Integrating evidence into programming
Over the last twenty years we have seen a growing number of publications about handwashing with soap and behaviour 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 programmes. In this blog I outline five key programme recommendations based on our current state of knowledge about handwashing.
1. 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 (1,2). Unfortunately, having bio-medical knowledge does not mean that people are more likely to wash their hands with soap. Several studies have demonstrated that handwashing programmes which only focus on improving bio-medical knowledge have no effect on behaviour (3-6). 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 bio-medical ‘facts’ sit alongside a range of other beliefs and competing priorities (1, 7-10). Just think about your own behaviour. 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 faecal-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.
2. Infrastructure really matters
Handwashing promotion programmes often deprioritise the most important mode of changing behaviour: improvements to handwashing infrastructure and products. Did you know that if households have access to a handwashing facility they up to 60% more likely to wash their hands with soap (6, 9, 11-16)? 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 (13, 17-22). When handwashing facilities are conveniently located near the kitchen or toilet (20) and desirable and attractive (e.g. the facility has bright colours, has a soap container, has a mirror) (11, 15, 23-25) this can increase handwashing rates even further. This means that if we design handwashing promotion programmes comprising of only ‘soft’ behaviour change techniques in areas where the basic handwashing ingredients are lacking, then we may see no effect on behaviour. We may also risk offending or disengaging local populations who might wonder why we are promoting a behaviour that is not feasible for them to practice.
Handwashing programmes should also think carefully about how physical environments can be modified to cue handwashing behaviour. Using ‘behavioural 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 behaviour increases by 64% (26). Another study paced an image of eyes above a handwashing facility, resulting in people being 10% more likely to wash hands (27). 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 (28).
3. 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 (29-35). 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)(33). On average people wash their hands for less than 10 seconds (36-38) – 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 (39). 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 healthcare settings or outbreak situations.
4. Meaningful behaviour change is not cheap, quick or easy
Handwashing promotion is often cited as one of the most cost-effective public health interventions (40, 41). These figures tend to be misinterpreted by donors and implementers alike and this commonly results in hygiene programmes being underfunded (42). The evidence suggests that sustained handwashing behaviour change is not normally cheap – nor is it quick to design and implement (43, 44). Achieving sufficient ‘dose’ seems to be a critical factor which can make or break a handwashing promotion programme (45-47). 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 behaviour change programmes need to interact with target populations on multiple occasions, over an extended period of time, in order to be effective (48, 49). Handwashing programmes also seem to be successful when they target multiple delivery channels (50-53). Ideally programme implementers should consider combining mass media strategies with interpersonal techniques which reach the target population at the community and household level.
5. Everyone wants to be seen to wash their hands
Handwashing with soap is a socially desirable behaviour in all cultures. This has several implications for hygiene programmes. Firstly, it means that people are almost 50% more likely to wash their hands if there are other people in a public bathroom (27, 54, 55). Handwashing interventions which remind people that others might judge them on their handwashing behaviour have been shown to be effective (54). Secondly, it can make measuring handwashing behaviour 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 behaviour typically overestimate actual practice. Although there is no perfect way of measuring handwashing behaviour (56-58) the Joint Monitoring Programme now suggests dropping self-reported handwashing measures in favour of using the new global handwashing indicator (59). This is a proxy measure which is rapid and cheap to assess and provides a meaningful comparable indicator.
This article will also be published by the Global Handwashing Partnership.
1. Curtis V, Danquah LO, Aunger RV. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health education research. 2009;24:655-73.
2. Rabbi SE, Dey NC. Exploring the gap between hand washing knowledge and practices in Bangladesh: a cross-sectional comparative study. BMC public health. 2013;13:89.
3. Biran A, Schmidt WP, Wright R, Jones T, Seshadri M, Isaac P. The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial. Trop Med Int Health. 2009;14.
4. Scott E, Herbold N. An in-home video study and questionnaire survey of food preparation, kitchen sanitation, and hand washing practices. Journal of Environmental Health. 2010;72(10):8-13.
5. Clayton DA, Griffith CJ, Price P. An investigation of the factors underlying consumers’ implementation of specific food safety practices. British Food Journal. 2003;105(7):434-53.
6. Contzen N, Meili IH, Mosler H-J. Changing handwashing behaviour in southern Ethiopia: A longitudinal study on infrastructural and commitment interventions. Social Science & Medicine. 2015;124:103-14.
7. Kaltenthaler EC, Drasar BS. Understanding of hygiene behaviour and diarrhoea in two villages in Botswana. J Diarrhoeal Dis Res. 1996;14(2):75-80.
8. Rheinlander T, Samuelsen H, Dalsgaard A, Konradsen F. Teaching minority children hygiene: investigating hygiene education in kindergartens and homes of ethnic minority children in northern Vietnam. Ethnicity & Health. 2015;20(3):258-72.
9. Biran A, Tabyshalieva A, Salmorbekova Z. Formative research for hygiene promotion in Kyrgyzstan. Health Policy Plan. 2005;20(4):213-21.
10. Rauyajin O, Pasandhanatorn V, Rauyajin V, Na-nakorn S, Ngarmyithayapong J, Varothai C. Mothers’ hygiene behaviours and their determinants in Suphanburi, Thailand. Journal of Diarrhoeal Diseases Research. 1994;12(1):25-34.
11. Ashraf S, Nizame FA, Islam M, Dutta NC, Yeasmin D, Akhter S, et al. Nonrandomized Trial of Feasibility and Acceptability of Strategies for Promotion of Soapy Water as a Handwashing Agent in Rural Bangladesh. American Journal of Tropical Medicine & Hygiene. 2017;96(2):421-9.
12. 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.
13. Nizame FA, Leontsini E, Luby SP, Nuruzzaman M, Parveen S, Winch PJ, et al. Hygiene practices during food preparation in Rural Bangladesh: Opportunities to improve the impact of handwashing interventions. American Journal of Tropical Medicine and Hygiene. 2016;95(2):288-97.
14. Mbuya MN, Tavengwa NV, Stoltzfus RJ, Curtis V, Pelto GH, Ntozini R, et al. Design of an Intervention to Minimize Ingestion of Fecal Microbes by Young Children in Rural Zimbabwe. Clinical Infectious Diseases. 2015;61 Suppl 7:S703-9.
15. Biswas D, Nizame FA, Sanghvi T, Roy S, Luby SP, Unicomb LE. Provision versus promotion to develop a handwashing station: the effect on desired handwashing behavior. BMC public health. 2017;17(1):390.
16. Dobe M, Mandal RN, Jha A. Social determinants of good hand-washing practice (GHP) among adolescents in a rural Indian community. Family & Community Health. 2013;36(2):172-7.
17. Luby SP, Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB. Household characteristics associated with handwashing with soap in rural Bangladesh. The American journal of tropical medicine and hygiene. 2009;81(5):882-7.
18. 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.
19. Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston R, Luby SP. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC public health. 2010;10(1):545.
20. Hirai M, Graham JP, Mattson KD, Kelsey A, Mukherji S, Cronin AA. Exploring Determinants of Handwashing with Soap in Indonesia: A Quantitative Analysis. Int J Environ Res Public Health. 2016;13:868.
21. Luby SP, Halder AK. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med Int Health. 2008;13(6):835-44.
22. Scott BE, Lawson DW, Curtis V. Hard to handle: understanding mothers’ handwashing behaviour in Ghana. Health policy and planning. 2007;22:216-24.
23. 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.
24. 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.
25. 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.
26. 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).
27. 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.
28. 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.
29. Hoque BA. Handwashing practices and challenges in Bangladesh. Int J Environ Health Res. 2003;13 Suppl 1:S81-7.
30. 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.
31. 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.
32. 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.
33. 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.
34. 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.
35. 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.
36. Borchgrevink CP, Cha J, Kim S. Hand washing practices in a college town environment. J Environ Health. 2013;75(8):18-24.
37. 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.
38. 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.
39. 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.
40. 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.
41. 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.
42. 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.
43. 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.
44. 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.
45. 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.
46. 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.
47. Chase CD, Quy-Toan. Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam 2012.
48. Cairncross S, Shordt K. It does last! Some findings from a multi-country study of hygiene sustainability. Waterlines. 2004;22(3):4-7.
49. 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.
50. 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.
51. 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.
52. 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.
53. 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.
54. 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.
55. Nalbone DP, Lee KP, Suroviak AR, Lannon JM. The Effects of Social Norms on Male Hygiene. Individual Differences Research. 2005;3(3):171-6.
56. Ram P. Practical Guidance for Measuring Handwashing Behavior. WSP website: Water and Sanitation Program 2010.
57. 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.
58. 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.
59. WHO, UNICEF. Monitoring Hygiene JMP website,: JMP; 2015 [Available from: https://washdata.org/monitoring/hygiene.