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The Global Handwashing Partnership

The 2018 Handwashing Behavior Change Think Tank Through the Lens of a Hygiene Knowledge Manager

January 22, 2019

By: Ebuwa Evbuoma, Global Handwashing Partnership

Participants at the 2018 Handwashing Behavior Change Think Tank in Manila, Philippines

The Global Handwashing Partnership’s Handwashing Behavior Change Think Tank events bring together multi-sector hygiene experts to drive learning and action in handwashing behavior change. The 2018 edition was held in the Philippines. It was the first Think Tank held in Asia and hosted 67 participants from 13 countries. The Think Tank presented a diversity of thought and resource potential for next steps in handwashing programming and problem solving.

I joined the Think Tank planning team as the GHP’s Knowledge Management Technical Officer and a Global Health Corps Fellow. In this post, I highlight my reflections of this event; as a young professional working in global health, and as a team member of the GHP Secretariat. I will provide an overview of core themes in this event, and the sessions I found most impactful in each of the three tracks.

Reflections on core themes at the Think Tank

Behavior change across settings

True behavior change requires desire and participation from the target population. This stood out to me from two sessions in particular – one on lessons across contexts, and one on handwashing in emergencies.

The session on Handwashing Behavior Change Lessons Across Contexts featured breakout poster presentations on four handwashing behavior change programs in the Philippines and Malawi. In all four case studies, involving the target community -preschoolers, teachers, healthcare workers and patients- in designing the intervention made a difference in program uptake and ability to scale. For instance, in the HiFive for Hygiene and Sanitation Program by the Center for Health Solutions and Innovations (CHSI) in the Philippines, the hygiene curriculum was co-developed with pre-school teachers, and this collaboration continued with feedback from the teachers during handwashing measurement in the implementation phase.

This track concluded with a session on Behavior Change Lessons in Challenging Contexts. The session defined program gaps in handwashing design for crisis regions, and innovations to address these problems. Field research with program managers revealed that the range of options for handwashing behavior change program design solutions in refugee camps and other settings was simply too broad, and the selection of a solution was often left to their discretion, influenced by previous crisis experience, or ease of availability.

The London School of Hygiene and Tropical Medicine (LSHTM) WASH’Em program aims to address this by tailoring program design to emergency setting needs. WASH’Em tools are hosted on an online platform that encourages hygiene program managers to select handwashing program designs based on evidence and the specific needs of their crisis context. I believe that the adoption of these programs rests strongly on the early involvement of the gatekeepers in the hygiene context under consideration. This ties in with the discussion on human-centered design, which I detail in the succeeding theme.

Design and innovation for behavior change

Modern development work asks implementers to think of target populations as participants and not beneficiaries. Human-centered design solidifies this thinking by asking designers to think only of the needs and desires of communities in achieving program goals. In a shift from traditional plenary style, the Think Tank also featured interactive workshops, one of which was built on these principles.  Designing a Better Handwashing Station explored traditional approaches to designing and delivering handwashing stations, and case studies of stations designed by the more collaborative human-centered design method. As a human-centered design enthusiast, it was rewarding to see representatives from different sectors roll up sleeves and attempt to think through typical biases in handwashing hardware interventions. Evidence-based concerns, such as soap availability and nudges for desired behavior remained motivators in the design cycle, but participants also weighed in practical considerations, such as household location, electricity, and water supply in their prototypes.

The largest highlight for me was the willingness of participants to view handwashing through the lens of target populations. For an event with attendees from over 13 countries, this multi-lens view was a great resource in the quality of engagement and prototype delivery.

Hygiene systems and integration

The successful scale-up of handwashing behavior change implementation has always relied strongly on partnerships and integrating systems. This theme appeared in two health and education sector-focused sessions, which explored policies and case studies in hand hygiene programming. An interesting example was the Department of Education’s program on hand and oral hygiene, rolled out in elementary schools across the country in partnership with UNICEF. GIZ’s WASH in Schools work in South East Asia was another highlight. GIZ uses the Three Star Approach, a standardized index, to measure policy and implementation of water, sanitation and hygiene structure and behavior approaches in schools.

The subsequent session, led by Dr. Robert Dreibelibis of the LSHTM’s Hygiene Center, explored research on hand hygiene behavior change among health care providers, with a case study from a tertiary health care facility in Nigeria. The evidence shows that knowledge has been proven to be insufficient to inform behavior change. Health care workers have knowledge of hand hygiene, but still struggle with balancing large caseloads and insufficient hygiene resources with the motivation to wash their hands at key moments. This point segued into a presentation from Ms. Allison MacIntyre, WaterAid Australia’s Technical Lead, on health systems strengthening for water, sanitation and hygiene behavior change in health facilities.

I found this session particularly interesting, as it resonated with my reflections on hospital WASH policy and practice when I worked as a medical doctor in tertiary care facilities in Nigeria. The hospital I had worked with launched an Infection Prevention and Control Committee (IPC) which was tasked with hand hygiene reforms, but the IPC simply could not maneuver around plumbing or hygiene supply delays. A healthy health system would make all the difference.

Reflections on participation and a pivot from hardware to behavior change

One example of how handwashing programs have shifted from hardware to behavior change was Dr. Om Prasad Gautam’s presentation of WaterAid’s work to change policies. This shift yielded measurable results in Nepal and Pakistan, including governmental collaboration, national level budget inclusion, and measurable behavior change in households. Further, Ms. Kristie Urich, World Vision’s (WVI) Knowledge Capabilities WASH Manager, highlighted learnings from WVI’s review of their over two-decade approach to solving WASH problems in developing countries. The core lesson of this sobering presentation was that participation and behavior change must be centered in the approach to WASH programming. The traditional focus on hygiene hardware, reflected in the large volume of environmental engineers in many WASH teams, must be pivoted to incorporate behavior change experts in program design and implementation.

The third day of the Think Tank featured a pleasant surprise- a collaborative Global Handwashing Day celebration. Over 150 pupils and staff of the Andres Bonifacio Elementary School in Pasay hosted the Think Tank participants at the event. With a school tour, musical performance (of a handwashing song), posters, learn-and-play sessions, and a communal meal called a Boodle fight, participants enjoyed the immersion into the school’s hand hygiene systems.

As a knowledge manager, this event presented a unique glance into the pains and gains of WASH researchers and practitioners, whom the GHP supports with tools, guidance and other knowledge resources. It was an opportunity to think with hand hygiene stakeholders, share experiences and make recommendations that can be carried into handwashing work in different regions.

The 2018 Global Handwashing Partnership Think Tank was co-hosted by the GHP, Procter & Gamble, and the Think Tank Planning Committee: UNICEF, GIZ, FHI 360, World Vision, USAID, WaterAid, and the Philippines Departments of Health and Education. Read more about the Think Tank and view the presentations here.

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