Handwashing with soap: why should we care?
Every year we celebrate Global Handwashing Day on 15 October with exciting, innovative activities across many countries. But why? What role should handwashing play in the global development agenda and why should we care about handwashing with soap? Om Gautam Prasad explains.
There is a simple and entirely sustainable way to improve the health and dignity of millions: handwashing with soap is one of the most cost-effective public health interventions in reducing the burden of global infectious diseases.1
Handwashing with soap (HWS) has been linked to:
- 16-23% reduction in risk of acute respiratory infection2
- 50% reduction in pneumonia3
- Substantial reduction in neonatal infections4
- Up to 48% reduction in risk of endemic diarrhoea.5
Repeated episodes of diarrhoea in early life have a long-lasting and irreversible impact on a child’s nutritional status6 and development potential. HWS has also been found to reduce school absenteeism by 43% fewer days.7 Infection-related infant deaths could be reduced by 27% by improving handwashing practices in healthcare facilities, and a further 40% by handwashing in the postnatal period.8 Not to mention that HWS also prevents other diseases such as Ebola, SARS and hospital-acquired infections.
Is handwashing with soap common worldwide?
Although it can prevent infection and save lives, good hand hygiene is not widespread in domestic, school and healthcare settings. Only 19% of people across the world wash their hands with soap after defecating.9 35% of healthcare facilities in low- and middle-income countries have no water and soap for handwashing10 and only 21% of schools in developing countries have handwashing facilities. Furthermore, compliance with handwashing behaviours are worse in many low-income settings.
How can we change behaviour?
Access to clean water and soap alone will not deliver the health and development benefits of handwashing. It is true behaviour change and the sustained and consistent practice of the new behaviour that ensures the positive results. Changing people’s behaviour is difficult and complex,11 but possible with the right approach and in the right context. Mounting evidence suggests that hygiene promotion programmes mostly focus on educating people about health, germs and disease often using complicated posters, leaflets and flipcharts. However, such approaches rarely result in positive, sustained behaviour change12 as they fail to account for the fundamental role of social norms, individual motives and environmental constraints.
Instead, evidence shows that certain factors can lead to more successful interventions. For example, the use of emotional triggers (disgust, nurture, affiliation and status) and the disruption of the social and physical setting where the behaviour should take place by placing eye-catching cues and visual reminders.13
Whatever the intervention, it needs to be simple, surprising, attractive and engaging. Behaviour change interventions and campaigns motivated by aspiration, for example, ‘be an ideal mother/ family’, ‘live in a clean village’, have all had success, but there are still lessons to be learnt.
Behaviour change is not a rocket science, nor a silver bullet; it is a social science and it requires a multi-disciplinary approach in order to design, implement and evaluate programmes more effectively. A collective effort from governments, donor agencies, I/NGOs, local capacity based organizations (CBOs), private sector, academia and civil society is urgently needed in the sector to implement and evaluate sustainable handwashing campaigns at scale.
Is handwashing adequately prioritised in global development agenda?
Target 6.2 of the Sustainable Development Goals (or Global Goals) calls on the global community to achieve access to adequate and equitable sanitation and hygiene for all by 2030. Despite this, hygiene still gets low levels of political attention in low and middle-income countries. One explanation for this is that historically, the WASH (water, sanitation and hygiene) sector focused on building taps and toilets, whilst the healthcare sector focused on treating patients and behaviour change has always been seen as a difficult undertaking.
Target 6.2 indicators for handwashing include the ‘proportion of populations with handwashing facilities with soap and water at home’. However, this indicator is just a proxy measurement, and doesn’t tell us whether people are actually practicing handwashing behaviours. There is therefore a need for each country to set up a behavioural outcomes-related indicator in addition to Target 6.2. Though there is growing recognition of the importance of behaviour change it is still highly neglected. The biggest challenge in the WASH sector right now is how to achieve sustained hygiene behaviour change at scale, and attain Global Goal 6 (clean water and sanitation for all). Not integrating handwashing with soap as part of the ongoing agenda in other development sectors such as health, education is a missed opportunity.
What role does WaterAid play?
Hygiene behaviour change is at the heart of all WASH programming because of its potential to maximise and improve health, wellbeing, and people's dignity. Handwashing with soap is one of the key behaviours on which WaterAid focuses. We aim to:
- Design an innovative behaviour change intervention package through a creative process informed by formative research.
- Execute a behaviour change intervention using novel approaches through sustainable service delivery mechanisms.
- Enhance capacity to integrate and scale up behaviour change programmes, within WASH and also sectors such as health (vaccination, neonatal care), nutrition, and education.
- Build monitoring and evaluating systems to demonstrate a sustained effect.
- Generate a body of evidence from our programmatic work to influence national and international policies, strategies and standards to impact the wider sector and development agenda.
WaterAid targets households, communities, healthcare and school and policy settings to implement hygiene programmes. We advocate for and implement hygiene promotion programmes everywhere we work, from the integration of hygiene into routine vaccination programme in Nepal, to the use of social art in behaviour change in Mali.
It is important that we continually engage governments about their national hygiene policies and work with them to formulate strategies. We must continue to work with academia and the private sector to research the factors that hold back the prioritisation of hygiene and innovate our behaviour change programming accordingly.
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4. Darmstadt G, Ahmed A, Saha S, Azad M, Alam M, Khatun M, et al. Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh. Journal of Perinatol. 2005; 25(5):331-5
5. Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in community: a systematic review. Lancet Infect Dis 2003: 3:275-81 and Aiello A, Coulborn R, Perez V, Larson E. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. American Journal of Public Health. 2008
6. Checkley W, Buckley G, Gilman R, Assis A, Guerrant R, Morris S, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. International Journal of Epidemiology. 2008; 37: 816-30
7. Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, et al. 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. 2007 Jun; 76(6): 1166-73
8. Evidence for action. MamaYe Facts and Figures on the link between Water, Sanitation and Hygiene (WASH) and Maternal and Newborn Health (MNH); 2015
9. Freeman M, Stocks M, Cumming O, Jeandron A, Higgins J, Wolf J, et al. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine and International Health. 2014; 19(9): 906-16
10.WHO, UNICEF. Water, sanitation and hygiene in health care facilities: Status in low- and middle-income countries and way forward; 2015
11.Curtis V, Kanki B, Cousens S, Sanou A, Diallo I, Mertens T. Dirt and diarrhoea: Formative research in hygiene promotion programme. Oxford University Press 1997; (12(2)): 122-31
12. Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A. Hygiene: new hopes and new horizons. Lancet Infect Dis. 2011; 11: 312-21
13. Biran A, Schmidt W, Varadharajan K, Rajaraman D, Kumar R, Greenland K, et al. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2014. March 2014; 2: e145–54
14. Gautam, O., et al., 2017. Trial of a Novel Intervention to Improve Multiple Food Hygiene Behaviours in Nepal. The American Journal of Tropical Medicine and Hygiene. ISSN: 0002-9637, E-ISSN: 1476-1645.