Handwashing promotion is an important part of hygiene projects, but it is not their exclusive domain. Given the impact of handwashing on global health and development, handwashing can, and should, be integrated and promoted in a number of ways by a wide range of actors, whether they work in WASH, health, nutrition, education, poverty, or other sectors.
Steps to Promote Handwashing Behavior Change
Handwashing promotion involves behavior change, and is thus a process along a continuum, and includes the following steps:
To learn about the four steps, simply click on the appropriate icon above. Or, read background information about behavior change, our recommendations for handwashing promotion at the program level, and find additional resources on this page.
The road to behavior change is a journey from being unaware of proper handwashing behavior to being aware and concerned; knowledgeable and able to act; motivated and ready to change; and finally to attempting a new behavior and then sustaining it and promoting it amongst others.
Within this journey there are roles that practitioners can play in delivering the right information, skills, and motivation to begin and/or permanently instill a new behavior.
We know that the most influential factors that determine if a person washes their hands include a combination of knowledge about when and how to wash, social norms driving handwashing at critical moments, the presence of a fixed handwashing station with soap and water, and the presence of emotional motivators such as disgust, and in some instances nurture. Research also tells us that handwashing behavior change takes time, and a one-off handwashing promotion intervention may not be sufficient to achieve lasting behavior change.
Despite the wide range of behavior change theories and models available, their use in the design and assessment of handwashing behavior change interventions is rare. Using behavioral theories or frameworks in the design and implementation of behavior change interventions can result in improved long-term behavioral outcomes. There is no evidence at present that one behavior change model is better than any other, but there is evidence that using a behavior change theory is better than not.
Given the importance and complexity of behavior change, the Global Handwashing Partnership hosts an annual Handwashing Behavior Change Think Tank which seeks to identify the gaps, take stock of the best, and articulate the way forward for handwashing behavior change. Read about the results from the most recent Think Tank here.
Knowledge is a basic element of most handwashing promotion programs. Traditionally, handwashing knowledge interventions have focused on educating people about the link between handwashing and disease prevention. Research has shown that many people are not aware of this link. Building awareness and knowledge of disease transmission mechanisms, and how to prevent diseases, using positive, inspirational messages can empower communities to act.
Nevertheless, research shows that while educational activities can increase knowledge and address the issue of handwashing facilities, they do not always result in sustained handwashing. In countless studies, a ‘gap’ is seen between people’s knowledge of the critical times to wash and their actual handwashing practices. Program designers are also sometimes surprised to learn that fear of disease is not a strong handwashing motivator. Knowledge is necessary, but by itself, it is not sufficient to prompt consistent and correct handwashing.
Behavior change communications initiatives and frameworks, based on the drivers of handwashing behavior (from local research or current global knowledge), can be used to shift knowledge into action by motivating people, instilling new habits, and providing social reinforcement for continuing to wash their hands. These models focus on the critical comments for handwashing, psychological factors, and the enabling environment.
Critical moments for handwashing
The two critical moments to wash hands are after contact with feces (such as using the toilet or cleaning a child) and before contact with food (preparing food, eating, feeding a child, and so on). Research has shown that these moments have the greatest impact on child health.
Handwashing is also recommended at other times, such as after contact with animals, after coughing or sneezing; after contact with a sick person, and if hands are visibly soiled.
The design of any behavior change program is strongly influenced by the critical moments it aims to address, because different moments have different drivers of handwashing behavior. For example, key drivers of handwashing after using the toilet (such as disgust) may differ from key drivers of handwashing associated with food preparation (such as nurture). Therefore, the design of behavior change interventions would differ accordingly. These drivers are one component of the psychological factors that motivate behavior change.
Psychological factors, such as emotional drivers, are very important for driving handwashing behavior change anywhere in the world. Research has revealed four powerful, crosscutting drivers or motivators: disgust (about having feces or foreign substances on hands), nurture, comfort, and affiliation with others. Additionally, mothers in numerous countries report that beauty and the desire to aspire to and affiliate with more affluent segments of society motivates their handwashing behavior. Motivators like these seem to be more effective at getting people to wash their hands than fear of disease. The SuperAmma Campaign is one example of successfully using emotional drivers to change handwashing behavior.
Another psychological factor necessary for increasing handwashing at critical times over the long-term is turning handwashing into a habit. Achieving this means understanding how habit science can be applied to handwashing programs.
Lessons learned in handwashing behavior change
Handwashing behavior change knowledge and best practices are constantly evolving. To stay up-to-date and promote forward momentum on this critical topic, the PPPHW hosts a regular Handwashing Behavior Change Think Tank which takes stock of the best, addresses the gaps, and articulates the way forward for hygiene behavior change. See the findings from our Handwashing Behavior Change Think Tanks here.
Address both the hardware and software components of handwashing behavior change.
Handwashing is a complex, socially desirable, yet difficult to change behavior. Program developers should consider addressing both the physical and social aspects of the enabling environment to support successful behavior change, including addressing inequities in access to the determinants of handwashing and the enabling environment.
Send simple, effective messages.
Rather than promoting handwashing as a long list of critical times, practitioners may choose to address a smaller subset that have been shown to be associated with health benefits, (post-defecation and pre-food preparation) or choose those that clearly fit within a larger program. One such example would be to promote handwashing at various food-handling times in the context of a nutrition intervention.
Use appropriate drivers.
Locally relevant perceptions may need to be better understood in order to develop successful messaging relating to handwashing at critical times. Importantly, programs should examine strategies to motivate handwashing through approaches other than simply increasing knowledge of the importance of handwashing to prevent disease. Nurture, beauty, disgust, and aspiration are all potentially powerful drivers of handwashing behavior.
Measure and share findings.
Evaluating, reacting to evaluation findings, and disseminating evaluation findings from individual programs are all critical to improving handwashing promotion programs at scale worldwide. Tools for monitoring and evaluating programs may be found here.
The Global Handwashing Partnership offers a number of resources that can help guide individuals who are working on handwashing promotion projects. These include:
- Our free handwashing behavior change program distance learning course
- Findings from our annual handwashing behavior change Think Tank
- A webinar on handwashing and the science of habit
- Listing of behavior change theories and models