FOAM and SaniFOAM are conceptual frameworks designed to help in the development, monitoring and evaluation of handwashing (FOAM) and sanitation (SaniFOAM) behaviours but can also be useful for a range of other health-related behaviour change programmes.
Focus, Opportunity, Ability and Motivation (FOAM) begins with Focus: clearly defining the desired target behaviour and the target group, followed by the identification and analysis of so-called behavioural determinants – factors that can facilitate or inhibit a behaviour of interest in a certain population. Behavioural determinants can be internal (factors that take place within a person’s mind, e.g. an individual’s knowledge or a belief) or external (factors that happen to an individual and are beyond their control, e.g. the availability of a product or social pressure from peers). SaniFOAM applies the FOAM approach specifically to sanitation behaviours (such as ceasing open defecation, or building a latrine). The behavioural determinants for both frameworks are broadly categorised and defined as follows:
Opportunity: does the individual have the chance to perform the behaviour? This depends on determinants such as access to and availability of products and services (e.g. a public toilet may have a sink but there is no soap available), product attributes (e.g. a badly maintained and smelly toilet), social norms (e.g. a public toilet user does not clean up after using it because the previous user did not) or explicit, formal sanctions and their enforcement (e.g. fines for not having a basic sanitation facility).
Ability: is the individual capable of performing the behaviour? This depends on determinants such as knowledge (inaccurate or lack of knowledge may prevent people from engaging in appropriate hygiene practices), Social Support T.46, skills (e.g. individuals know how to construct a toilet or empty a full latrine pit), roles and decisions (e.g. female heads of household may have the final say in hygiene matters but male heads of household decide on major household expenditures) and affordability (e.g. ability to pay for hygiene-related goods and services).
Motivation: does the individual want to perform the behaviour? This depends on determinants such as attitudes and beliefs that may prevent an individual from adopting positive behaviours. It includes emotional, physical or social drivers (such as safety, privacy, convenience and status) or the use of Social Norms and emotional reactions T.45 such as in the approach of Community-Led Total Sanitation (CLTS, F.2) or the willingness to pay (e.g. households might not see the benefit of a toilet in comparison to its costs).
Formative research prior to an intervention contributes to a more in-depth understanding of the most important behavioural determinants of the envisioned behaviours in that context. It enables programme planners to identify which determinants should be prioritised in the intervention.
Typically, formative research is carried out using tools such as:
FOAM also provides a useful checklist as well as a framework for organising the findings and it can be used to inform the design of questionnaires and observation tools.
FOAM is not usually recommended during an acute response because the in-depth formative research of behavioural determinants takes time. It can be applied from the stabilisation phase onwards. FOAM was developed initially for use in resource-poor settings but can be adapted to a variety of other contexts. FOAM and SaniFOAM can assist programme managers working in hygiene promotion at all stages of their interventions from programme design through implementation to Monitoring M.2 and Evaluation M.3.
Conducting formative research on the FOAM behavioural determinants takes time. Human resources are needed to conduct interviews T.23 or group discussions T.14, analyse data and design (and later implement) behaviour change interventions. The time needed depends on the target behaviour and target group and the available human resources; it can take several weeks or several months.
Whilst there is evidence from research in psychology on the determinants of behaviour there is little available evidence on the application of the FOAM approach itself. A recent review indicated that the overall quality of the evidence on ‘handwashing determinants’ remained poor and that the literature was skewed towards reporting certain types of determinants at the expense of a more complete understanding of the routines, norms, context and the physical and biological environments and motives.
Use the framework creatively to understand the Barriers and Motivators [T.3] for handwashing and sanitation
Use this approach to conduct a formative assessment in conjunction with other methods and tools
Do not underestimate the time required to undertake a thorough formative assessment
Do not forget to return to the findings to identify gaps and opportunities as the programme progresses
The CHISHPIN Project in Nigeria uses the CLTS F.2 approach, Nigeria’s national approach in the sanitation sector, but it used the SaniFOAM Framework for the baseline and KAP Survey T.24. The survey findings helped United Purpose, the grant holder, to answer questions about sanitation behaviour, especially on the barriers and motivators for change in sanitation practice.
To identify and address key determinants of hygiene behaviours
Devine, J. (2009): Introducing SaniFOAM: A Framework to Analyze Sanitation Behaviors to Design Effective Sanitation Programs, WSP World Bank
Coombes, Y., Devine, J. (2010): Introducing FOAM: A Framework to Analyze Handwashing Behaviors to Design Effective Handwashing Programs, WSP World Bank
White, S., Dreibelbis, R. et al. (2020): The Determinants of Handwashing Behaviour in Domestic Settings: An Integrative Systematic Review, International Journal of Hygiene and Environmental Health. Vol. 227