Women are uniquely affected by lack of access to handwashing, but gender-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]
Significant gaps in the provision of WASH in healthcare facilities in low- and middle-income countries compromise healthcare safety and quality for women 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.[iii] 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.[iv] 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.[v]
In addition to the effect of poor access to menstrual hygiene management facilities on education, 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%.[vi]
Interventions that aim to improve access to essential handwashing infrastructure must include the full participation of women.[vii] They 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.[viii] Failing to recognize gender dimensions often leads to ineffective interventions that fail to serve women and girls, or perpetuate inequities.[ix]
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.[x][xi][xii]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.
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.
Girls, 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. 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. Girls need access to handwashing stations with soap and water for good menstrual hygiene management. Solutions also exist to meet the challenge of poor access to water and sanitation facilities among the poor.
Handwashing programs and approaches to promoting equity
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. Community-based initiatives have been successful in encouraging households to improve handwashing behaviors, and in turn improving equity.
Promotion of handwashing with soap can help poor people control a key determinant of health.[xiii] 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.[xiv] 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.[xv]
[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] Jansz S, Wilbur J. (2013). Gender equality and water, sanitation and hygiene (WASH). WaterAid.
[v] Jansz S, Wilbur J. (2013). Gender equality and water, sanitation and hygiene (WASH). WaterAid.
[vi] Jansz S, Wilbur J. (2013). Gender equality and water, sanitation and hygiene (WASH)). WaterAid.
[viii] Water and Sanitation Program (2010). Gender in Water and Sanitation: Mainstreaming Gender in Water and Sanitation.
[xi] 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.
[xiv] Water and Sanitation Program (2011). Vietnam: A Handwashing Behavior Change Journey for the Caretakers’ Program.