Making hygiene behaviour change inclusive in responses to COVID-19

11 min read
Image: WaterAid/HSBC/ DIRK/ Parvez Ahmad

With the response to COVID-19 transitioning from emergency to long-term ways of working, Om Prasad Gautam and Lara Kontos look at how we are ensuring our hygiene campaigns include and reach everyone.

As COVID-19 has devastating impacts on people’s health, education and livelihoods across the globe, handwashing has never been better recognised as a first line of defence in public health. At WaterAid, our long experience of promoting handwashing with soap and water as part of our WASH (water, sanitation and hygiene) and behaviour change programming has enabled us to respond quickly to COVID-19, scaling up our existing hygiene work through government-led mechanisms, focusing mainly on hygiene behaviour change.

Tackling COVID-19 requires a comprehensive package including interventions that will protect people and prevent the disease from spreading. The first phase of our response is focused on promoting key hygiene behaviours such as handwashing with soap, respiratory hygiene (covering the mouth and nose when coughing or sneezing and wearing a mask in public), maintaining physical distance and cleaning frequently touched surfaces, to reduce the risk of transmission.

However, we know that many people are not able to practise these life-saving behaviours. For some people, deeply rooted inequalities and barriers they face daily mean they do not have access to clean water or a private place to use the toilet safely, let alone somewhere to wash their hands with soap or the ability to stay at home and avoid crowds. That is why it is critical that our hygiene response to COVID-19, complimented by increased access to water and sanitation facilities, is inclusive, accessible and attainable for all people – especially those already marginalised and excluded, because they are most at risk during this time.

Guardians of children under 15 months attending a hygiene session before the children are vaccinated, in a local health institution in Nepal,
Guardians of children aged 0-15 months attending a hygiene session as they wait for the children to be vaccinated at a local health centre in Nepal.
Image: WaterAid Nepal

Who is likely to be excluded during a pandemic?

Economic and social context, gender, disability, health and livelihood status all contribute to determining affordable access to WASH and the products (handwashing facilities, soap, masks) needed to practise good hygiene. Moreover, during crises marginalised people are even more at risk than they usually are because of the effects of social measures or scarcity of resources. Tackling these inequalities must therefore be central to our emergency response to COVID-19.

To ensure our hygiene response is inclusive, especially during this pandemic, we need to specifically respond to groups including:

  • People with disabilities – who might have limitations in accessing information, facilities and resources, and in performing self-care.
  • People living in poverty, informal or slum settlements or indigenous groups – who are more likely to have underlying health conditions and poor housing, and to be denied their rights.
  • Refugees and internally displaced people – who are particularly at risk because of overcrowding, social exclusion and lack of access to health services.
  • Homeless populations and groups with no access to services – who often rely on infrastructure such as public handwashing facilities and toilets. When these are closed or restricted for hygiene and physical distancing reasons, those with no other support will suffer.
  • People in particular social classes or castes, and socially excluded groups – who might be restricted from existing services and access points.
  • Women and children – who are often responsible for most hygiene-related work, yet whose voices may not be heard because they are excluded from decision making as a result of social norms and power dynamics.
  • People living in geographically remote or hard-to-reach areas – who will have poor access to safe water and to healthcare services.
WaterAid Zambia launches a universal handwashing facility accessible for people with disabilities to use, as part of our COVID-19 response.
WaterAid Zambia launches universal handwashing facilities that are accessible for people with disabilities, as part of our COVID-19 response.

Steps we are taking to ensure our hygiene response is inclusive and empowering

We are using a flexible Behaviour Centred Design approach to design and implement our hygiene programme, building on our organisational experience and expertise while following do no harm principles. We understand that traditional approaches to hygiene fail to change the behaviours of the people most in need, and can further entrench inequalities because these people are often socially excluded (PDF). Using the Behaviour Centred Design approach enables us to make programmes inclusive and focus our attention on specific groups – such as visually impaired people – and design a targeted hygiene behaviour campaign around their experiences and realities.

We define key behaviours for focus interventions, define target populations and design intervention packages with inclusive hygiene behavioural products, such as handwashing facilities for disabled people, through a creative process, responding to diverse needs and experiences of the target populations. Specific needs and motives may vary between target audiences, which is why we work with creative teams in consultation with groups such as disabled people's groups, women’s groups and youth groups when designing and disseminating materials to use in mass media, social media, digital and other non-contact promotional methods. COVID-19 has demanded enhanced creativity, because it limits our scope to reach individuals through direct contact or group gatherings.

As we continue to scale up our response activities, promote hygiene behaviour change and provide handwashing facilities, we must ensure we are using inclusive approaches that consider geographical, cultural and social dynamics and religious beliefs. COVID-19 is affecting people in different ways. It is vital to support gender- and socially inclusive responses in hygiene behaviour change and avoid stereotyping. We are doing this through four approaches: innovation; collaboration; driving inclusive programming; and increased advocacy.

1. Innovation to make inclusive handwashing facilities

We aim for our hygiene campaigns to be surprising and attention grabbing, focusing on defined behaviours. We want behaviours to last after COVID-19 has passed – while fear is currently one of the main drivers of new handwashing behaviours, we know this is a temporary stimulus. So, to ensure sustainability, it is crucial to add other motives such as attraction, social pride, affiliation and nurture to inspire people to practise key behaviours.

Many of our country teams are installing handwashing facilities in public places such as train and bus stations, marketplaces, schools and health centres. These are contactless – or hands-free – to prevent contamination. Many of these stations rely on foot pedals, which are difficult for wheelchair users to operate, so we are also making handwashing facilities that are designed to be accessible and inclusive to all, located in places that are safe for women, children and people with disabilities.

Some examples of our work:

  • In Zambia, we carried out a vulnerability assessment and partnered with disabled people's and women’s rights organisations to understand the issues they face in practising good hygiene behaviours. We also adapted hands-free handwashing facilities that don’t rely solely on foot pedals, so they are easy to use by people in wheelchairs or who have physical disabilities.
  • In Bangladesh, we have developed a technological list of handwashing stations (PDF) that are easy to use and based on context and target population.
  • In Nepal, we have developed a hands-free handwashing station with an adjustable basin height, making it child- and disability-friendly.
  • We developed a technical guide on handwashing facilities in public places, which contains inclusive and accessible designs. The siting of handwashing facilities for easy access is as important as the design of the facility itself; the guide has a list of very important initial considerations, which include consulting different users to understand their views, and making sure the handwashing facility is in a place that will make it easy and safe to use.

2. Ways of working

Partnerships and collaboration have always been key to our work. By working with government, local organisations and community leaders, we are well-placed to identify those who might be more at risk and to adapt our approaches to their needs. Working alongside disability rights, women’s rights and indigenous rights groups is essential to shape our response in a way that is empowering and does no harm.

During our formative assessment, where possible, and creative stages that shape the advertisements, visual images, or TV or radio content that communicates the ideal behaviours, we need to involve women’s groups, disabled people's groups and the people the intervention will target to develop context-specific interventions and products, and test them before producing them. We also do stakeholder mapping to identify the right partners. During implementation, special attention is given to specific groups, while avoiding stereotyping and negative exposure.

Some examples of our work:

  • In South Africa, we are supporting women and girls in domestic abuse centres, and collaborating with groups such as Days for Girls and United Nations Population Fund Africa, and running a joint media campaign with the Department of Women to integrate hygiene interventions with women’s other priorities.
  • In Zambia, we are collaborating with celebrities and people with disabilities to showcase the importance of handwashing for everyone, without discrimination, and to show some of the challenges faced by people with disabilities that need to be addressed to avoid creating barriers to access.
  • In Madagascar, we are working with local government to disinfect primary schools in Nanisana so they can be used as temporary shelters by homeless people. Additionally, we have created specific hygiene campaigns for people with hearing impairments.
  • In Timor-Leste and Zambia, we are supporting rapid vulnerability assessments to identify people who are vulnerable and how to mitigate dangers for them.
  • We are sharing documents and guidance with our external networks and contributing to a global hygiene hub to support actors in low- and middle-income countries. There are specific pages on gender, disability, and working in camps and camp-like settings and water-scarce areas.
  • We make sure our messaging and images do not reinforce gender stereotypes in relation to WASH, for example we show men as well as women performing WASH tasks in any media assets we produce.
  • We work with specialist partners to continually make our work more inclusive where possible. For example, we work with slum dwellers’ associations, women’s rights groups and disabled people’s organisations to make sure we understand what approaches and messages will be most effective.
A man reads awareness-raising messages through a megaphone from the back of a tricycle as part of the COVID-19 response. Bangladesh. April 2020
Public health COVID-19 awareness-raising messages have been spread to communities across Bangladesh.

3. Inclusive packages

We need to ensure, as much as possible, that package materials and dissemination approaches are inclusive to a diverse population. Because increased handwashing increases the need for water and soap, the burden and pressure on those responsible for collecting water is increased. To avoid strengthening the idea that it is a particular person’s responsibility to do this, we create promotional materials that portray everyone in the household participating in household duties (i.e. not just women). Similarly, people with different impairments, for example visual, have different needs for accessing behaviour change promotions. We adapt communications, information and materials on COVID-19 to be appropriate, accessible and inclusive, and ensure they reach marginalised groups where possible.

Some examples from where we work:

  • In Ghana and Colombia, we are developing hygiene campaign materials in indigenous languages to reach rural communities with hygiene promotion and handwashing facilities. In many countries we are producing hygiene behaviour change packages in local languages.
  • In Bangladesh, we are ensuring slum inhabitants receive accurate information on COVID-19 and its prevention.
  • In Mozambique, we created a video showing people of different abilities washing their hands.
  • In Nepal, Bangladesh and eSwatini, we produced a series of videos featuring sign language instructions to cater to audiences with hearing impairments.
  • In eSwatini, we published a news article on tackling inequalities in COVID-19 response work and addressing the need for available and inclusive toilets for people with disabilities and women and girls.
  • In Tanzania, we are using vehicles branded with messages and megaphones to reach rural communities.
  • We led mobile hygiene campaigns in Zambia using a drone and in Mozambique using branded cars and trucks to take messages to hard-to-reach communities.
  • In many countries, we are using loud-speakers to reach people who cannot access TV, radio or mobile.
A still from a TV advert created by WaterAid Ethiopia featuring a sign language interpreter as part of their hygiene behaviour change programme response.
A still from a TV advert created by WaterAid Ethiopia featuring a sign language interpreter, as part of the team's hygiene behaviour change programme response.
Image: WaterAid Ethiopia

4. Advocacy and influencing

Advocacy is another key area of our focus; now more than ever this is critical, to put WASH and, especially, hygiene behaviour change at the top of policy makers’ agendas. COVID-19 has shed light on the fact that many people do not have access to water and soap for basic handwashing – this is an opportunity to remind governments of their responsibility to fulfil the human rights to water and sanitation.

How to advocate hygiene behaviour change:

  • Ensure hygiene services and behaviour change programmes are prioritised and funded within COVID-19 responses and tracking.
  • Advocate that governments are held accountable for water supply and availability. Access to water for domestic use is a human right, and governments have an obligation to ensure everyone has access.
  • Promote inclusion of hygiene components in routine monitoring, and ensure hygiene data (including age, disability, gender and location) are presented and analysed during sector and programme reviews.
  • Advocate alongside and in support of marginalised people – they will likely be disproportionately impacted on by COVID-19. For example, in Bangladesh we are advocating that suppliers provide water for informal settlements.
  • Advocate that financial and coordination mechanisms promote hygiene in schools, communities, healthcare facilities and workplaces. Advocate basic minimum hygiene and health standards for these environments.

Hygiene behaviour change at the forefront of a new reality

As we drive our large-scale hygiene behaviour change campaigns, we are focusing on transitioning from our initial emergency response into a new, long-term strategy and driving long-lasting sustained behaviour change. Now, more than ever, we need sustainable, accessible and inclusive WASH and robust hygiene behaviour change programmes to achieve sustained hygiene behaviour on a massive scale.

Never has there been a time when handwashing has been at the forefront as it is now. Now is the time to call on governments, donors, schools, healthcare facilities, private sector and media outlets to come together, promote and demonstrate good hand hygiene behaviours and ensure hand hygiene for all.

By being innovative and creative, collaborating with others, driving inclusive programming and increasing advocacy efforts, we can ensure everyone, everywhere can practise the lifesaving habits of handwashing and other key behaviours.

Om Prasad Gautam is WaterAid's Senior WASH Manager – Hygiene. He tweets as @OmPrasadGautam. Lara Kontos is WaterAid's Programme Officer  Hygiene.