Why are we so off track on increasing the number of people globally who wash their hands? Who is having their access to good hygiene denied? This Global Handwashing Day, Om Prasad Gautam discusses the importance of a behaviour-centric approach to creating and sustaining improved hand hygiene habits for everyone.
Global Handwashing Day offers an opportunity to advocate the importance of handwashing with soap – the most cost-effective way to prevent transmission of diseases and a way to save millions of lives every year. In many countries, the day opens the door for multiple sectors to discuss improved cross-sectoral coordination, financing, sector monitoring, institutional mechanisms and the sectoral guiding framework necessary to drive better water, sanitation and hygiene (WASH) and hygiene-specific programming.
This year’s Global Handwashing Day theme is ‘Clean hands for all’. Inequalities in access to handwashing facilities with soap, discriminatory promotional programmes and low levels of compliance can put people and societies at risk from disease transmission, low educational attainment and productivity. Clean hands for all benefits everyone – and leaves no one behind.
Why is poor hygiene a problem?
Poor hygiene, including poor hand hygiene, causes preventable diseases and outbreaks, keeping children out of school, stopping adults from working, putting more babies and mums in hospital, and putting institutions such as schools and healthcare facilities at risk (read our report Transforming health systems).
Bittings Nkhata, health care in-charge, happy to wash his hands inside the hospital ward, Kamsonga Health Centre, Ntchisi, Malawi. Photo: WaterAid/ Dennis Lupenga
The facts are hard to swallow. Every day around 800 children under five die from diarrhoea caused by unsafe water, inadequate sanitation and poor hygiene.1 On top of this, repeated diarrhoea in early life has a long-lasting and irreversible impact on a child’s nutritional status and development potential.2 Globally, 156 million children under five are stunted (low height for age) and 50 million are wasted3 (low weight for height) because they don’t have adequate WASH facilities and behaviours.
What difference does handwashing make?
Simply washing hands with soap and water after going to the toilet, before eating or feeding and before preparing food can help prevent life-threatening illnesses such as diarrhoeal diseases, cholera, pneumonia and intestinal worms. It reduces incidence of skin infections, and washing faces with soap can reduce the likelihood of contracting blinding trachoma.
The evidence of its importance goes on:
- Rigorous hygiene, including handwashing with water and chlorine, was key in slowing the spread of Ebola.
- Handwashing with soap has been linked to 16-23% reduction in incidence of acute respiratory infection,4 50% reduction in pneumonia,5 substantial reduction in neonatal infections6 and up to 48% reduction in risk of endemic diarrhoea.7,8
- Handwashing with soap has been found to reduce school absenteeism by 43% fewer days.9
- 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.10
Is hand hygiene progress on track?
Current progress is quite slow, mostly in low- and middle-income countries. Globally 40% of households still don’t have handwashing facilities with soap and water,11 and just 19% of people wash their hands with soap after defecating.12 Almost half of healthcare facilities lack basic handwashing facilities with soap and water13 and almost half of schools in developing countries lack handwashing facilities.14
Wealth, rural/urban location, age and disability result in inequalities
The gap between urban and rural access has not reduced since 2012. The available data show huge disparities, even by proxy measures i.e. availability of a handwashing facility on the premises with soap and water. Only 34% of people living in rural areas have access to a basic handwashing facility; people in rural areas are much less likely to have access to soap and water than are those in urban areas.
Many high-income nations have almost universal coverage of basic handwashing facilities, but in the least-developed countries only 28% of households have access. In 51 of 82 countries with disaggregated JMP data, basic handwashing coverage among the richest wealth quintile was at least twice that in the poorest quintile.11
Handwashing with soap is particularly crucial for children, older people and people with disabilities, and ensuring they are included is still a challenge. This Global Handwashing Day offers an opportunity to discuss these disparities and urge researchers, programme implementors and policy makers to address them.
Hygiene behaviour change links with many Sustainable Development Goals (SDGs)
Achieving sustained hygiene behaviour change is fundamental to achieving SDGs 1, 2, 3, 4, 6, 10, 11, 13 and 17. Making handwashing part of normal daily routines is a cost-effective way to reduce the disease burden and associated deaths and help reach these goals. Transformative change is needed to realise adequate progress.
SDG 6’s Target 6.2 calls for access to adequate and equitable sanitation and hygiene for all by 2030. Indicators for handwashing include the ‘proportion of populations with handwashing facilities with soap and water at home’. But this indicator doesn’t tell us whether people are practising handwashing – each country needs to also establish a behavioural outcomes-related indicator.
How can we make interventions more effective?
Gishu Jafar demonstrating handwashing during a hygiene behavioural change campaign that combines theatre, music and handwashing demonstrations in the marketplace of Safoge, Oromia, Ethiopia. Photo: WaterAid/ Genaye Eshetu
Although recognition of the importance of behaviour change is growing, it is still highly neglected in WASH, health, education and nutrition sectors. Among the reasons for continued low coverage are lack of prioritisation for hygiene; knowledge-focused interventions; positioning hygiene as an add-on activity; designing interventions based on expert thinking; siloed implementation of hygiene programmes; and lack of dedicated financing and output-focused monitoring mechanisms. Key shifts are needed.
- Designing an innovative behaviour change intervention package through a creative process informed by formative research and use of people’s emotions, environmental cues, reminders, nudges, behavioural products and creating social desire and norms.
- Executing a branded umbrella behaviour change intervention focusing on novel approaches through the sustainable delivery and institutional mechanism.
- Enhancing capacity to integrate and scale implementation of behaviour change programmes, in WASH and other sectors such as health, nutrition and education.
- Building, monitoring and evaluating systems to demonstrate a sustained effect.
- Making hygiene programme empowering and inclusive of everyone.
How is WaterAid addressing evidence, programmatic and policy gaps?
We have abandoned ineffective traditional educational approaches with repeated messages focused on germs and the health benefits of good hygiene. To attain sustained behaviour change, we have embraced behaviour-centred design approaches in which we truly listen to communities to understand the universal behavioural determinants – their drivers, motives and ambitions – through formative research.
We work with creative teams to design innovative and engaging approaches, using emotions to engender lasting positive behaviour change. Crucially, we support governments to increase their capacity to execute, prioritise and allocate funding for hygiene behaviour change and sanitation interventions. And we demonstrate how much more effective such campaigns can be.
We also work with governments to integrate hygiene behaviour change into other sectors such as health (e.g. immunisation [see our Nepal project], neonatal care), nutrition (read our latest research) and education, and help build (or strengthen) monitoring and evaluation systems. Our focus on changing multiple behaviours including handwashing with soap, and on delivering interventions through sustained institutional mechanisms, emphasises behaviour change rather than just improving knowledge. We are currently supporting 11 behaviour change campaigns in Bangladesh, Ghana, Malawi, Madagascar, Mali, Mozambique, Nepal, Nigeria, Pakistan, Tanzania and Zambia.
And we analyse sectoral policies and coordination mechanisms, and financing for behaviour change, and use the results in our influencing work – for example, our state of hygiene analysis in the South African Region. To share lessons from campaigns, we ran WaterAid’s first global hygiene conference in February 2019. We support think tank events to shape the hygiene agenda.
Achieving clean hands for all requires a step change in progress and demands re-evaluation of methods, leading to transformative programmes. We have learned a lot – and the most important part is that we are still learning. I hope this year’s global celebration will generate will among stakeholders, including governments, to prioritise and implement novel behaviour change programmes at scale.