indicator Survey (LSIS) 2011-12, Lao PDR, 2012. Population Services International (PSI), Vietnam: Social Marketing for Improved Water, Sanitation, and Hygiene, http://www.psi.org/publication/psi-vietnam-social-marketing-for-improved-water-sanitation-and- hygiene/, 2017. Scott,B, et al, Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana, Health Education Research (2008) 23 (3): 392- 401. Tippy Tap, http://www.tippytap.org/the-tippy-tap, accessed 2017. United Nations International Children’s Emergency Fund (UNICEF), More than soap and water: Taking hand washing with soap to scale, Hand washing training manual, 2008. Water and Sanitation Program, Consumer research in inform rural sanitation behaviour change and marketing communication for Lao PDR, 2014. World Bank Indicator Statistics, accessed 2017, http://data.worldbank.org/indicator/IT.CEL.SETS.P2?contextual=default&end=2015&locations=LA&name _desc =true&start=2000&view=chart World Food Program, https://www.wfp.org/countries/lao, 2017. World Health Organisation, http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf, 2014. World Health Organisation, http://www.who.int/ceh/risks/en/, 2017.
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