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The Global Handwashing Partnership

How Can Handwashing Implementers Consistently Integrate the Latest Evidence in their Work?

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.

Women at a training event for smartphone-based data collection in their roles as Resident Enumerators (RE) for the PMA2020 project in Rajasthan, India.
© 2016 Linnea Zimmerman/PMA2020, Courtesy of Photoshare

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.

Want to learn more about handwashing research? Explore our published 2018 Handwashing Research Index and visit our Resources Hub.

Citations
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[xii] George CM, Monira S, Sack DA, Rashid M-u, Saif-Ur-Rahman KM, Mahmud T, et al. Randomized Controlled Trial of Hospital-Based Hygiene and Water Treatment Intervention (CHoBI7) to Reduce Cholera. Emerging Infectious Diseases. 2016;22(2):233-41.

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[xviii] Oswald WE, Hunter GC, Kramer MR, Leontsini E, Cabrera L, Lescano AG, et al. Provision of private, piped water and sewerage connections and directly observed handwashing of mothers in a peri-urban community of Lima, Peru. Tropical Medicine & International Health. 2014;19(4):388-97.

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[xxii] Scott BE, Lawson DW, Curtis V. Hard to handle: understanding mothers’ handwashing behaviour in Ghana. Health policy and planning. 2007;22:216-24.

[xxiii] Jenkins MW, Anand AR, Revell G, Sobsey MD. Opportunities to improve domestic hygiene practices through new enabling products: a study of handwashing practices and equipment in rural Cambodia. International Health. 2013;5(4):295-301.

[xxiv] Hulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, et al. Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC public health. 2013;13:877.

[xxv] Rahman MJ, Nizame FA, Unicomb L, Luby SP, Winch PJ. Behavioral antecedents for handwashing in a low-income urban setting in Bangladesh: an exploratory study. BMC public health. 2017;17(1):392.

[xxvi] Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK. Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh. International journal of environmental research and public health. 2016;13(1).

[xxvii] Pfattheicher S, Strauch C, Diefenbacher S, Schnuerch R. A field study on watching eyes and hand hygiene compliance in a public restroom. Journal of Applied Social Psychology. 2018;48(4):188-94.

[xxviii] Watson J, Dreibelbis R, Aunger R, Deola C, King K, Long S, et al. Child’s play: Harnessing play and curiosity motives to improve child handwashing in a humanitarian setting. Int J Hyg Environ Health. 2018.

[xxix] Hoque BA. Handwashing practices and challenges in Bangladesh. Int J Environ Health Res. 2003;13 Suppl 1:S81-7.

[xxx] Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS medicine. 2011;8.

[xxxi] Lin CM, Wu FM, Kim HK, Doyle MP, Michael BS, Williams LK. A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. J Food Prot. 2003;66(12):2296-301.

[xxxii] Friedrich MN, Julian TR, Kappler A, Nhiwatiwa T, Mosler HJ. Handwashing, but how? Microbial effectiveness of existing handwashing practices in high-density suburbs of Harare, Zimbabwe. American journal of infection control. 2017;45(3):228-33.

[xxxiii] Bloomfield S, Aiello A, Cookson B, O’Boyle C, L. Larson E. The Effectiveness of Hand Hygiene Procedures in Reducing the Risks of Infections in Home and Community Settings Including Handwashing and Alcohol-Based Hand Sanitizers2007.

[xxxiv] Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidemiol Infect. 1997;119(3):319-25.

[xxxv] Huang C, Ma W, Stack S, editors. The hygienic efficacy of different hand-drying methods: a review of the evidence. Mayo Clinic Proceedings; 2012: Elsevier.

[xxxvi] Borchgrevink CP, Cha J, Kim S. Hand washing practices in a college town environment. J Environ Health. 2013;75(8):18-24.

[xxxvii] Lee M-S, Hong SJ, Kim Y-T. Handwashing with soap and national handwashing projects in Korea: focus on the National Handwashing Survey, 2006-2014. Epidemiology and health. 2015;37:e2015039-e.

[xxxviii] Garbutt C, Simmons G, Patrick D, Miller T. The public hand hygiene practices of New Zealanders: a national survey. The New Zealand medical journal. 2007;120(1265):U2810.

[xxxix] Devamani C, Norman G. A simple microbiological tool to evaluate the effect of environmental health interventions on hand contamination. International journal of environmental research and public health. 2014;11(11):11846-59.

[xl] Cairncross S, Valdmanis V. Water supply, sanitation, and hygiene promotion. In: Disease Control Priorities in Developing Countries (2nd Edition). New York: Oxford University Press. 771-792. 2006.

[xli] Townsend J, Greenland K, Curtis V. Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China. Tropical Medicine & International Health. 2017;22(1):74-81.

[xlii] Moreland LD, Gore FM, Andre N, Cairncross S, Ensink JHJ. Monitoring the inputs required to extend and sustain hygiene promotion: findings from the GLAAS 2013/2014 survey. Tropical Medicine and International Health. 2016;21(8):1029-39

[xliii] Greenland K, Chipungu J, Chilekwa J, Chilengi R, Curtis V. Disentangling the effects of a multiple behaviour change intervention for diarrhoea control in Zambia: a theory-based process evaluation. Global Health. 2017;13(1):78

[xliv] Rajaraman D, Varadharajan KS, Greenland K, Curtis V, Kumar R, Schmidt WP, et al. Implementing effective hygiene promotion: lessons from the process evaluation of an intervention to promote handwashing with soap in rural India. BMC public health. 2014;14:1179.

[xlv] Greenland K, Chipungu J, Curtis V, Schmidt WP, Siwale Z, Mudenda M, et al. Multiple Behaviour Change Intervention for Diarrhoea Control in Lusaka, Zambia: Cluster Randomised Trial. Lancet Global Health 2016.

[xlvi] Lewis HE, Greenland K, Curtis V, Schmidt WP. Effect of a School-Based Hygiene Behavior Change Campaign on Handwashing with Soap in Bihar, India: Cluster-Randomized Trial. The American journal of tropical medicine and hygiene. 2018.

[xlvii] Chase CD, Quy-Toan. Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam. 2012.

[xlviii] Cairncross S, Shordt K. It does last! Some findings from a multi-country study of hygiene sustainability. Waterlines. 2004;22(3):4-7.

[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.

[l] Scott BE, Schmidt WP, Aunger R, Garbrah-Aidoo N, Animashaun R. Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana. Health education research. 2008;23:392-401.

[li] Galiani S, Gertler P, Ajzenman N, Orsola-Vidal A. Promoting Handwashing Behavior: The Effects of Large-scale Community and School-level Interventions. Health Econ. 2016;25(12):1545-59.

[lii] Gautam OP, Schmidt WP, Cairncross S, Cavill S, Curtis V. Trial of a Novel Intervention to Improve Multiple Food Hygiene Behaviors in Nepal. American Journal of Tropical Medicine & Hygiene. 2017;96(6):1415-26.

[liii] Biran A, Schmidt W, Varadharajan K, Rajaraman D, Kumar R, Greenland K, et al. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet. 2014;In print.

[liv] Judah G, Aunger R, Schmidt WP, Michie S, Granger S, Curtis V. Experimental pretesting of hand-washing interventions in a natural setting. American Journal of Public Health. 2009;99 Suppl 2:S405-11.

[lv] Nalbone DP, Lee KP, Suroviak AR, Lannon JM. The Effects of Social Norms on Male Hygiene. Individual Differences Research. 2005;3(3):171-6.

[lvi] Ram P. Practical Guidance for Measuring Handwashing Behavior. WSP website: Water and Sanitation Program 2010.

[lvii] Ram PK, Halder AK, Granger SP, Jones T, Hall P, Hitchcock D, et al. Is Structured Observation a Valid Technique to Measure Handwashing Behavior? Use of Acceleration Sensors Embedded in Soap to Assess Reactivity to Structured Observation. The American journal of tropical medicine and hygiene. 2010;83(5):1070-6.

[lviii] Contzen N, De Pasquale S, Mosler H-J. Over-Reporting in Handwashing Self-Reports: Potential Explanatory Factors and Alternative Measurements. PLOS ONE. 2015;10(8):e0136445.

[lix] WHO, UNICEF. Monitoring Hygiene JMP website,: JMP; 2015. Available from: https://washdata.org/monitoring/hygiene.

 

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