April 22, 2019
Editor’s Note: This post is an installment in our Ask the GHP series.
By: Sian White
Over the last twenty years we have seen a growing number of publications about handwashing with soap and behavior change. It can be hard to keep up with the literature. It can also be hard to know how to apply research findings to your programs. In this blog I outline five key program recommendations based on our current state of knowledge about handwashing.
Knowledge is not the answer
Almost everyone has a basic understanding of disease transmission and can explain the benefits of handwashing in simple terms – even populations with low levels of formal education. [i] [ii] Unfortunately, this bio-medical knowledge does not mean that people are more likely to wash their hands with soap. Several studies have demonstrated that handwashing programs which only focus on improving bio-medical knowledge have no effect on behavior.[iii] [iv] [v] [vi] Maybe this is not so surprising. If about 90% of people already know the benefits of handwashing, then increasing this by a few percentage points is not going to create a change of public health significance. Research also suggests that biomedical ‘facts’ sit alongside a range of other beliefs and competing priorities. [i] [vii] [viii] [ix] [x] Just think about your own behavior. At the times when you need to wash your hands, say for example when you are about to sit down and enjoy a nice homemade dinner, you are not likely to be contemplating the transmission of fecal-oral pathogens! You will be smelling the tasty food, worrying about all the things you have to do, talking to your family, etc. All these other distractions mean that we rarely activate the health knowledge we possess at the times when it could be most useful.
Infrastructure really matters
Handwashing promotion programs often deprioritize the most important mode of changing behavior: improvements to handwashing infrastructure and products. Did you know that if households have access to a handwashing facility they are up to 60% more likely to wash their hands with soap? [vi] [ix] [xi] [xii] [xiii] [xiv] [xv] [xvi] If soap and water are always available at that handwashing facility then people are 2-3 times more likely to wash their hands with soap than if these things were absent. [xiii] [xvii] [xviii] [xix] [xx] [xxi] [xxii] When handwashing facilities are conveniently located near the kitchen or toilet [xx] and desirable and attractive (e.g. bright colors, has a soap container, has a mirror) [xi] [xv] [xxiii] [xxiv] [xxv] this can increase handwashing rates even further. This means that if we design handwashing promotion programs comprising of only ‘soft’ behavior change techniques in areas where the basic handwashing ingredients are lacking, then we may see no effect on behavior. We may also risk offending or disengaging local populations who might wonder why we are promoting a behavior that is not feasible for them to practice.
Handwashing programs should also think carefully about how physical environments can be modified to cue handwashing behavior. Using ‘behavioral nudges’ is one way of doing this. For example, one study showed that if you paint footprints on the path between the toilet and the handwashing facility handwashing behavior increases by 64%. [xxvi] Another study placed an image of eyes above a handwashing facility, resulting in people being 10% more likely to wash hands. [xxvii] Lastly, a study in a displacement camp found that putting toys in soap made handwashing more fun for children and made them 4 times more likely to wash their hands with soap. [xxviii]
Focus on getting people to wash their hands more frequently rather than more thoroughly
You will have all have seen posters which spell out the multiple steps of ‘correct and thorough handwashing with soap’. It might surprise you though that we don’t have good evidence to support most of these steps. We know that the following things can be beneficial: running water that allows you to rub both hands against each other to create a good soapy lather, cleaning under your nails and under jewelry, and drying your hands. [xxix] [xxx] [xxxi] [xxxii] [xxxiii] [xxxiv] [xxxv] We know that your hands do get cleaner the longer you wash them for but we do reach a point of diminishing returns (where lots of effort is required for fairly minimal additional pathogen removal). [xxxiii] On average people wash their hands for less than 10 seconds [xxxvi] [xxxvii] [xxxviii] – this nowhere near the WHO recommended 40-60 seconds. We also know that within an hour hands typically get as dirty as they were prior to them being washed. [xxxix] This means that if we want to make a public health difference we should focus on getting people to wash their hands more frequently even if they do it for a shorter, more realistic amount of time. Having said all this, thorough handwashing for longer durations, is much more important in health care settings or outbreak situations.
Meaningful behavior change is not cheap, quick or easy
Handwashing promotion is often cited as one of the most cost-effective public health interventions [xl] [xli] These figures tend to be misinterpreted by donors and implementers alike and this commonly results in hygiene programs being underfunded. [xlii] The evidence suggests that sustained handwashing behavior change is not normally cheap – nor is it quick to design and implement. [xliii] [xliv] Attaining a sufficient ‘dose’ seems to be a critical factor which can make or break a handwashing promotion program. [xlv] [xlvi] [xlvii] The easiest way to conceptualize ‘dose’ is to think about an analogy of a vaccine. Some vaccines are effective after only one dose but for many vaccines a person needs more than one injection in order for the vaccine to work. Similarly, most behavior change programs need to interact with target populations on multiple occasions, over an extended period of time, in order to be effective. [xlviii] [xlvix] Handwashing programs also seem to be successful when they target multiple delivery channels. [l] [li] [lii] [liii] Ideally, program implementers should consider combining mass media strategies with interpersonal techniques which reach the target population at the community and household levels.
Everyone wants to be seen to wash their hands
Handwashing with soap is a socially desirable behavior in all cultures. This has several implications for hygiene programs. Firstly, it means that people are almost 50% more likely to wash their hands if there are other people in a public bathroom. [xxvii] [liv] [lv] Handwashing interventions which remind people that others might judge them on their handwashing behavior have been shown to be effective. [liv] Secondly, it can make measuring handwashing behavior rather challenging. If you ask people if they wash their hands with soap at critical times, most people know that the ideal answer is ‘yes’. This is one of the reasons why we find that self-reported measures handwashing behavior typically overestimate actual practice. Although there is no perfect way of measuring handwashing behavior,[lvi] [lvii] [lviii] the Joint Monitoring Program now suggests dropping self-reported handwashing measures in favor of using the new global handwashing indicator. [lix] This is a proxy measure which is rapid and cheap to assess and provides a meaningful comparable indicator.
About the Author: Sian White is a Research Fellow in the Department of Disease Control at the London School of Hygiene and Tropical Medicine (LSHTM). She has a Master’s in Public Health in Developing Countries and is currently doing her PhD on hygiene behavior in humanitarian crises. Sian has over a decade of experience working on projects to do with hygiene, behavior change and public health programming in Australia, Asia, the Pacific, Africa and the Middle East.
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[xlix] Tidwell JB, Gopalakrishnan A, Lovelady S, Sheth E, Unni A, Wright R, et al. Effect of Two Complementary Mass-Scale Media Interventions on Handwashing with Soap among Mothers. J Health Commun. 2019:1-13.
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