How do we get more people to wash hands?

It is difficult to pinpoint exactly when Meena became a national icon for children across Bangladesh but it is easy to remember how. Among other things, Meena taught a generation of children the importance of handwashing to fight transmissible diseases, and likely nudged a number of them to pick up healthy handwashing habits.

It has been estimated that routine handwashing with soap can prevent a million deaths yearly. In 2015 alone, globally more than 300,000 children below the age of five died from diarrhoeal infections, an occurrence that could have been prevented by practicing handwashing with soap. Handwashing can help reduce risk of respiratory infections by 16%, which is extremely significant at a time when the world is fighting against the raging COVID-19 pandemic. Global experts indicate that handwashing can directly contribute to combating one’s risk of contracting COVID-19.

At a time when systematic and holistic promotion of handwashing has become a necessity, especially in high population-density contexts such as Bangladesh, it is important to take a step back and learn from global initiatives which have proven successful to promote hygiene behaviour change at scale.

Innovation and hand hygiene

While hand washing with soap is one of the most cost effective methods of controlling infectious disease, one might ask: how do you implement it in parts of the world that do not have access to running water?

Surprisingly, there is more than one simple solution. There are various portable handwashing devices requiring little to no hand contact with the devices, the most well-known of which is the tippy tap. Invented over 30 years ago in Zimbabwe, these devices can be set up at minimal cost using used old containers, branches and string. Once set up, pressing the pedal will tip the container and provide a running water source.

How effective are these devices? A study in Uganda found that the presence of tippy taps in schools led to more students washing their hands – from 1% to 40%. The incidence of using soap when washing hands increased from 13.5% to 84.5%. Students also experienced less stomach pains — 80% of students reported zero pain in the previous month during the follow-up, compared to the 7% who reported no pain prior to the study.

Another study discovered that communities had a 47% increase in installation of tippy taps in one year upon being shown the benefits and methods of installation by community health volunteers. This effectiveness can be attributed to the simplicity of operating, and the cost-effectiveness of the device, allowing it to be a great solution for low-income communities.

Beyond access

Access to handwashing facilities is not the only barrier to overcome. Habits, behaviour and barriers to adopting healthy behaviours play an important role in ensuring everyone is washing their hands effectively.

Among the plethora of frameworks used in behaviour change campaigns, from the project action focused ABCDE steps of behaviour centred design, to the more external barrier focused FOAM framework, some common themes appear. Almost all approaches focus on understanding the barriers to adoption and designing collaboratively with the target communities, which forms the basis of human centred design.

An example of the effectiveness of such campaigns is Super School of Five, a collaborative programme by Sightsavers and Lifebuoy implemented in Kenya, Ethiopia and Zambia to combat trachoma, a visually impairing infectious eye disease. To prevent hand-to-hand transmission of trachoma, the project used five superheroes to urge children to wash hands with soap at five different times of the day. In the course of the project, more than 370,000 children took part in the study. An evaluation of participating schools in Turkana, Kenya found a 40% increase in face and handwashing with soap, sustained even 20 months after the program had ended.

Access to handwashing facilities is not the only barrier to overcome. Habits and behaviour also play an important role in ensuring everyone is washing their hands

Another example is SuperAmma in India, which targeted both the idea that mothers are the ones responsible for children’s hygiene and that stories motivate children. They did so with multimedia campaigns, use of engaging characters, behavioural nudges and an effort to convert community members to advocate for handwashing. A study following the intervention discovered a 15% increase in handwashing with soap at key events compared to the control group within six weeks of implementation.

Crucially, both of these programmes did the same thing right: they understood the communities they worked with, their underlying behaviours and motivations, and tailor-made interventions accordingly.

Hand hygiene in COVID-19 and HBCC

Getting people to adopt healthier hand hygiene is now more important than ever. BRAC has been working towards generating evidence via scalable solutions, as a part of the hygiene and behaviour change coalition. By the end of May 2021 BRAC will have set up 1,000 foot pedal-operated hand washing stations, and motivated more than 158,000 people in local communities across Bangladesh to wash their hands with soap. These stations are being fitted with posters that have been designed after rigorous behavioural testing. Moving forward, different nudges will be tested to encourage use and identify what works best.

BRAC has also reached out to the population of the country through mass media using national icons to disseminate necessary information in light of the outbreak, keeping a focus on handwashing.

In order to drive sustainable behaviour change in hygiene, access to facilities must be coupled with interventions targeting regular hygiene habits, cultural norms and behavioural barriers. BRAC is committed to overcoming these challenges together with the communities it serves.

Kazi Ashfaqul Huq is a Project Coordinator for BRAC-HBCC with the BRAC Social Innovation Lab. Arshae Ahmed is a Project Coordinator for BRAC-HBCC with the BRAC Social Innovation Lab.