October 13, 2023
By: Meriam Zegeye and Aarin Palomares
Photo credit: UNICEF
As we prepare to mark the Global Handwashing Day on October 15 and engage with the upcoming UNC Water and Health Conference starting on October 23, 2023, this month is practically the unofficial ‘hand hygiene awareness’ month of the year. These events provide an impetus to put hand hygiene back in the spotlight. In honor of this month, I will highlight the latest evidence on hand hygiene behavior change using evidence from the latest Hand Hygiene Research Summary published by the Global Handwashing Partnership.
Published in May of this year, the 2022 Hand Hygiene Research Summary compiles and synthesizes peer-reviewed literature from the previous year and summarizes the latest findings and lessons learned from hand hygiene activities. These summaries provide guidance on hand hygiene best practices for program implementers, policy actors and researchers.
After searching three databases for handwashing studies published in 2022, 152 studied were identified as including relevant hand hygiene research. The studies were further categorized by study design, outcome focus, and intervention setting (domestic, school-based, healthcare facility, workplace, public space, and humanitarian), revealing context-specific insights.
Determinants of hand hygiene behavior
Sustaining hand hygiene behavior change requires addressing a range of behavioral determinants. Behavioral determinants are factors that influence behavior. Determinants for hand hygiene behavior include social norms, affiliation, enabling technologies/infrastructure, nurture, disgust, perceived susceptibility and perceived severity of diseases. The Handwashing Handbook groups these determinants into reflexive, habitual factors (such as culture, environmental cues, and nudges) and more reflective, conscious decision-making factors (such as knowledge and emotional motivators).
Enabling technologies are a critical determinant for hand hygiene behavior. Undoubtedly, it is not possible to maintain good hand hygiene without the necessary facilities. However, in a study surveying 29 countries in Sub-Saharan Africa, Endalew et al. (2022) determined that 66.16% of handwashing facilities lacked either water or soap. Access to facilities and supplies cannot be neglected, but it is not the only determinant for hand hygiene behavior.
Emotional motivators, such as the feeling of affiliation, nurture, or disgust are also crucial factors for hand hygiene behavior. One such example is from a study which assessed the impact of the Mum’s Magic Hands resource in promoting handwashing among mothers in humanitarian settings (White et al., 2022). The storyboard features a mother and her efforts to care for her daughter and instill good handwashing habits despite their difficult emergency context. This resource uses the emotional motivators of nurture and group affiliation to capture the effect of positive social factors and motivate handwashing. Through its touching and engaging images, the storyboard presents handwashing as a crucial part of a mother’s care for her children. These innate motivators can move mothers to action even in emergency contexts where other pressing needs seem more urgent.
The presence of role models is also a notable factor for hand hygiene behavior. A cross-sectional study done in Ethiopia by Berhanu et al. (2022) found that students with strong handwashing role models were 4.41 times more likely to wash their hands as compared to students who did not have strong role models. Another study by Ahmadipour et al. (2022) identified improper behavioral patterns of supervisors among one of the main barriers to handwashing among health care workers in Iran. The study found that healthcare workers mirrored the practices of head doctors and nurses, admitting to underestimating the importance of handwashing because of the noncompliance of their supervisors. Managers and supervisors play a large role in setting the norms for hand hygiene practices. Their own behaviors as role models can either reinforce or undermine the training that health workers receive regarding hand hygiene. Interventions should empower supervisors in their positions as role models as a mechanism for social norm change in healthcare environments. The same is true in public settings. A study by Akter et al. (2022) on the barriers and facilitators of a COVID-19 intervention demonstrated that influential community members can act as role models to influence hand hygiene behavior.
Decades of research show us the need to better understand our target audience and the key factors that influence their hand hygiene behavior. Good behavior change programming goes beyond knowledge and education, rather good program design understands the barriers and enablers of hand hygiene behavior to develop effective, context-specific interventions.
Developing sustainable interventions
Behavior change takes time. Not only do people need to be motivated initially to take up a healthy behavior, but this motivation must be sustained for the maintenance of this behavior. Whether due to fatigue or the rise of other immediate needs, without reinforcement, healthy habits drop down on the priority list. Several studies in the 2022 report highlight the need for sustainable interventions for lasting behavior change.
In a domestic setting, Sedekia et al. (2022) conducted a study and held 20 household sessions on soil-transmitted helminth (STH) among children after which 18 households installed handwashing stations. However, after 8 months, only 8 households had maintained the handwashing stations. These findings show that, although the sessions were initially effective, sustained interventions were necessary to motivate households to maintain and utilize the handwashing stations. Similar effects were seen in a study by Nalule et al. (2022) assessing the effectiveness of hand hygiene interventions including building facilities, providing training, and establishing cues on improving hand hygiene practices among midwives and caregivers. The study found significant improvements among midwives and caregivers in healthcare facilities but only limited improvements in the postnatal home environment.
Both examples highlight the need for sustained interventions to maintain behavior change long-term. Once behavioral determinants are identified, program managers must select, refine and implement a set of activities or interventions that best address those determinants to not only change but sustain hand hygiene behavior.
Overall, the 2022 Hand Hygiene Research Summary emphasizes what many of us already know: Increased knowledge of hand hygiene practices does not automatically lead to improved hand hygiene behaviors. While improvements have been made to go beyond health education programs, the latest evidence emphasizes that more should be done to promote hand hygiene behavior change in different contexts.
The research for the use of emotional motivators as a determinant for sustained behavior change is promising. Health-related motivators are a good catalyst to raise perception of susceptibility of disease. However, this needs to be paired with emotional motivators such as the desires to nurture and have group affiliation. Furthermore, nudges, environmental cues, and continued messaging are necessary to maintain compliance. Influential role models also have the potential to uphold good hand hygiene as the norm by modeling positive behaviors and through the motivation for affiliation. For children especially, the involvement of parents and caregivers at home is necessary to reinforce hand hygiene education at school. This determinant should continue to characterize interventions in school, healthcare and public settings. Finally, the evidence shows the importance of interventions that promote long-term behavior change through sustained activities.
The 2022 Hand Hygiene Research Summary shows growing understanding that hand hygiene promotion efforts must move beyond awareness to long term behavior change. As we celebrate this unofficial ‘hand hygiene awareness’ month and look toward the future, it is important that we build on the latest research and continue to address context-specific motivators and barriers to ensure lasting behavior change.
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