Handwashing

Background

It is now well known that handwashing with soap has a greater impact on morbidity from diarrhoeal disease than any other single intervention (see chart below). Why then, do NGOs focus so many of their activities and so much more money on supplying clean water and sanitation facilities?  Why are these recognised as core activities while handwashing is considered a ‘bolt-on’ activity? And why do NGOs always include water quality and latrine use as important indicators of success in logframes and monitoring strategies but rarely include handwashing, even though it is known to be a better success indicator?

Relevance of handwashing in disease prevention

In developing countries the biggest killers of young children are respiratory infections and diarrhoeal diseases – both can be reduced with hand washing. Hands are the last line of defence in the chain of transmission of gastrointestinal germs either directly by hand-to-mouth, or indirectly by handling food or water. Hands also play a part in the transmission of respiratory tract, skin and eye infections: – hands can be contaminated by respiratory viruses, and infections transferred by rubbing the eyes. 

Handwashing is particularly important in disaster situations; displaced people may lack an adequate supply of water, their circumstances can put them in situations where it is difficult for them to manage their hygiene, and access to soap may be limited. It is important to ensure that promotion and provision of handwashing facilities are prioritised in all responses where public health is at risk.

Handwashing at all times

Effective hand washing is a key consideration in all WASH programmes, and at all phases in the programme cycle:

• Assessment: it is important to know people’s existing behaviour; whether they wash their hands after defecation and before food preparation and eating. Do they use soap or other agents? Do different groups – men, boys, women, girls etc have different practices?  PHP staff should include an assessment of hand-washing knowledge, attitudes and practice in all rapid WASH assessments and baseline surveys
• Planning: involve the affected population in planning and ensuring all responses are appropriate and relevant to the situation.  Funding for handwashing devices, including soap, should be included in budgets. Choice of handwashing device should as much as possible be informed by what is traditionally used by the community. Appropriate behavioural change should be incorporated as an important part of programme planning
• First-phase response: consideration must be given to handwashing from the outset – emphasis should be at communal latrines or defecation areas at very least, as well as at food preparation points. A campaign to disseminate key handwashing messages may be appropriate. Training hygiene promoters and community mobilisers is a useful way to promote handwashing; tools and training materials have been produced by the WASH Cluster 

• Maintenance: all handwashing facilities should have a consistent supply of water and be well maintained to ensure they are useable. In the first phase it may be necessary to pay water suppliers or use community mobilisers to refill handwashing facilities, but in the longer term all facilities should have water conservation systems or continuous filling processes as needed 
• Monitoring: observation and focus group discussions can be used to monitor handwashing practices; they complement each other in highlighting what people really do vs what they say they do. Anecdotal information should be collected in conjunction with other data. Ensure all data is written and analysed to monitor any changes in handwashing behaviour. Active listening to the views of the community is key to understanding community attitudes

Practical Considerations 

Peoples’ practices:

• Consultation with the population is important; (including men, women and children) on their views on the types of devices used and their preferences, to ensure they are  appropriate; e.g. the taps should not be too high or too difficult for children elderly and people with disabilities to operate

• In some cultures men may not share the same facilities with women, so facilities should be appropriate for the cultural context  
• Handwashing techniques may differ between communities. Several countries have produced posters describing the steps involved in hand washing, and the Sphere handbook has a chapter on the ‘right’ techniques for handwashing to be effective (length of time rubbing your hands, what medium to use, length of fingernails etc).  All health promoters should know and promote these techniques.

Handwashing Facilities: 

• Handwashing facilities should be made available at sanitation areas at very least
• Consideration should be given not only to ensuring there are hand washing facilities at the latrines, but also at the household level – encouraging people to wash their hands at all key times, such as before feeding children, preparing food, eating etc. Soap is also less likely to get stolen at household level compared to communal hand washing areas. 
• Different handwashing facilities will be appropriate for different situations; e.g. large drums for community facilities or smaller devices such as the Tippy Tap for households. 
• Soap is a valuable commodity and might be taken from communal sites, so put some thought into ways of minimising this risk – e.g. tying it to string, or diluting it in water
• All handwashing sites should have adequate drainage to prevent muddy conditions. 

Just water, soap, or ash?

• Soap is the ideal agent, but this is not always available or affordable.
• Antibacterial soap is not advised where there is a high incidence of skin diseases (such as in flood situations) as it can be irritable. There also seems to be no difference in effectiveness between antibacterial soap and plain soap.
• If no soap is available, washing hands with ash is preferable to no agent at all. Soil, ash or mud as an alternative to soap may have risks as they can be contaminated with pathogens  – use ‘fresh’ ash straight from the source
• It is the rubbing of the hands which is important.

Promoting handwashing

• Promotion has to suit the context – culture, gender, children, environment etc; these issues should be considered at the assessment stage, to help with planning interventions
• It is important to know the target population’s existing behaviours and preferences for promotional material; e.g. Haitians enjoy music, so a catchy song by a popular singer can work well.  Traditional childrens’ games can be very successfully adapted to include hygiene messages, and can be fun to carry out 
• Ensure the language / idiomatic expression and the method used in the promotional material is understood; e.g. not everyone can read – especially women in some communities
• Encouraging handwashing should be included in all latrine attendants’ and health promoters’ job descriptions
• Women are usually the cooks and carers, so it is important to target them for promotional activities
• Health may not be the most important motivator for changes in hygiene behaviour.  The desire for privacy & dignity, the observation of religious or cultural norms, or personal comfort may be stronger driving forces. Refer to the chapter on Hygiene Promotion in the Sphere handbook which has a guidance note on motivating different groups to take action.
• Use shock tactics, if appropriate! To change a habit you may have to shock people into doing something different, giving them a powerful message that really motivates them to think about what they are doing  and change it 

Methods that have been used successfully for handwashing promotion include:

• Drama, plays, dances
• Songs
• Puppets
• Clowns
• Games
• Door-to-door distribution of posters or leaflets
• Demonstrations

Places for handwashing promotion include:

• Schools
• Places of worship
• Community centres
• Market areas
• Health centres / clinics
• In the home

In summary, key criteria for ideal handwashing devices are:

• Low manufacturing cost
• Lightweight/transportable
• Strong/durable
• High water conservation
• Locally replicable
• Unisex, and cross-generation appropriate
• Simple to operate
• Disability conscious
• Theft resistant
• Maximum water filling frequency of two times/day
• Culturally appropriate and acceptable by the community.

At the absolute minimum…

• All institutional latrines constructed by Oxfam must have handwashing facilities provided with soap or a proxy agent, especially in the acute stage of an emergency response
• Communal handwashing places should be constructed to raise awareness about the importance of handwashing; demonstration facilities are useful
• Special focus should be given to children, since children share information on handwashing with their families. Demonstrations and monitoring in school are useful to help children learn and practice effective handwashing
• Promotion of handwashing should consider the context; people’s behaviour, the culture, amount of water available etc
• Vulnerable groups, such as those with disabilities or HIV and AIDS need especially easy access to handwashing facilities
• Monitoring, evaluation and learning activities must include assessments of changes in handwashing practice and appropriate use of handwashing facilities.More details in the WASH Minimum Requirement document. 

References

WELL Factsheet on health impact of handwashing with soap: http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-htm/Handwashing.htm 

http://www.humanitarianreform.org/Default.aspx?tabid=343 , also Hygiene promotion training materials and visual aids available on DVD.  There are some relevant sessions in the Essential to know (part 1 of 3), such as key actions to prevent diarrhoea, community involvement in the design of facilities.

An example of Hand washing steps poster:  http://www.redcross.org/www-files/Documents/pdf/Preparedness/ScrubClubHandWashing.pdf 

Luby S. et al (2004) ‘Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk communities in Pakistan: A Randomised Controlled Trial’ The Journal of the American Medical association 292 (14) 

Bloomfield, S. F. and Nath, K.J.  (2009) Use of ash and mud for handwashing in low income communities. International Scientific Forum on Home Hygiene 

Sphere Project, (2011) Humanitarian Charter and Minimum Standards in Humanitarian Response, www.sphereproject.org 

Curtis, V. (2009) July Soapbox, the newsletter of the Global public private partnership for hand washing with soap ⁸Oxfam GB, Water Sanitation and Hygiene Promotion Minimum Requirement (MR WASH).see Oxfam GB O Drive.

For more information and guidance, please contact any of the Regional or Humanitarian Department Public Health Promotion Advisers