The main communication objectives of the campaign were to:

• create awareness of the benefits of handwashing with soap among 50% of mothers and caregivers of children under five years and 50% of school children aged 6-15 years in the first year and raising it to 80% in the third year; and
• increase the practice of handwashing with soap at critical times among mothers and caregivers of children and school children aged 5-16 years by 50%.

To achieve these objectives, the programme used commercial marketing, through three main integrated communications channels: mass media, direct consumer contact (DCC), and a district-level programme through schools, health centres, and communities. The communication strategy, in addition, included a public relations and advocacy component that addressed policy makers and opinion leaders and promoted the provision of handwashing infrastructure in schools and public latrines.

Mass Media: During Phase One of the campaign, the programme utilised marketing strategies to promote handwashing with soap based on concepts that organisers considered most effective with mothers and schoolchildren. The campaign materials focused on "disgust based on nurture" as the key driver for behaviour change for mothers and caregivers and on "disgust based on acceptance by family" for children. The guiding concept for this phase of work was "your hands are only truly clean if washed with soap". Two radio adverts and 2 television adverts were produced. The 2 radio adverts and 1 of the television adverts addressed mothers and caregivers, while the remaining television advert addressed children. The radio and television adverts were supported by posters and billboards distributed in all 110 districts and 10 regional capitals of the country, and by the distribution of below-the-line materials such as badges, T-shirts, branded poly bags, and soap. The radio and television adverts ran for 6 months, with a more intensified focus in the first 3 months of the campaign.

Direct Consumer Contact (DCC): An event management firm visited 2 districts per region in 6 regions in Phase One and conducted 128 events in schools to reach 103,313 schoolchildren, 2,930 teachers, and 926 food vendors. They also ran 132 events in health centres and communities for 11,500 mothers. According to the Initiative, DCC is used as an interpersonal communication strategy that provides information on handwashing with soap in an interactive manner and provides a platform for the audience to raise concerns and have questions addressed.

District Level Programme: Handwashing Steering Committees in Ghana's 110 districts developed handwashing action plans for the implementation of the district-level programme. Each district was supported with funding from the World Bank Assisted Community Water and Sanitation Programme Phase Two (CWSP II) to organise a district launch event. In addition, orientation workshops were held for members of district and regional steering committees on the vision, objectives, rationale, and strategy for the PPPH Initiative in Ghana. The objective of the district-level programme was to ensure that all government facilities, health centres, schools, and community infrastructure deliver the handwashing with soap messages and advocate for the provision of handwashing facilities and soap in public and school toilets, especially because over 60% of the intended audience were estimated to use public toilets. District-level activities to support the campaign continued throughout 2004 and the first half of 2005.

Public Relations and Advocacy: Designed for opinion leaders and strategic audiences, this strategy component delivered continued press and media coverage in support of the aims of the handwashing campaign. A number of radio and television talk shows and interviews were broadcast on national media and district-specific FM radio stations. An advocacy brochure that outlined the strategy for the initiative was also produced and distributed to strategic audiences and partners.

The evaluation of the first six months of the communication campaign, undertaken in August 2004, confirmed that the campaign had on the whole been effective in creating awareness about the importance of and critical times for washing hands with soap. However, to maintain visibility, promote behaviour change, and maintain handwashing with soap, the PPPHW Initiative determined that it needed to continue to remind intended audiences of the handwashing with soap message. In the first half of 2005, the mass media programme was back on air on Ghana Television (GTV), the national television station, to reinforce the handwashing messages. In January 2005, there was a repeat broadcast of the television discussion programme in the six main local languages. In addition, several feature articles about the programme appeared in a number of newspapers, including Junior Graphic, a weekly paper for schoolchildren, and Public Agenda, a bi-weekly private newspaper for opinion leaders.

Health, Sanitation.

In Ghana, diarrhoea accounts for 25% of all deaths in children under 5 and is among the top 3 reported causes of morbidity. Children under 5 typically have 3 to 5 annual episodes of diarrhoea and a similar number of respiratory infections. According to statistics, 9 million episodes of disease could be prevented each year by washing hands with soap.

A handwashing behaviour study carried out in 2002 in 4 districts suggested that:

• 24% of mothers of children under 5 washed hands with soap after using the toilet while 41% used water alone; and
• 16% of mothers washed hands with soap after cleaning up a child who has defaecated while 28% used water alone.

The World Bank, the Water and Sanitation Program, the London School of Hygiene and Tropical Medicine, the Academy for Educational Development (AED), and the private sector - in collaboration with the United States Agency for International Development (USAID), the United Nations Children's Fund (UNICEF), and the Bank-Netherlands Water Partnership - have developed the Global Public-Private Partnership for Handwashing with Soap in an effort to promote the use of handwashing with soap in developing countries. The initiative aims to reduce the incidence of diarrhoeal diseases in economically poor communities through public-private partnerships (PPPs) promoting handwashing with soap.