Handwashing and hygiene: measuring behaviour change

3 min read
Image: WaterAid/ Anil Cherukupalli

Handwashing with soap is a highly cost-effective public health intervention, but the questions of how to deliver successful behaviour change and how to monitor its effectiveness remain unanswered. WaterAid’s Technical Support Manager Om Prasad Gautam explores the issue.

At WaterAid, we have been implementing hygiene programmes since 1995 and, as in all our WASH work, behaviour change plays a central role. 

We know that hygiene is one of the most cost-effective public health interventions through which we can maximise benefits, saving millions of lives every year. Effective hygiene programming at scale is essential in improving behaviours: preventing diseases, maintaining health, and improving the full benefits of water and sanitation programmes. 

Behaviour change is also essential to creating sustainable services and maximising the public health impact of our investment in water and sanitation. Without hygiene behaviour change, toilets might not be used, water could still be contaminated, food will continue to be polluted, and dignity will be compromised. 

But, despite greater realisation, we still have not been able to crack all of the problems within the hygiene behaviour change domain. 

One of the most cost-effective public health interventions

Changing people’s behaviour is a complex undertaking; it is now broadly acknowledged that raising awareness of the importance of hygiene is not enough on its own to change and sustain behaviour.

A primary school student washing her hands before a mealtime at a waterpoint installed with WaterAid support. Karnataka, India.

Demonstrating good hygiene practices as part of daily routines, and sustaining this behaviour, requires innovation, creativity and novel approaches.

This is especially true for handwashing, which is recognised as one of the most cost-effective public health interventions.

Simply washing hands with soap and water after going to the toilet, before eating or feeding, and before preparing food helps people to protect themselves from life-threatening diseases.

Handwashing alone could cut the risk of diarrhoea almost in half and of pneumonia by a third, saving hundreds of children's lives every day – that’s why it’s essential to draw political attention to the need for a dedicated handwashing programme.

The challenges of measuring behavioural outcomes

In terms of measuring the behavioural outcomes associated with good hygiene, various methods have been tested.

Assessing hygiene behaviours requires simple, reliable and measurable indicators and approaches that minimise bias. Behaviour can be directly observed, or measured using proxy indicators, reported behaviours or assessment of knowledge. 

Assessment by observed behaviours is often gold standard but costly, not always easy and sometimes impossible to perform. As a result, proxy indicators have been used to ascertain whether behaviour has been happening and whether programmes are being effective. 

In light of this, we need to define an appropriate set of indicators to measure, monitor and evaluate at baseline, during programme implementation and in follow up, so that multiple methods and tools can be used to monitor and measure behavioural outcomes and the effect of the behaviour change programme.

A truly global issue

Hygiene is a truly global issue and certainly not one that has been ‘dealt’ with in high-, middle- and low-income countries. 

The recently adopted Goal 6 (of the 17 Global Goals) includes a target on hygiene, which is very good. However, there is still work to be done in the formation of these goals to ensure the world delivers on their potential, with decisions still to be made about how the world measures its progress; a dedicated indicator and measurement framework is needed to actually make all states and other actors accountable to delivering targets. 

Hygiene indicators would provide an opportunity to actually demonstrate whether we are concentrating efforts in cost-effective public health interventions  ̶  which is why it’s essential to include hygiene in the global indicators and to ensure that there are tools and methods available to measure its success.