Certain population groups are uniquely affected by lack of access to handwashing, but equitable programming has high potential to improve hygiene.
Access to proper handwashing facilities—as well as water needed for handwashing—and exposure to effective handwashing promotion that drives people to use them at critical times, vary widely across the world. This contributes to inequities in global health, nutrition, education and economic outcomes. However, handwashing also has the potential to contribute to reduced inequities in health, education, and work.
In many low- and middle-income countries, women and children are traditionally responsible for domestic water supply and maintaining a hygienic household environment.[i] Women often travel long distances in dangerous conditions to collect water for handwashing or other needs.[ii][iii]
Significant gaps in water, sanitation and hygiene (WASH) in health facilities in low- and middle-income countries compromise healthcare safety and quality for women and newborns. This can increase the risk of death or disability for women and newborns, and can deter women from deciding to give birth in a healthcare facility.[iv] Only 44% of births that take place in healthcare settings, and 24% of those in delivery rooms, have safe water and adequate sanitation. Sepsis, which causes 11% of maternal deaths, can mostly be prevented if women give birth in a location with sufficient water and soap for washing, and a trained assistant is available to provide quality care.[v] Clean birth practices, including handwashing with soap for mothers and birth attendants in homes and in health facilities, can help prevent this, increasing newborn survival rates by up to 44%. Access to basic hygiene can help children avoid diarrhea and pneumonia, and ensure their survival.[vi]
Women and girls need access to handwashing stations with soap and water for good menstrual hygiene management. In addition to the effect of poor access to menstrual hygiene management facilities on education,[vii] it can be a significant barrier to work for women. Often, policies in the workplace do not consider women’s need to manage menstruation; latrine design does not commonly address the specific needs of women; and where hygiene promotion programs exist, many exclude the issue of menstrual hygiene. In Bangladesh, where 80% of factory workers are young women, a study found that 60% were using dirty rags from the factory floor as menstrual cloths. This resulted in 73% of women missing work for an average of 6 days per month. When measures were introduced to change this, absenteeism dropped to 3%.[viii]
Interventions that aim to improve access to essential handwashing infrastructure must understand and address the gender-specific aspects of handwashing for all people, and consider this in decisions related to legislation, policies or programs. The perspectives and experiences of all genders are integral to the design, implementation, monitoring, and evaluation of high-quality programs and can reduce stigma and inequities.[ix] Failing to recognize gender dimensions often leads to ineffective interventions that fail to serve women and girls, or perpetuate inequities.[x]
There is clear evidence that, around the world, poorer households, those located in rural areas, and those with less education have lower access to functional handwashing stations than wealthier households, those in urban areas, and those with higher education. According to the 2017 progress report on WASH and SDG baselines update, the WHO/UNICEF Joint Monitoring Program found that coverage of basic handwashing facilities was higher in urban areas in all regions than rural areas.[xi][xii][xiii]As a result, families and communities that are already more susceptible to death from illnesses caused by poor hygiene are less equipped to protect themselves.
In a 2017 research review that analyzed proxy measures of handwashing behavior in Multiple Indicator Cluster Surveys and Demographic & Health Surveys, researchers found that in almost every country, households in higher wealth quintiles and urban areas were much more likely to have soap in the home and places for handwashing with soap and water than those in lower wealth quintiles and rural areas.
Global data monitoring for WASH by the JMP found that within countries, rural populations have lower levels of access to WASH facilities than urban populations. This disparity is further explored in this World Bank working paper[xiv] which examined access to quality WASH services among poor people in 18 countries. In the Democratic Republic of Congo, for instance, financing to the WASH sector improved access to water in urban areas by 81%, compared to 31% in rural areas.[xv]
In 2016, the JMP expanded its database to reflect monitoring and indicators for WASH in schools. 81 countries reported sufficient data to estimate basic hygiene services in schools. Globally, 36% of schools had no hygiene service at all. The largest burden of these reports came from Sub-Saharan Africa and Asia, with a wide variance between countries.[xvi]
The WHO Global Action Plan on WASH in Healthcare Facilities is a platform for national and regional monitoring and collaboration to provide universal access by 2030. Its 2015 report found disparities in country reporting, with the least representation from countries in Asia. Data from 54 reporting countries showed that 38% of healthcare facilities do not have an improved water source, and 35% do not have water and soap for handwashing; compromising the quality of service delivery and infection prevention and control measures.[xvii]
People who are already disadvantaged or vulnerable tend to have disproportionately lower access to good handwashing facilities and effective handwashing promotion programs. As a result, these individuals are less likely to wash their hands at critical times, putting them at a higher risk of developing diarrheal and respiratory infections, which contribute to poorer health, nutrition, education, and economic outcomes. This can easily increase vulnerability and perpetuate inequality.
People with disabilities, and people from minority ethnic/sociopolitical groups or from marginalized and isolated communities can be disproportionately affected by a lack of access to proper handwashing in schools. A 2018 multi-country survey found that although people living with disabilities may not have poorer access to WASH at the household level, they may have poorer quality of access within their households. Students with disabilities need accessible handwashing stations and soap, in schools particularly as they are more likely to touch the floors and walls of latrines where fecal matter may be present.
Diarrhea is responsible for 25 to 40% of child deaths in crisis settings.[xviii]Displaced populations typically have less access to handwashing facilities, exemplified by this study among residents of long-term refugee camps in Thailand, Ethiopia and Kenya.[xix]Solutions exist to meet the challenge of poor access to water and sanitation facilities among the persons affected by emergency and crisis situations, but further innovation is needed.
Handwashing programs and approaches to promoting equity
The 2018 synthesis report on Sustainable Development Goal 6[xx] highlights the progress made across indicators, but also raises the call for greater action towards an integrated approach to the 2030 Agenda. This approach must include better data monitoring, localized solutions, partnerships and a commitment to equity. This review article highlights the gaps in monitoring systems for WASH in non-household settings – schools and healthcare facilities – with recommendations for national-level monitoring.[xxi]
Interventions must not focus only on providing services within a community, creating an environment that enables all users to overcome social, cultural, and geographic barriers to access essential WASH services. This includes establishing opportunities that provide poor and marginalized communities the same coverage, affordability, and access.[xxii]Community-based initiatives have been successful in encouraging households to improve handwashing behaviors, and in turn improving equity.
Handwashing with soap can help poor people control a key determinant of health.[xxiii]Community-based handwashing projects, such as the World Bank Multi-Sectoral Handwashing Initiative in Vietnam and Community-Led Total Sanitation (CLTS) programs, are effective in engaging political and social institutions to promote gender equity, foster the role of women in project design and implementation, and fulfill the rights of communities.[xxiv]School-based hygiene education and effective handwashing facilities in schools can help resolve barriers to use and stigma faced by girls, children with disabilities, and students from marginalized communities.[xxv]Financing for WASH programs must take into context the inequity of access and water quality faced by the poor.[xxvi]
Handwashing often remains a low priority in research for WASH and equity. There are few studies available, many of which are dated, single-study, or have not been replicated. Research efforts must focus on these gaps to understand how programs can scale access to handwashing in the face of inequity.
[ii] Graham JP, Hirai M, Kim SS. An Analysis of Water Collection Labor among Women and Children in 24 Sub-Saharan African Countries. PLoS One, 2016; 11(6): e055981.
[iii] Pommells M, Schuster-Wallace C, Watt S, Mulawa Z. Gender Violence as a Water, Sanitation and Hygiene Risk: Uncovering Violence Against Women and Girls as it Pertains to Poor WASH Access. Violence Against Women, 2018; 24(15).
[iv] Jansz S, Wilbur J. (2013). Women and WASH: Water, Sanitation and Hygiene for Women’s Rights and Gender Equality. WaterAid.
[vi] Jansz S, Wilbur J. (2013). Women and WASH: Water, Sanitation and Hygiene for Women’s Rights and Gender Equality. WaterAid.
[vii] Icddr,b/ Policy Support Unit: Government of Bangladesh/WaterAid (2014). Bangladesh National Hygiene Baseline Survey: Preliminary Report
[viii] WaterAid/WSSCC/Unilever (2013). ‘We Can’t Wait’: A Report on Sanitation and Hygiene for Women and Girls’.
[ix] Water and Sanitation Program (2010). Gender in Water and Sanitation: Mainstreaming Gender in Water and Sanitation.
[xii] Swapna K. (2013). Handwashing behavior in 20 countries: analysis of proxy measures of handwashing in Multiple Indicator Cluster surveys (MICS) and Demographic Health Surveys (DHS), 2009-11. UNC Water and Health Conference 2013.
[xvi] WHO/UNICEF (2018). WASH in Schools: Estimates on Drinking Water, Sanitation and Hygiene in Schools.
[xix] Biran AB, Schmidt, WP, Zeleke M, Emukule H, Khay H, Parker J, Peprah D. Hygiene and Sanitation Practices Amongst Residents of Three Long-Term Refugee Camps in Thailand, Ethiopia and Kenya. Tropical Medicine & International Health, 2012; 17(9): 1133-1141.
[xx] UN Water (2018). SDG 6 Synthesis Report 2018 on Water and Sanitation.
[xxi] Chatterly C, Slaymaker T, Badloe C, Nouvellon A, Bain R, Johnston R. Institutional WASH in the SDGs: Data Gaps and Opportunities for National Monitoring. Journal of Water, Sanitation & Hygiene for Development, 2018; 8(4); 595-606.
[xxiv] Water and Sanitation Program (2011). Vietnam: A Handwashing Behavior Change Journey for the Caretakers’ Program.