Global Handwashing Day in the sustainable development era
Om Prasad Gautam, Technical Support Manager for Hygiene at WaterAid UK, discusses what has and hasn’t worked so far in behaviour change around handwashing, and where focus should be applied.
Happy Global Handwashing Day!
15 October is Global Handwashing Day – a chance to highlight the importance of handwashing, bring multiple sector stakeholders together, and to share lessons. It offers us an opportunity to celebrate, to debate policies, challenges, and the monitoring of behaviour in different settings, and discuss cost-effective public health interventions that could prevent diseases and save millions of lives every year.
This year’s Global Handwashing Day theme is ‘Make Handwashing a Habit!’, focusing on long-term sustainability of behaviour change. Long-term change requires sectoral shifts to build understanding of how habits can be formed, of approaches to creative design and implementation of behaviour change programmes, and of scientific evaluation to demonstrate the sustained change.
Today around 900 children will die from the diarrhoeal diseases caused by poor water, sanitation, and hygiene practices around the globe. Their deaths are preventable and treatable, and handwashing plays a crucial part.
Handwashing with soap has been suggested to be the most cost-effective way to reduce the global infectious disease burden. It has been linked to a 47% reduction in risk of endemic diarrhoea, a 16–21% reduction in risk of acute respiratory infections, a 50% reduction in risk of pneumonia, substantial reductions in neonatal infections, and improved absorption of nutrients. Handwashing promotion has also been found to reduce school absenteeism by 43%.1,2,3
Education versus behaviour change
Despite the huge public health benefits of handwashing with soap, only up to 19% of people across the world world do so after defecating. A recent study in 54 low-income and middle-income countries found that 35% of health-care facilities had no water and soap for handwashing. The World Health Organization found that even in high-income settings where water and soap are available doctors and health workers are estimated to wash their hands on less than 38% of occasions on which WHO defines this as necessary. From the limited data available we see that only 21% of schools in developing countries have handwashing facilities.
Evidence shows that handwashing occurs predominantly when hands are visibly dirty, smelly, or greasy – often after eating rather than before. Soap is available in homes almost everywhere. However, it is regarded as a precious commodity and often prioritised for tasks such as bathing, clothes washing, and dishwashing.
However, traditionally, handwashing promotion interventions are limited. They have focused on educating communities about the link between handwashing with soap and germs or diseases, using materials such as posters, pamphlets, and leaflets. There is increasing evidence to suggest that education around handwashing using these messages to create fear is unlikely to change behaviour, and that these programmes increase knowledge but do not result in sustained behaviour change. Behaviour change has been seen as a greater challenge.
The Millennium Development Goal (MDG) era
We know what did and didn’t work in handwashing promotion in the MDG era:
- What didn’t work: health, germs, death, and disease-related messages didn’t change behaviour, except in crisis settings. Negative messages didn’t motivate people. Posters, leaflets, pamphlets, caps, and t-shirts, without accompanying participatory and surprising activities, didn’t work. The cognition model of behaviour change, that is training or education alone, didn’t work. One-off meetings, events, or focus group discussions to promote hygiene didn’t work.
- What did work: a systematic approach worked – for example, designing an intervention on the basis of formative research through creative process. Interventions based on emotional drivers such as nurture, disgust, status appeal, affiliation, purity, or comfort worked. Interventions based on changes in social and physical settings such as availability of behaviour change products in behaviour change places, placement of visual cues or nudges in behaviour places worked. Focus on behaviour change using surprising and engaging activities, consumer-centred marketing approaches, people-centric approaches, collective consensus, lots of participatory approaches, and interventions implemented in campaign approaches with inspirational desire (for example to become an ideal family or mother [SuperAma]) worked.
The Sustainable Development Goal (SDG) era
Handwashing with soap has been included in SDG 6, and in target 6.2 for sanitation and hygiene. Target 6.2 calls on the global community to achieve access to adequate and equitable sanitation and hygiene for all by 2030. Relevant indicators include the percentage of populations using safely managed sanitation services, including a handwashing facility with soap and water.
The targets aim to ensure that, by 2030, every health-care facility will have a reliable and sufficient supply of clean running water, safe toilets for patients and staff (child-friendly, with locks and lights, and accessible to people with disabilities), functional sinks, soap and alcohol-based hand rubs for health workers and patients in all treatment and birthing rooms, and sufficient cleaning materials to maintain a sterile environment.
Achievement of targets on hygiene and handwashing is important for attaining other targets such as those on child survival, nutrition, education, equity, and gender.
The inclusion of these targets is great news, but, if we hope to reach this worthwhile goal, we must break out of our ‘business as usual’ approach and change current weak practices. The sector needs new approaches to behaviour change.
Working to achieve goals
WaterAid, the London School of Hygiene and Tropical Medicine, and the Global Public-Private Partnership for Handwashing co-sponsored the 2016 Handwashing Think Tank event, and discussed three thematic areas for handwashing: integration; settings; and scale/sustainability. Experts exploring the cutting edge of each of these topics worked together to identify gaps and challenges, and articulate how the sector should respond.
At WaterAid, our experiences of working on hygiene including handwashing with soap have increased our focus on hygiene – our Global Strategy explicitly includes it. Handwashing with soap is one of the key behaviours on which we focus, both in programme and influencing work. Hygiene behaviour change is at the heart of all water, sanitation and hygiene (WASH) programming, because of its potential to maximise and improve health, wellbeing, and dignity.
Making key strategic shifts in our hygiene behaviour change programming, we have: designed an innovative behaviour change intervention package informed by formative research; executed a behaviour change intervention focusing on novel approaches through the sustainable service delivery mechanism; enhanced capacity to integrate and scale up behaviour change programmes, within WASH and also sectors such as health (vaccination, neonatal care), nutrition, and education; and we are building monitoring and evaluating systems to demonstrate a sustained effect. Apart from our regular hygiene promotion programmes in all countries where we work, the integration of hygiene into routine vaccination programmes in Nepal and a nationwide behaviour change campaign in Pakistan are examples of implementation at scale.
We are aware that there are various approaches in the sector to promotion of handwashing behaviour change, with some successes and challenges. You can read details of these in our new guide: Approaches to promoting behaviour-change around handwashing-with-soap.
It is important that we continually engage with governments in national hygiene policy and strategy formulation processes. We must be a partner in implementation, and work with academia and the private sector to continue research to address the factors that hold back prioritisation of hygiene and adoption of good hygiene practices.
We should monitor and evaluate behavioural outcomes throughout improvements in methods and processes. It is vital that the availability of handwashing stations with soap and water is measured as required by the SDGs; however, access to handwashing stations does not guarantee use. Programming and monitoring should both continue to attain sustained behaviour change and address the availability of facilities and products such as soap and water.
Handwashing in the SDG era
Building on what has worked so far, to attain sustained behaviour change we need to design an innovative and creative but simple and surprising behaviour change intervention, informed by formative research targeted at implementation at scale (district-wide and nation-wide). The policy environment should be conducive, with national strategies and guidelines, an institutional home for hygiene promotion, and a robust monitoring system in place to demonstrate effect. Hygiene promotion (handwashing) should be integral to WASH, health, nutrition, and education programmes.
This year, we are celebrating Global Handwashing Day with lots of excitement and innovative activities across many countries. One focus for this year is to work with health-care professionals to discuss how important handwashing with soap is to reducing the incidence of life-threatening preventable infections among newborns. We hope that this year’s focus will help realise and ascertain the need for WASH facilities and adequate handwashing behaviours in health-care settings.
- Bowen A, Ma H, Ou J, et al (2007). A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. The American journal of tropical medicine and hygiene. 76(6):1166-1173.
- Meadows E, Saux N. (2004). A systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children. BMC Public Health. 4(1):1.
- Talaat M, Afifi S, Dueger E, et al (2011). Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt. Emerg Infect Dis. 17(4):619-625.