Step one: Pave the way
Paving the way refers to how program designers can make it easier for people to adopt good handwashing behaviors. Some of the ways to do this include:
- Address the enabling environment
- Focus on critical moments for promotion
- Understand drivers of behavior
- Select handwashing behavior change strategies
- Pursue opportunities for integration
Address the enabling environment
The so-called “hardware components” that comprise the enabling environment for handwashing include availability soap; access to water that can be used for handwashing; and access to appropriate and desirable handwashing stations.
Soap is a key enabling technology for handwashing. It must be available, and at a cost that is perceived as affordable, to increase the likelihood that households will purchase it. Although using soap is the most effective way to clean hands, access to soap is not universal. Often poorer households invest in soap for washing clothes or washing dishes, are less likely to use it for handwashing. Handwashing with soap rather than water alone substantially increases the behavior’s effectiveness and health benefits. Where soap is not available or difficult to obtain, soapy water is a potential low-cost alternative.
Access to water is needed for handwashing. Piped water is not required for handwashing; water that can be poured or run over hands is sufficient. A frequently asked question is whether the microbiological quality of water is relevant for achieving the decontamination and health benefits of handwashing. Research studies have typically not addressed this, but one study showed that handwashing with soap still delivered health benefits such as diarrhea reduction even when the water used was likely to be contaminated. If water for handwashing is unavailable or inconveniently located (i.e. far from the toilet, food preparation area, food consumption area, or far from the soap) the likelihood of sustained handwashing behavior change may be reduced.
Handwashing stations can facilitate the habit of correct handwashing by making handwashing more feasible. They can also serve as a reminder or “cue to action” when located near a food preparation area or toilet. There are a range of handwashing stations that can be built or purchased, depending on the context. Household surveys have found that the presence of water and soap at a handwashing station is associated with increased handwashing behavior.
The “software” components of the enabling environment include knowledge about handwashing; motivation to adopt the behavior; and the social context in which to use the hardware.
Social context also plays an important role in the enabling environment. A lack of social norms around handwashing, and lack of social approval and reinforcement, can be barriers to adopting and sustaining handwashing behaviors. At the same time, a strong social norm can help motivate people to practice good handwashing behaviors. For instance, in qualitative research focusing on handwashing in the perinatal and early infancy periods in Bangladesh, mothers reported that handwashing was generally not a habit in their community. As a result, they feared being ridiculed for adopting handwashing behavior in the perinatal period.
Inequity is another major factor in the enabling environment that affects handwashing. Access to hand washing stations, for example, can vary widely between countries. For example, people in urban areas often have better access than those in rural areas. An analysis of data in Sub-Saharan Africa found that households lacking a positive enabling environment for handwashing tended to be in lower wealth quintiles, live in rural areas, and have less educated heads of household. Without adequate handwashing options, these people are more likely to become sick, leading to worsening health, nutrition, and education outcomes, thereby further widening the equity gap. It is important to ensure behavior change programs address equity and strengthen the enabling environment for handwashing.
Focus on critical moments for promotion
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. Click here to see the CDC’s recommended times to wash hands.
Understand drivers of behavior
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.
Drivers are the psychological or other factors that influence people to wash their hands. Handwashing programs aim to increase or leverage these drivers to increase handwashing behavior. Drivers are not the same in every context or for every person. Therefore, program implementers must understand which drivers are most relevant in their program context. They should also adapt strategies, activities, messages and other program component to the drivers they find. Drivers can be addressed overtly (for example, through messages or posters) or indirectly through structural changes. To learn more about different drivers for handwashing behavior change, watch our 2017 webinar on the topic.
Select handwashing promotion channels
Channels are the methods and tools used to communicate with populations. The most effective channel will be suitable to your message, accessible to your audience, and familiar or trusted by your audience. Here are some examples of different channels that can be used.
Mass media
The evidence for the effectiveness of mass media on behavior change is mixed. Some studies have demonstrated the efficacy of mass media (including TV, radio, videotapes, slide shows, and pamphlets) on increasing handwashing among mothers with young children. For example, in Ghana in 2007, the National Truly Clean Hands campaign run by a professional advertising agency demonstrated a 10% rise in handwashing with soap, after their television advertisement. However, more recent mass media approaches in Peru and Vietnam did not yield substantial improvements in handwashing behavior or health outcomes. If mass media is used to promote handwashing behavior change, it should be included as part of a range of interventions.
One-on-one and group interventions
Demonstrating handwashing behaviors directly to caregivers and children by skilled health workers, educators, or peer hygiene promoters has been found to be an effective approach to achieving handwashing behavior change. Programs that include one-on-one or group interventions may include education and training on the skills of correct and consistent handwashing and other hygiene practices, as well as seek to motivate participants to wash their hands routinely by using the concepts of nurture and affiliation, for example.
Community or religious events
Cleanliness is an important part of many religious rituals and community ceremonies. Often, religious leaders are also thought leaders in their communities, and by promoting handwashing with soap they can help promote health amongst their congregations and communities. Religious organizations can be involved in promoting handwashing through building handwashing stations, working with partners to celebrate Global Handwashing Day, and educating the community about the importance of good hygiene for health.
Mobile phones
The power and reach of information and communications technology is being harnessed to educate and empower people with handwashing promotion messages and reinforcing these messages in a personalized way. Mobile phones are becoming a particularly exciting tool in handwashing promotion, as mobile use is increasing worldwide. For one example of how mobile technology was used in handwashing behavior change, read about our webinar on Mobile Health (mHealth) Messaging to Facilitate Handwashing with Soap Behavior Change.
Pursue opportunities for integration
Handwashing with soap is a cornerstone of public health. The benefits of handwashing can be seen in nutrition, maternal and child health, education, and much more. This brings opportunities to promote handwashing within or in partnership with programs focused on other health areas. A few examples of organizations or projects that can promote handwashing are:
- Water and sanitation projects
- Maternal, newborn and child health projects
- Nutrition projects
- School, health facility, or other institutional programs
Visit our resource hub or the Clean, Fed, and Nurtured web site to learn more about integrating hygiene with other programs.