You may, or may not, be aware that today – October 15 – is Global Handwashing Day (GHD). You may have missed the estimated 200 million people in 100 countries marking the importance of handwashing with soap; been blind to the dedicated Twitter campaign to get #iwashmyhands trending worldwide; or been otherwise distracted when the WASH community began pulling together excellent research, evidence and practical tools in support of handwashing activities worldwide. It’s all there, happening now, and Plan International is playing its part to spread the word.
You can probably sense there is a ‘but’ in the narrative that’s about to appear. And it’s this: despite the fact that the tremendous outreach and advocacy efforts highlighted above do make a tangible difference; despite knowing that handwashing alone significantly reduces neonatal mortality and hygiene promotion is one of the most cost-effective public health interventions, the stark reality is that hygiene behavior change is a long neglected and overlooked part of the WASH equation. Even within our own community of practice, handwashing with soap tends to be considered the poor relation to infrastructure initiatives for water and sanitation.
So far, so obvious for a sector which has had a long love-affair with water supply, and is only latterly recognizing and prioritizing sanitation and hygiene. Perhaps the cause of this institutional blindness is down to the subtle and, at times, complicated characteristics of our understanding about why and when handwashing approaches work. Let’s review some of the (surprising?) reasons for this, drawn from recent thinking and experience:
- The myth of health as a driver: behavior change such as handwashing with soap is about motives (not knowledge), and ‘health’ is generally not a prime motivator. Typical drivers for handwashing have been found to be affiliation with a group, disgust, comfort and the wish to nurture others. Some of the best messages found to work in one handwashing campaign were: ‘Is the person next to you washing their hands?” (affiliation) and “don’t take the loo with you” (disgust).
- Monitoring hygiene behavior needs multiple methods, including direct observation: Unless we monitor behavior change, and particularly change over the long-term, we cannot know the effectiveness nor sustainability of behavior change interventions. But measuring hygiene behavior is notoriously difficult. Studies have found high levels of reporting bias - for instance, if 90% people say they did wash hands with soap, verification studies indicate that actually only 5% had done so.
- Formative research on target groups is fundamental to planning and managing well-developed behavior change interventions. But formative research (which examines ‘why’ people behave the way they do, and what the best potential motivators might be to shift behavior) and the social science methods behind it are generally poorly understood by engineers, who tend to lead and direct WASH programs. Do we need a common language of engagement in the WASH sector?
So what can be done? What are the preconditions for getting a bigger and better ‘bang for our buck’ when promoting handwashing? In June of this year, Plan International USA participated at a think tank meeting of the Global Public Private Partnership for Handwashing (PPHW). The Partnership brought together leading organizations (NGOs, academics, donors, private sector and the United Nations) who focus on handwashing and children’s health. The not-so-well distributed outcomes from this meeting are worth repeating here (and often). It’s a mix of lessons learned and focus for our collective energy and institutional investments. If we can address these parts of the equation in the next few years, especially as we move towards the Sustainable Development Goals after 2015, we have a much better chance of making an impact with our work:
- Promote fewer critical times for handwashing for greater impact. Keep it simple: 1. after faeces: after using latrine or cleaning baby, and 2. before food: before eating or preparing food. Perhaps we need a ‘critical times’ ladder: start with one or two critical times and expand from there. Timing messaging to teachable moments like school enrollment, pregnancy, vaccinations, etc. may further present opportunities for handwashing messages.
- Difficult to get the same level of health impacts from handwashing at-scale programs. At-scale handwashing behavior change programs have struggled to get the same level of impact as those seen in small-scale, highly-controlled trials/programs. Integration of handwashing behavior change into sanitation, nutrition, school and other large-scale programs may be effective at reaching scalable operation.
- How do we make handwashing a habit and a social norm? Here, we have to do a better job to learn from private sectors’ skill in creating habit.
There are no prescriptions for success in the above list, just our best and most informed thinking. So, time for me to get off my own soapbox and put into practice this agenda for change. It starts for me this week, as I work with our WASH advisers and Plan colleagues in our Asia region focusing on their recent and best experiences in WASH, and is followed by a few days with our Plan Cambodia office, where we are implementing large scale behavior change programs in rural communities.