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The Global Handwashing Partnership

2016 Handwashing Think Tank: Integration, Settings, Scale/Sustainability

Published: April 27, 2016

The facts about handwashing are clear. It prevents illness–from the commonplace such as influenza, diarrhea, and pneumonia–to the rare, yet deadly–such as Ebola. Its benefits are far reaching as it impacts not only health, but also nutrition, education, and equity. And, in addition to being effective, it is affordable and accessible.

All presentations available for download here.

Yet, despite the clear benefits of hygiene, far too often it isn’t prioritized from the personal level to the policy level.

To address this gap, the Global Handwashing Partnership, the London School of Hygiene and Tropical Medicine, and WaterAid, hosted the 2016 Handwashing Think Tank as a way to learn how the evidence in the Thematic Areas of handwashing integration, settings, and scale/sustainability can be acted upon.

Objectives for the 2016 Think Tank were to:

  1. Explore current knowledge about handwashing with soap,
  2. Spark collaborative thinking about handwashing, and
  3. Drive the sector forward.

Key deliverables from this event include:

Working Group Session One: Setting the Stage

The Latest Evidence

Presentations for this working group session are available here.

We know that self-reporting often overestimates the frequency of handwashing, but observation also presents drawbacks. Ultimately, unless we are looking for trends, self-reporting data should be utilized less, and when it is used, questions about automaticity of handwashing should be included. In terms of observation, repeated visits can be influential, so implementers must ensure that measurement tools don’t inadvertently become part of the intervention. It is also important to consider bias when measuring handwashing behavior (i.e. social norms).

Challenges & Gaps

  1. There needs to be a discussion and consensus on how we measure handwashing, including data quality and outcome measurement.
  2. Soap is defined in a variety of ways (e.g. detergent, laundry soap, bar soap, soapy water, ash), so data vary as a result.
  3. With the new SDG indicator, metrics will increasingly become important to governments. The hygiene indicator means that a country that previously made progress on sanitation coverage might now be considered to be lagging in the SDGs depending upon the availability of handwashing stations.
  4. Measurement of handwashing station use, rather than just function, is important. Which cues demonstrate that handwashing stations are actually being utilized (e.g. Does the soap have residue? Is the water discolored?)
  5. In emergency settings, handwashing is often assigned a low priority. This results in a lack of clear targets, little consensus on how to begin handwashing promotion, and a bias towards hardware provision rather than behavior change.
  6. Promoting handwashing habits at primary schools may be too late. We need to address the question of “How can we form habits around handwashing at an earlier age?”

Working Group Session Two: Integration

 Presentations for this working group session are available here.

CLTS, ODF and the Importance of Hands – Carolien van der Voorden (WSSCC)

Community-Led Total Sanitation (CLTS) facilitates a process that rallies the community around key outcomes. By definition, handwashing is an integral part of CLTS; however, the certification components of on open defecation free (ODF) community vary.

Good CLTS leads to improved knowledge of the critical handwashing times, the ability to demonstrate the critical times, and a greater likelihood that handwashing stations with soap and water are present.

Opportunities for integration
CLTS programs focus on creating a movement with strong engagement by natural leaders, champions, and community consultants. CLTS is often implemented by district health officials, which can lead to further integration and long-term follow-up.

Challenges & Gaps

  1. Measuring handwashing—from scale/sustainability to the reliability of indicators and beyond—is very complicated.
  2. More needs to be done on triggering tools of integration.
  3. There are gaps in terms of the “how” of implementing integrated handwashing and CLTS projects.
    a. How do we measure handwashing facilities, knowledge, and use?
    b. When should handwashing be introduced into the CLTS process?
  4. Greater evidence about the effectiveness of the CLTS approach, and individual components, is needed.
Integrating Handwashing into Newborn Care – Pavani Ram (University at Buffalo)

There are many behaviors that are important for newborn wellbeing and health, including breastfeeding promotion, skilled birth attendance, treatment for birth asphyxia, and the prevention and treatment of malaria in pregnancy. Handwashing is just one component of newborn care.

Theoretically, the disruption that having a new baby can cause in routine presents an opportunity to uptake a handwashing habit. The evidence shows that there are modest handwashing behavior increases during this period, but behavior change is oftentimes not permanent.

In the late neonatal period, sepsis decreases significantly; this helps us identify how national health policy programs could shift so that we are not crowding interventions in the neonatal period. However, the majority of neonatal deaths occur during the first 24-hour period and first week of life.

Challenges & Gaps

  1. Mothers of newborns face many challenges to handwashing once they are home, including a lack of available handwashing materials, inconvenient processes, a feeling of being too busy, and a lack of a pre-existing habit or social norms for handwashing.
  2. We don’t have an agreement upon the critical times for handwashing with this population, as data is not available. Are critical times before breastfeeding or when children have respiratory infections? Also, besides the mother, whose hand cleanliness matters most? Fathers, other female caregivers (mothers-in-law), children that play outside? There needs to be an f-diagram for neonates.
  3. There are behavioral barriers that need to be addressed, such as the balance between behavioral feasibility with product costs?
Clean Hands: Key Ingredients in the Recipe for a Healthy Child – Sandy Callier (USAID WASHplus)

We know from the vicious cycle of diarrhea and undernutrition that WASH and nutrition are linked. Increasingly, the sectors are working together.

Maternal handwashing during the complementary feeding period, when solid foods are introduced, can help prevent illness. There are a number of projects that work on linking handwashing to improved child feeding practices, including the Alive & Thrive project; the SPRING project, which, in Bangladesh, led to the Tippy Tap being considered an essential handwashing prompt; and the USAID WASHplus Project that is introducing commercial handwashing stations in partnership with WaterSHED.

Gaps & challenges

  1. What evidence supports integrating handwashing and young child nutrition?
  2. We need to measure the effectiveness of integration, including the cost effectiveness.
  3. The sustainability of initial behavior change remains a challenge.
  4. Handwashing after defecation is a different behavior than handwashing before preparation of food. How can we define these motivators and use them in interventions? Food preparation is a complex, multi-stage process that is often interrupted. Multiple behaviors need to be changed as a result.
  5. In implementation, we face challenges around the “how” in addition to the “why” (e.g.: Where should handwashing stations be located? How can we making maternal handwashing aspirational through products?
  6. As distinct disciplines, WASH and nutrition have a myriad of differences that present challenges, including different government ministers, approaches, and ways of measuring success.

Working Group Session Three: Settings

Settings are an important mechanism for behavior, as the cues from settings tell us how to behave within that context.

Behaviour-Centred Design – Bob Aunger (LSHTM)

The presentation for this working group session is available here.

To determine the formation of habits, one must ask both where and how to insert a behavior. Though behavior is linear, all factors are actually occurring simultaneously in organized streams. Routines are often organized in the same way, with optimal sequences. Habit formation depends upon the perception of a positive result (i.e. if someone assumes there will be a reward every time the action is performed or completed, they are more likely to do the action). If a behavior is intrinsically rewarding, automaticity is more likely. This accelerates the behavior becoming routine.

Gaps & Challenges

  1. Routines vary widely depending on context (urban/rural, income level, etc.), so we need to take these contexts into consideration.
Changing Multiple Behaviors through Settings – Om Prasad Gautam (WaterAid)

The presentation for this working group session is available here.

Disturbing the setting (physical, biological, and social) is important for changing behavior. People follow “scripts” that correspond with procedures and specific roles. Changing the script involves introducing new settings and new norms that can help prompt people to commit to and practice new behaviors or actions.

It is essential to create desire within the community, so changing the script in a positive manner (i.e. you can have the ideal family), fostering a social norm (i.e. public pledging) can encourage or reinforce behaviors. These changed scripts also include the physical environment in which the behavior occurs.

Gaps & Challenges

  1. What “roles” and “narratives” can be leveraged that aren’t necessarily health related? For instance, is there a way to tap into women who want to be perceived as promoting equality?
  2. What is the sustainability of environmental cues, such as posters? At what point do they stop triggering the desired behavior?

Working Group Session Four:  Scale & Sustainability

The presentation for this working group session is available here.

Sustainability & Scale, Ingeborg Krukkert (IRC-WASH)

Ingeborg posed the challenging question: “Is it possible to do handwashing activities at a larger scale?” and shared how BRAC is working in Bangladesh to deliver WASH services. Their experience showed that sustained behavior change was the result of community buy-in, a high level involvement of water and sanitation stakeholders (including the government and the private sector), and ongoing, intense hygiene promotion. Success was also the result of an integrated approach, where hygiene was mainstreamed into sanitation promotion. The project found that handwashing was, in some instances, a motivator to end open defecation. We discussed integration on the first day of the Handwashing Think Tank, but its linkage with scale and sustainability is evident.

Lessons

  1. Sustained behavior change is possible, but in this instance it required frequent and intense hygiene promotion.
  2. This program was comprehensive and included a range of building blocks, including demand creation, supply of products and services, strengthening the enabling environment, and domestic resources mobilization. The private sector involvement focused on higher level activities related to product development and market demand creation; this allowed NGOs and CSOs to focus on delivery to lower quintile populations. It’s important for partnerships to allow different sectors to focus on their strengths.
  3. Intervention length is important because the longer the intervention, the more likely people were to have a toilet and hygiene resources. This access is significant because those who did have the appropriate hardware were more likely to use it. Hardware use was also influenced by its quality (i.e. cleanliness and functionality).

Challenges

  1. In this program, those who received or purchased toilets or latrines were not inclined to upgrade.
  2. The integrated approach BRAC took included a specific budget for hygiene, buy-in from a range of actors (e.g. communities, the private sector, local government), and provisions for financial inclusion. As such, it’s not possible to identify one or two individual components that were particularly important. However, IRC believes that it is likely that the program would not have been as successful if one or more components had been excluded.
  3. IRC echoed one of the major challenges to measuring program sustainability: funding for long-term evaluation is lacking.
Sanitation Co-Innovation for Handwashing – Cheryl Hicks (Toilet Board Coalition) and Richard Wright (Unilever)

Cheryl Hicks of the Toilet Board Coalition and Richard Wright of Unilever described how the Toilet Board Coalition seeks to catalyze the business sector to deliver universal access to sanitation by using a business accelerator model and focusing on innovation. Through this process they used consumer feedback as a way to improve the design and uptake of their product. In the 2014 Think Tank we heard from the Water and Sanitation Program on the design of the Mrembo handwashing station, and they also emphasized the need to be responsive to local desires when designing products.

Throughout this process, the Toilet Board Coalition found that the toilet needed to be aspirational and attractive, but also practical (i.e. stackable). Consumer feedback indicated that additional design modifications would be advisable. For instance, odor, splashing, and visible waste devalued the aspirational attributes of the toilet, if not the function.

In terms of integrating hygiene alongside sanitation, they found that private toilets were more likely to have hygiene products available. The messaging around using soap for hygiene might not be as effective when soap is considered a beauty product, so this also was a consideration.

An Update on the LaBobo Portable Handwashing Station – Geoff Revell (WaterSHED Asia)

Geoff Revell of WaterSHED Asia gave an update on the Happy Tap/LaBobo portable handwashing station, which was likewise the result of human-centered and aspirational design research.

This product was introduced in Vietnam where extensive behavior change campaigns had already happened. As such, handwashing information had already been widely disseminated. Therefore, people knew the “why” (i.e. the critical times of handwashing and the appropriate movements), but failed to follow through on the behavior due to constraints, such as the time required to collect water for handwashing.

In marketing this handwashing station, WaterSHED found that they needed to differentiate between consumer wants and needs. Messages around convenience, time-saving, money savings, water savings, and status/modernity were tested. They found that convenience was the biggest motivator, but they couldn’t just market it on convenience alone. Similarly, marketing it for modernity was counterproductive. Instead, it was marketed to parents as an appeal to their personal responsibility in protecting the health of their children and their community. These messages were emotional in nature, but they also provided consumers with the right narrative to help them justify the purchase.

Moving Forward

For the final session, Dr. Val Curtis (London School of Hygiene and Tropical Medicine) led participants in an exercise outlining how we should move forward as a result of our discussions and commitment-making. It is clear that there are opportunities for the Global Public-Private Partnership for Handwashing to continue to share knowledge about what does and does not work in behavior change and to promote advocacy for hygiene at the global and national level. Measurement of handwashing was a thread that ran throughout the discussions, and this is an area where both handwashing programs and researchers can work together.

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