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Before yesterday3. Hygiene

Working with communities to position handwashing for disease prevention

24 April 2020 at 22:01

This post was originally posted on the USAID Afya Uzazi Program news section.

Washing hands with soap is a simple yet effective way to prevent diseases.  It is recommended that family members wash hands with soap and running water at critical times including after visiting the toilet, after changing diapers, before food preparation and before eating.

But not everyone washes their hands due to various barriers. For instance, families may not have access to enough water or soap, the practices is not reinforced as a norm, especially among younger children.

USAID’s Afya Uzazi Program promotes handwashing as part of a package of water, health and sanitation (WASH) interventions to protect the health of households.

Working with the community health strategy teams at the counties, Afya Uzazi has trained community volunteers, local elders and other trusted champions to promote handwashing alongside other healthy behaviours that include  treatment of drinking water, use latrines and keeping their compounds clean.

One of the most successful approaches to encouraging handwashing is community led total sanitation (CLTS) which uses powerful motivators to encourage people to build latrines and handwashing stations, including the easy-to-make tippy tap.

Another strategy is the population, health and environment (PHE) intervention that empowers communities to integrate health promotion in environmental conservation activities.

“ Children ever used to wash hands  after visiting the toilet, but after making a tippy tap they always do and even encourage visitors to,” says Mary Sang, a mother of three in Kuresoi sub-county, Nakuru County.

Mary’s case is replicated in thousands of homes across Baringo and Nakuru counties where the two approaches have been used.

At health facilities in the two counties, Afya Uzazi and county teams have helped to position handwashing as a key infection prevention and control measure.

Covid-19 in low-income countries – we need rapid learning about effective handwashing initiatives

9 April 2020 at 22:31

Frequent and proper handwashing with soap is one of the most important measures that can be used to prevent the spread of the Covid-19 virus, along with physical distancing, avoiding touching one’s face (eyes, nose and mouth) and practising good respiratory hygiene. However, like physical distancing measures, frequent handwashing with soap and water is next to impossible for huge swaths of the global population.

Global figures on handwashing facilities are stark – 40 percent of households and 50 percent of schools do not have a facility with soap or water and 40 percent of healthcare facilities do not have access to soap and water or hand sanitizer at points of care. The UK Government recently pledged £50 million of UK Aid to fund a global programme to tackle the spread of coronavirus with an addition £50 million coming from Unilever. Money will be spent to raise awareness about handwashing and also provide over 20 million hygiene products. This should be welcomed but how it is used effectively to change behaviours in the short-term and over the long-term is a question which has to remain open.

Changing handwashing behaviours is notoriously difficult

Approaches to tackle handwashing usually include a focus on ‘hardware’ (handwashing stations, soap etc.) and ‘software’ (handwashing promotion and behaviour change communication often done through face-to-face engagement and community meetings). Changing handwashing behaviours is notoriously difficult unless people see an imminent threat and believe their actions will help mitigate it.  A systematic review published in 2017 reviewed evidence from 42 impact evaluations and 28 qualitative studies across low and middle-income countries concluded that community-approaches were most effective but even these approaches struggle with sustaining handwashing behaviours.

We still do not know how communities in different parts of the world are going to react to the threat of Covid-19. We do know that messaging needs to take care it does no harm – that handwashing is not viewed as the sole solution but as one of different behaviours needed to slow the spread. We also know that handwashing promotion and behaviour change activities, including tackling the spread of misconceptions, will only work if communities are fully engaged.

Community engagement is key

Experts who worked on Ebola response and on the HIV/AIDs pandemic have also stressed the importance of community-engagement – empowering people to be able to take actions to protect themselves. Therefore rapid community engagement is vital to tackle handwashing and the pandemic more widely.

How we go about physically distanced community-engagement and hygiene promotion is a question we do not have a definitive answer for. Yes, there are people with smart phones and social media accounts but they cannot be relied upon to spread messages to the most vulnerable who may not have access to these.

Logistical challenges of community engagement

In the UK, for example, news reports have highlighted the challenges of interacting with elderly relatives using newer forms of communication, like WhatsApp or FaceTime, that many of us take for granted. We need to think through the different ways to engage communities remotely and maintain their central role in interventions as well as answer the logistical challenges of providing services to those who need them most. Both of these will require rapid action learning and sharing: learning and research methods that produce timely findings that are in-touch and up-to-date and which can be acted on. Platforms such as the Social Science in Humanitarian Action can be utilised for sharing these lessons.

In this highly dynamic and uncertain global situation, we need to be both innovative and coordinated in how we respond, as practitioners attempt to increase handwashing facilitates and influence behaviours. We need to be innovative in ways we can learn and share lessons from across different governments and agencies and adapt to this ever-evolving crisis.

What is working and what is not?

We need to be identifying what is working, as well as what is not, and disseminating lessons learnt rapidly to others. Building on each other’s successes and avoiding making the same mistakes twice. This includes government-led activities and citizen-led actions where governments have failed to act in a timely way.

In Nicaragua, a civil society coalition, Unidad Nacional, together with a scientific committee are creating a movement to get correct information to families and communities – inspiring citizen-let solutions in the streets, shops and markets. This includes setting up handwashing stations and developing communication materials.

If we can achieve this in this time of crisis, we need to ensure that we maintain momentum on handwashing as normality resumes and with a strong learning agenda in order to achieve safely managed sanitation and hygiene for all by 2030!

The Sanitation Learning Hub is committed to supporting Rapid Action Learning on handwashing during the Covid-19 crisis and for the WASH sector more broadly. If you would like more information, please see our programme page or email j.myers2@ids.ac.uk

Did you get the message? My favorite behavior change studies can inform the COVID-19 response

11 April 2020 at 17:42

By: Julia Rosenbaum, FHI 360

This article was originally posted on FHI 360’s R&E Search for Evidence Blog. 

Photo credit: nopphonpattanasri/FreePik

Caught off-guard by the rapid novel coronavirus (COVID-19) transmission, governments and implementing partners are scrambling to develop prevention responses. To be effective, prevention communication must effectively spur individual and household actions. By now we’ve all seen the communication messages and know the recommended behaviors – for example, wash your hands frequently and at specific times, and don’t touch your face. But the question is: will current communications effectively trigger and sustain behavior change? I’ve been looking at behavior change evidence for many years, specifically in the context of handwashing. Success depends on how a message is crafted and how current evidence is applied. In this post, I explore some of my favorite evidence on fear-based messaging, the use of nudges to reflexively trigger behaviors, and specific determinants that influence handwashing behavior that I find useful. These studies can inform an evidence-based COVID-19 prevention and communication response.

Fear-based messaging alone doesn’t work to change behaviors

A common tactic to spur behavior change is the use of shock or fear. This tactic is too commonly used by health and communication professionals, government officials, and educators as well. But lessons learned from HIV prevention show that using fear tactics alone is ineffective, without a close link to a protective action and a high sense of efficacy to perform the action.

The Extended Parallel Process Model is a framework developed by Kim Witte (1992) to explain how individuals will react when exposed to fear messaging, considering both emotional and rational considerations as fundamental to the equation. Emotional factors include the individual’s perception of risk and severity of risk. The rationale sphere is perceived efficacy (Bandura, 1982) or one’s self-assessment of having the confidence, skills, social support and supplies to mitigate the risk. When fear is high, but efficacy is low, the individual will manage the fear – by minimizing the risk or ignoring the messaging – rather than managing the risk by taking protective action. When perceived efficacy to act is higher than fear, the individual will take the desired preventive actions.

The implications for COVID-19 prevention are clear. Avoid fear appeals, particularly without a close link to “small doable actions” that your target audience feels are feasible to take. If positive prevention actions are to be taken, the audience’s sense of efficacy must be greater than their fear. I developed figure 1 based on Witte’s model to illustrate the impact of fear-based messaging with and without efficacy and action. You can clearly see that fear messaging alone doesn’t change behaviors. With fear alone, people act to manage their fear, not the danger, in this case the danger of COVID-19.

Figure 1: Developed based on Witte's Extended Parallel Process Model (1992)

Figure 1: Developed based on Witte’s Extended Parallel Process Model (1992)

Incorporate reflexive cues or “nudges” into messaging

As I describe in a recent blog post, nudges are physical cues that influence individuals to behave in a certain way, without particular messaging or promotion of any behavior. Nudges avoid direct instruction, mandates or enforcement. The term “nudge” became popularized in 2008, after publication of Thaler and Sunstein’s book by that name. Nudges engage audiences at a subliminal level and work reflexively, rather than providing information to audiences to reflect upon and then act. An easy way to think of it: nudges are reflexive not reflective.

Nudge theory operates by designing elements or architecture in an environment which encourages positive or improved behaviors. Nudge principles have been applied for social good as well as in commercial marketing. For example, when searching for a hotel room on priceline.com, the pop-up saying “5 people are looking at this hotel right now!” nudges individuals to not lose the opportunity and book now! without actually promoting this action. Another example can be found at an airport or food court, where bakeries intentionally emit sweet cinnamon scents to spur you to buy donuts or cinnamon buns. Nudging has also been successfully used for traffic safety, recycling and toilet etiquette.

In what has now become the iconic handwashing nudge example, cheerful footsteps in demarcated pathways led Bangladeshi school children from school latrines to handwashing stations brightly decorated with handprints. Findings show these nudges to be an effective way to nudge children to wash their hands after the toilet. Without additional handwashing education or motivational messages, handwashing with soap among school children increased from 4% at baseline to 68% the day after nudges were completed – and 74% at both two-weeks and six-weeks post-intervention (Dreibelbis et al., 2016).

Photo credit: Dreibelbis et al., 2016; https://doi.org/10.3390/ijerph13010129

Findings show the nudge intervention and the hygiene education intervention to be equally effective at sustained impact over five months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). The simultaneous delivery of the hygiene education intervention significantly outperformed the sequential hygiene education delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17). These findings generated high interest in integrating nudges into behavior change programs; including, handwashing in health facilities (iNudgeyou, 2016), schools (Thrive Networks, 2017), and communities.A second, larger trial showed nudges to be as effective as intensive health education without the intensive or expensive effort (Grover et al., 2018). Researchers designed this study as a cluster-randomized trial, comparing rates of handwashing with soap after using the latrine (the primary outcome) between various intervention groups among primary school students in rural Bangladesh. Eligible schools were identified (government run with on-site sanitation and water, no hygiene interventions in the last year, and fewer than 450 students), and 20 randomly selected schools were then assigned to one of four interventions (with five schools per group): simultaneous handwashing infrastructure and nudges; sequential infrastructure then nudges; simultaneous high-intensity hygiene education and infrastructure; and sequential handwashing infrastructure and hygiene education.

Target the factors that most influence handwashing behavior change

Also essential for effective COVID-19 prevention communication is integrating what we know about relevant behavioral determinants. The final study included in this post is a bit of a cheat because it is a review of the literature (not findings from a single study) to identify the most influential determinants of handwashing behaviors in crisis and routine settings, synthesizing findings from 78 studies that met strict quality criteria. It’s hot off the presses, published after the emergence of COVID-19.

The review by White et al. concluded that our understanding of the determinants of handwashing “remains suboptimal” and found many limitations in how determinants are defined and measured. Unfortunately, the authors are not able to draw solid conclusions about the determinants of behavior in outbreaks or crisis. They did more generally identify the most commonly reported determinants: risk, psychological trade-offs or discounts, knowledge, demographic (non-behavioral) traits (like gender, wealth and education), and infrastructure. The authors conclude, “Hygiene promotion programmes are likely to be most successful if they use multi-modal approaches, combining infrastructural improvement with ‘soft’ hygiene promotion which addresses a range of determinants rather than just education about disease transmission.”

In conclusion, even though the situation with COVID-19 feels new, it turns out we have a lot of existing evidence from handwashing promotion that’s highly relevant to inform prevention interventions. Applying the findings from these studies sets you on the road to effective COVID-19 prevention and communication efforts. Nudges work to influence behavior; I encourage you to develop and test nudges for prevention behaviors like physical distancing! Also, fear doesn’t trigger protective behaviors, but assuring individuals have the skills, supplies, social support and efficacy to carry out feasible behaviors will make it more likely that they try and maintain preventive practices. And build in the evidence on determinants into your planning of COVID-19 behavior change activities.

Hand Hygiene – Could COVID-19 Permanently Change Hand Hygiene?

10 April 2020 at 23:10

By: Gideon Lasco, University of the Philippines

This post was originally posted on covid19andculture.com.

Here in the Philippines, as in many parts of the world, there’s been an outbreak of hand sanitizers. Since late January, pump dispensers and bottles have appeared everywhere: airports, schools, dining tables, handbags. In SM, the country’s largest chain of shopping malls, large containers of hand sanitizers greet visitors as they pass through security. “This is a sanitized zone,” SM’s posters read. “Thank you for using the alcohol/disinfectant provided.”

When the enhanced community quarantine started here on March 17, sanitizer showed up at road checkpoints. And though the shops in the mall are closed, customers can still shop at mall supermarkets—after the staff sprays alcohol on their hands.

This is not surprising. The COVID-19 pandemic has spurred people around the world to panic-buy Purell and other hand sanitizers, soaps, and antibacterial wipes. What is surprising is that, until the pandemic hit Western countries, the trend was going in the opposite direction.

Over the past decade, there’s been a growing concern that the impulse to kill all germs could have serious consequences, such as the creation of resistant superbugs. This has certainly impacted people’s hand hygiene habits.

For the last few years, the U.S. Food and Drug Administration (FDA) has advised people to stop using antibacterial soap, which is no more effective at preventing illness than regular soap and may negatively impact health. After discovering that common ingredients in antibacterial soap—most notably triclosan and triclocarban—disrupt hormones in lab animals and induce antibiotic resistance, the FDA banned those chemicals in 2016 and replaced them with alternatives.

However, when soap and water are unavailable, hand sanitizers and wipes are considered an acceptable alternative because they rely on alcohol to vanquish certain viruses (including coronaviruses) and bacteria.

Still, before the current pandemic, some health experts urged people to cut back even on alcohol-based hand sanitizer. That’s partly because some bacteria are becoming more tolerant of alcohol. And it’s partly due to concerns that sanitizers might harm the microbiome—the trillions of microbes living on and in the human body that are essential for healthy immune function, digestion, and more.

hand hygiene

Photo Credit: U.S. Food and Drug Administration

In recent years, many researchers have expressed concerns that over-sanitized societies are contributing to autoimmune disorders, allergies, and inflammatory conditions. This “hygiene hypothesis” is controversial, but there’s no question that scientists and the public have been awakening to the fact that some microbes can be beneficial.

Yet in the midst of the COVID-19 pandemic, everyone is understandably consumed by the process of hand sanitizing, and many people are finding it nearly impossible to buy sanitizer online or in stores. People who just weeks ago purposely petted dogs to boost the diversity of their microbiomes now find themselves disinfecting their hand sanitizer bottles with antibacterial wipes.

To understand this sudden change, it is revealing to explore the complex history and anthropology of hand cleansing. What motivates people’s handwashing habits? How do beliefs about sanitizers and microbes figure in? How have previous epidemics led to shifts in these notions? And what might the post-COVID future hold for hand hygiene?

Even before 19th-century scientists discovered that germs cause disease, handwashing was important for hygienic and symbolic purposes in many societies and religious traditions. The Prophet Muhammad, for instance, called on Muslims to wash their hands in a variety of situations, including “before and after any meal,” “after going to the toilet,” “after touching a dog, shoes, or a cadaver,” and “after handling anything soiled.”

In other societies, hand hygiene practices primarily originated from secular discoveries. In 1846, Hungarian doctor Ignaz Semmelweis observed that mothers giving birth were more likely to die if they were treated by doctors who handled cadavers beforehand. So, Semmelweis mandated that hospital staff wash their hands with soap and chlorine. He later became known as the father of hand hygiene. A few years later, forward-thinking nurse Florence Nightingale implemented handwashing in British army hospitals.

Photo Credit: J.A. Benwell/Wikimedia

Despite the efforts of these pioneers, the practice of widespread, regular handwashing was slow to take off in most of the world. In the U.S., the first national hand hygiene guidelines weren’t published until the 1980s, spurred by several foodborne outbreaks and hospital-associated infections. It was in that decade that a global hand cleansing movement was born.

The rise of hand sanitizers mirrors this move of hand hygiene from the hospital to the world at large. Some accounts claim that Lupe Hernandez, a nursing student in California, invented hand sanitizer in 1966 when she realized alcohol mixed with gel could help hospital staff clean their hands in a jiffy.

Others trace its beginnings to Gojo, a family-owned Ohio company that launched a hand cleanser for auto mechanics then tweaked the recipe and released it in 1988 as Purell. After a slow start, the product achieved the near ubiquity it enjoys today.

Incidentally, alcohol-based hand sanitizers once caused ambivalence among Muslims, owing to alcohol being haram (forbidden). But today, Muslim health care workers largely accept them, even though the question of whether hand sanitizers are halal (permissible) continues to spark debate.

Epidemics have repeatedly stimulated the popularity of hand sanitizers. In the Philippines, a clothing store called Bench introduced Alcogel shortly after the 1997 H1N1 outbreak. It attained “phenomenal success,” according to Bench’s CEO Ben Chan. A similar sanitization surge occurred in the U.S. during the H1N1 epidemic of 2009.

As The Guardian’s Laura Barton wrote in 2012, “Thanks to the heightened fear of contamination experienced during recent flu epidemics, there is now a value judgment attached to carrying and using an antibacterial gel.”

Infectious disease outbreaks have also influenced societies’ soap-and-water habits. A 2003 study of six international airports found that in Toronto—which was hit by a major outbreak of severe acute respiratory syndrome (SARS) that year—95 percent of male travelers and 97 percent of female travelers washed their hands in the public restrooms. By contrast, in New York’s John F. Kennedy Airport, only 63 percent of men and 78 percent of women washed their hands.

So, is fear of disease a great motivator for soaping up or squirting hand gel? Perhaps during a pandemic, the answer is yes. However, fear generally has only a temporary effect on ablutions, according to a review led by anthropologist Valerie Curtis. Furthermore, Curtis has warned, creating cleanliness campaigns that play on people’s anxiety is not good for mental health.

Instead, she recommends harnessing a different emotion.

In the early 2000s, Curtis was aiming to change the handwashing habits of people in Ghana, where only 4 percent of adults regularly used soap after going to the bathroom. Previous campaigns had failed, and the situation was urgent, since an estimated 84,000 children were dying of diarrhea each year.

So, Curtis created a campaign designed to generate disgust. At the time, bathrooms were considered cleaner alternatives to pit latrines, so they didn’t inspire an ick factor that might prompt Ghanaians to lather up. Curtis and her group developed ads that showed mothers and children exiting bathrooms with their hands covered in purple pigment, which they then transferred to everything they touched. Soap use subsequently rose by 13 percent following trips to the toilet and by 41 percent before eating.

Such a campaign could inspire future efforts in the wake of COVID-19. In a study released in December 2019, researchers at the Massachusetts Institute of Technology (MIT) and the University of Cyprus calculated that if travelers at airports raised the bar on their soap-use habits, the impact of a future pandemic could be reduced by 24 to 69 percent. Yet the same researchers estimated that, although 70 percent of air travelers wash their hands, most do not wash them adequately (frequently, with soap, for at least 20 seconds), so only 20 percent actually have clean hands.

Pandemics arguably tip the scale back to a Pasteurian paradigm.

Shifting views about microbes may complicate the issue of disgust. MIT anthropologist Heather Paxson has written that many people hold a Pasteurian worldview, in which they “blame colds on germs, demand antibiotics from doctors, and drink ultra-pasteurized milk and juice, while politicians on the campaign trail slather on hand sanitizer.”

But Paxson also points out that there is an emergent, alternative paradigm: a “post-Pasteurian” view. Post-Pasteurians “might be concerned about antibiotic resistance” and embrace microbiome diversifiers like probiotics, unpasteurized milk, kombucha, and unsanitized handshakes.

Since Paxson’s work was published in 2008, this post-Pasteurian paradigm has grown. Scientists have even considered ways they might promote more positive feelings for microorganisms and foster collaboration in human-microbe relationships.

Pandemics arguably tip the scale back to a Pasteurian paradigm. Currently, people are bombarded with images (and imaginings) of a potentially deadly virus for which there is, at least at the moment, neither vaccine nor cure. Thus, hand sanitizers and wipes emblazoned with the statement “kills 99.9 percent of germs” give people a sense of control over an unseen, and suddenly hostile, microbial world.

But people’s hand hygiene practices are also motivated by a visible and often friendlier force.

In 2016, researchers found that doctors and nurses at a California hospital washed or sanitized their hands 57 percent of the time when they knew that designated “hygiene patrol” nurses were watching them but only 22 percent of the time when volunteers who they didn’t recognize observed them.

Just like the wearing of face masks, social pressure can certainly motivate people to clean their hands. A recent review from Curtis and other researchers showed that people were more likely to lather up when there was more than one person present in a public restroom.

Prompted by the COVID-19 pandemic, some health experts are attempting to “responsibilize individuals” by framing handwashing as a selfless act that saves lives. Social media campaigns like #SafeHands and #HandwashingHeroes are also making appeals to social responsibility by showing celebrities and adorable children getting sudsy to prevent disease.

Similarly, face masks became an emblem of “public spiritedness” during the 1918 influenza pandemic. In some places, for instance, Japan, the practice of wearing masks continued and became part of the country’s hygiene culture.

Photo credit: Flickr/lazysupper

In the aftermath of past pandemics, people have generally returned to their previous handwashing habits. But the COVID-19 crisis is different from other outbreaks. Never before have hand sanitizing and social distancing practices been enacted on such a global scale.

So, could COVID-19 cause permanent changes to handwashing habits around the planet? Could hand sanitizer become an enduring symbol of responsible world citizenship? Could the pro-microbe perspective swing back to a Pasteurian panic over germs?

Only time will tell. But it’s something to ponder while you scrub or sanitize your hands for at least 20 seconds.

How Washing Hands with Soap Destroys the Coronavirus

8 April 2020 at 22:30

This article was originally published in Ingenious Probiotics as a copy of a New York Times post by Ferris Jabr.

Soap is one of our most effective defences against invisible pathogens
At the molecular level, soap breaks things apart. At the level of society, it helps hold everything together.  It probably began with an accident thousands of years ago. According to one legend, rain washed the fat and ash from frequent animal sacrifices into a nearby river, where they formed a lather with a remarkable ability to clean skin and clothes. Perhaps the inspiration had a vegetal origin in the frothy solutions produced by boiling or mashing certain plants. However it happened, the ancient discovery of soap altered human history. Although our ancestors could not have foreseen it, soap would ultimately become one of our most effective defences against invisible pathogens.

Soap is gentle and soothing – and can be extremely destructive for micro-organisms
People typically think of soap as gentle and soothing, but from the perspective of microorganisms, it is often extremely destructive. A drop of ordinary soap diluted in water is sufficient to rupture and kill many types of bacteria and viruses, including the new Coronavirus that is currently circling the globe. The secret to soap’s impressive might is its hybrid structure.

Soap is made of pin-shaped molecules, each of which has a hydrophilic head — it readily bonds with water — and a hydrophobic tail, which shuns water and prefers to link up with oils and fats. These molecules, when suspended in water, alternately float about as solitary units, interact with other molecules in the solution and assemble themselves into little bubbles called micelles, with heads pointing outward and tails tucked inside.

Some bacteria and viruses have lipid membranes that resemble double-layered micelles with two bands of hydrophobic tails sandwiched between two rings of hydrophilic heads. These membranes are studded with important proteins that allow viruses to infect cells and perform vital tasks that keep bacteria alive. Pathogens wrapped in lipid membranes include Coronaviruses, HIV, the viruses that cause hepatitis B and C, herpes, Ebola, Zika, dengue, and numerous bacteria that attack the intestines and respiratory tract.

When you wash your hands with soap and water, you surround any microorganisms on your skin with soap molecules. The hydrophobic tails of the free-floating soap molecules attempt to evade water; in the process, they wedge themselves into the lipid envelopes of certain microbes and viruses, prying them apart.

“They act like crowbars and destabilize the whole system,” said Prof. Pall Thordarson, acting head of chemistry at the University of New South Wales. Essential proteins spill from the ruptured membranes into the surrounding water, killing the bacteria and rendering the viruses useless.

How Soap Works
Washing with soap and water is an effective way to destroy and dislodge many microbes, including the new Coronavirus. For more about the how the virus affects the body, see How Coronavirus Hijacks Your Cells.

Photo Credit: Jonathan Corum and Ferris Jabr

In tandem, some soap molecules disrupt the chemical bonds that allow bacteria, viruses and grime to stick to surfaces, lifting them off the skin. Micelles can also form around particles of dirt and fragments of viruses and bacteria, suspending them in floating cages. When you rinse your hands, all the microorganisms that have been damaged, trapped and killed by soap molecules are washed away.

On the whole, hand sanitisers are not as reliable as soap
Sanitisers with at least 60 percent ethanol do act similarly, defeating bacteria and viruses by destabilizing their lipid membranes. But they cannot easily remove microorganisms from the skin. There are also viruses that do not depend on lipid membranes to infect cells, as well as bacteria that protect their delicate membranes with sturdy shields of protein and sugar. Examples include bacteria that can cause meningitis, pneumonia, diarrhoea and skin infections, as well as the hepatitis A virus, poliovirus, rhinoviruses and adenoviruses (frequent causes of the common cold).

These more resilient microbes are generally less susceptible to the chemical onslaught of ethanol and soap. But vigorous scrubbing with soap and water can still expunge these microbes from the skin, which is partly why hand-washing is more effective than sanitizer. Alcohol-based sanitizer is a good backup when soap and water are not accessible.

Soap in water remains one of our most valuable medical interventions
In an age of robotic surgery and gene therapy, it is all the more wondrous that a bit of soap in water, an ancient and fundamentally unaltered recipe, remains one of our most valuable medical interventions. Throughout the course of a day, we pick up all sorts of viruses and microorganisms from the objects and people in the environment.

When we absentmindedly touch our eyes, nose and mouth – a habit, one study suggests, that recurs as often as every two and a half minutes — we offer potentially dangerous microbes a portal to our internal organs.

As a foundation of everyday hygiene, hand-washing was broadly adopted relatively recently. In the 1840s Dr. Ignaz Semmelweis, a Hungarian physician, discovered that if doctors washed their hands, far fewer women died after childbirth. At the time, microbes were not widely recognized as vectors of disease, and many doctors ridiculed the notion that a lack of personal cleanliness could be responsible for their patients’ deaths. Ostracized by his colleagues, Dr. Semmelweis was eventually committed to an asylum, where he was severely beaten by guards and died from infected wounds.

Florence Nightingale, the English nurse and statistician, also promoted hand-washing in the mid-1800s, but it was not until the 1980s that the Centers for Disease Control and Prevention issued the world’s first nationally endorsed hand hygiene guidelines.

Washing with soap and water is one of the key public health practices that can significantly slow the rate of a pandemic and limit the number of infections, preventing a disastrous overburdening of hospitals and clinics.

But the technique works only if everyone washes their hands frequently and thoroughly:
Work up a good lather, scrub your palms and the back of your hands, interlace your fingers, rub your fingertips against your palms, and twist a soapy fist around your thumbs. Or as the Canadian health officer Bonnie Henry said recently:

Wash your hands like you’ve been chopping jalapeños and you need to change your contacts.”

Even people who are relatively young and healthy should regularly wash their hands, especially during a pandemic, because they can spread the disease to those who are more vulnerable.

Soap is more than a personal protectant; when used properly, it becomes part of a communal safety net. At the molecular level, soap works by breaking things apart, but at the level of society, it helps hold everything together.

Remember this the next time you have the impulse to bypass the sink: Other people’s lives are in your hands.

Health Care Facilities Are Everyone’s Frontline

6 April 2020 at 17:14

This article was originally posted on Global Health NOW. 

By: Margaret Muldrow

This labor and delivery room has no water. Photo Credit: Haik Kocharian

COVID-19’s multiple frontlines now include at least 46 countries across the African continent. Many, including Ethiopia, have frontline health care facilities battling without one of the most critical tools: adequate water and sanitation.

In an email as truth-telling as it is disturbing, my colleague and friend, Shimeta, ordered his employees to work from home by the time his country was reporting 19 cases (the count is now ~44): “Medical facilities and structures are very weak to handle such pandemic diseases. In Africa and especially in Ethiopia, the death toll will be unheard of up until now. One of the small advantages is that if this outbreak had started in Africa, the world would have heard of it very late, as was the case with the Rwandan genocide and Ebola in DRC.”

Ethiopia’s rural southwest was once my home. My dad moved his young family there from New Mexico and when he volunteered in the local health clinic, I would tag along. When I was 8-years-old, I remember a woman came in, in extraordinary pain. She’d been in labor for days. Her baby was dead and though my father tried, he could not save her life.

I became a doctor. In my work with Ethiopian women suffering from childbirth injuries, things have not improved nearly as much as they should. Women still die in childbirth by the hundreds of thousands globally and health care systems remain dilapidated. In 2016, my organization surveyed 14 rural health posts in Ethiopia. Not one had access to consistent water and sanitation—undercutting everything from the ability to prevent maternal and neonatal injury and death, to the spread of diseases. This fundamental global health problem is solvable and now more urgent than ever with COVID19 spreading across low- and middle-income countries.

Drought can be an issue, but missing infrastructure and broken pipes, pumps, faucets and wells are a massive problem. There are different reasons for poor maintenance—lack of funds, training, prioritization, coordination—but the result is always the same: unsafe, undignified health care. I’ve seen women deliver side-by-side in filthy rooms with little water and blood splattered everywhere in a dilapidated regional hospital that serves 1.5 million people. Mothers tell me they are afraid to deliver in such conditions, but they are also afraid to die in labor at home.

If we think these facilities will be effective against COVID19, consider that health professionals, assistants and cleaners in some areas struggle to wash their hands, let alone much else. Pit latrines overflow in the rainy season spilling patient sewage onto facility compounds; open defecation is common; trash and biohazards are thrown into open, unfenced pits. It’s not just Ethiopia; these conditions are a common sight inside hospitals and clinics in many LMICs. The first UN global baseline report, released in 2019, found that 49% of facilities in sub-Saharan Africa lack basic water services and 64% of health care facilities in eastern and southeastern Asia lack basic hygiene services. 2 billion people must rely on facilities that lack basic water services and 1.5 billion on facilities without sanitation.

Emergency measures to contain COVID19 and prevent resurgence must include global access to Water/Sanitation/Hygiene, WASH. Then health and development leaders, public and private, must make WASH permanent and sustainable. Like other core global health solutions, WASH requires ongoing commitments to funding, training, maintenance and far better coordination.

As leaders focus on vaccines that are months, if not years away, I fear we will continue to overlook the fundamentals of infection prevention and control inside the very places where sick people gather in numbers. Many will die, and we will remain unprepared for the next health crisis. There is simply nothing more effective and nothing more basic to infection prevention and control than WASH. Right now, with a pandemic out of control, what happens in health care facilities is everyone’s frontline.

Margaret “Migs” Muldrow, MD received her medical degree from the Johns Hopkins University School of Medicine and was the Johns Hopkins Centennial Scholar for her humanitarianism in medicine. She is the founder & board chair of the Village Health Partnership based in Denver, Colorado.

Healthcare Facilities in Developing Countries a High Risk for Coronavirus Transmission

3 April 2020 at 14:57

By: Brett Walton, Circle of Blue

This article was originally posted on WaterNews, Circle of Blue. 

Few healthcare facilities in developing countries have complete water, sanitary, and hygienic services. They are vulnerable to Covid-19 transmission, health experts say.

Pharmacist Madani Coulibaly helps Dr. Martin Koné, health director, to clean equipment that has been used to treat a patient at Talo Health Centre, in the municipality of Falo, Mali. Photo © WaterAid/Basile Ouedraogo

The front lines in the battle to limit damage from the new coronavirus are expanding.

Covid-19, the disease caused by the virus, emerged in China and then blossomed in comparatively wealthy countries like Italy, South Korea, and the United States.

Now, the virus is spreading in poorer regions — in sub-Saharan Africa, South Asia, and parts of Latin America — where essential defensive measures against infectious disease are often missing.

Healthcare facilities in low- and middle-income countries are a potential weak link in the fight against Covid-19, health experts say. Hospitals and clinics in countries like Nepal and Tanzania often lack handwashing stations, proper waste disposal, hygienic equipment, and even running water.

“It’s huge,” said Maggie Montgomery about the role of water, sanitation, and hygiene in healthcare facilities. Montgomery is the World Health Organization technical officer for water, sanitation, and hygiene, also called WASH.

“Fundamentally, hand hygiene is the number one means of prevention,” Montgomery told Circle of Blue. “For a disease with no vaccine, no clear course of treatment, it’s even more important. Also, because there is a lack of personal protective equipment” — items like masks and gloves — “hand hygiene becomes the fundamental measure to interrupt disease transmission.”

Limited Resources

The World Health Organization says that “frequent and proper” handwashing is one of the most important bulwarks against spreading the virus. But in many healthcare facilities, it is difficult even to find soap.

Absent these basic precautions, global health experts worry that healthcare workers in developing countries could be a vector for spreading the virus.

“It is very vital to offer quality handwashing services and reduce cross infection,” Om Prasad Gautam, global hygiene lead for WaterAid, a charity that focuses on WASH, told Circle of Blue. “If those facilities are not there, workers will act as an epicenter of transmitting disease.”

Where handwashing facilities are limited, especially in countries in Africa and Asia, it may be very difficult to control the virus once it is established, Gautam added.

“If the virus started spreading in these countries, it may spread very fast,” Gautam said.

Underfunded and neglected, clinics in developing countries frequently see doctors tending to ill patients without minimum protections against disease transmission.

University of North Carolina researchers examined environmental conditions in healthcare facilities in 78 low- and middle-income countries. The results, published in 2018, paint a dismal picture. Only half of the nearly 130,000 healthcare facilities in the analysis had piped water. Thirty-nine percent did not have handwashing soap. One-third did not have satisfactory toilets. Nearly three-quarters did not have sterilization equipment. Only two percent of facilities had the complete package of water, sanitation, hygiene, and proper waste disposal.

“The statistics are quite alarming,” Gautam said.

Though alarming, the numbers alone may not tell the whole story, cautions Aaron Salzberg, the director of the Water Institute at the University of North Carolina, Chapel Hill. Data on Covid-19 transmission is limited and healthcare facilities are challenged by a host of other pressures in their efforts to treat and control the disease. Clinics may not have enough masks and gloves. Or their facilities may be cramped, putting ill people in close contact with each other.

“At this point, we have to be cautious stating that the lack of access to WASH services is a major pathway for transmission of Covid-19,” Salzberg, the former top official for water at the U.S. State Department, told Circle of Blue. “Many factors, including overcrowding, the lack of physical space, and the absence of supplies to protect healthcare workers may be bigger issues.”

‘A Story of Coping’

For WaterAid, some of those factors — population figures and potential overcrowding of hospitals — are informing its strategy to respond to the pandemic. The main transmission pathway for the virus is close, personal contact. It is spread mainly through coughs, sneezes, and handshakes. It can survive on surfaces: roughly four hours on copper, 24 hours on cardboard, and several days on steel and plastic. Thus the medical community’s recommendation for social isolation, disinfection of surfaces, and frequent handwashing.

Gautam said that WaterAid’s top-priority countries are those with a trio of risk factors. They have inadequate hygienic services in healthcare facilities, large populations, and have already recorded Covid-19 cases. Those countries are Bangladesh, Ethiopia, India, Nigeria, and Pakistan.

The number of confirmed cases in these countries is quite low as of March 18: 187 cases in Pakistan, 137 in India, eight in Bangladesh, five in Ethiopia, and two in Nigeria.

Low numbers of confirmed cases, however, are an incomplete indicator. Without widespread testing, there is no way to know how bad the situation is, said Lindsay Denny, health advisor to Global Water 2020, a WASH advocacy group.

The true number of cases is one of many unknowns. Other questions center on the environmental conditions that nurture the virus. The survival of similar coronaviruses is dependent on temperature and relative humidity, according to research from Lisa Casanova at Georgia State University.

Lower temperatures and low humidity are more favorable for survival. Higher temperatures kill the virus. Countries with the largest outbreaks to date are in the northern hemisphere, which is transitioning away from cooler winter temperatures.

“The picture of this virus is evolving very rapidly,” Casanova said on a conference call last week.

If there is a coming wave of infections in the southern hemisphere as it moves into autumn and winter, governments need to be prepared, said Michael Ryan, executive director of the health emergencies program at the World Health Organization.

Ryan said that while many countries in sub-Saharan Africa have fragile health systems, they are not helpless against viruses, having gained experience during the Ebola outbreak and with other diseases.

“I have worked with African colleagues and in Africa for many, many years, and what I see is a story of resilience, a story of coping, and an ability to overcome adversity through communities, by building on community intervention and building community acceptance,” Ryan said at a press conference. “If we can match community participation with good governance, then I believe that Africa can succeed. It has demonstrated that time and time again.”

Putting equality, inclusion and rights at the centre of a COVID-19 water, sanitation and hygiene response

2 April 2020 at 14:44
By: Priya Nath and Louisa Gosling, WaterAid

This article was originally posted on WaterAid’s WASH Matters blog. 

WaterAid/ De Sharbendu

The poorest and least powerful sections of all societies are likely to be worst affected in crises, but we can work to alleviate inequalities through our response. Priya Nath and Louisa Gosling highlight how our emergency response to the coronavirus pandemic can mitigate new and existing vulnerabilities among people affected.

Handwashing with soap is the first line of defence in tackling the COVID-19 pandemic. Yet inequalities abound in access to water, sanitation and hygiene (WASH), services, and following the advice to wash your hands with soap regularly is not as easy for some as it may sound.

Years of experience and evidence show that income, economic context and landlessness; age, disability and health status; geographical location; and ethnicity, race, religion and gender all play huge roles in determining whether individuals, households and communities have appropriate, available, affordable and accessible WASH. At WaterAid, we have committed to tackling inequalities in all aspects of WASH access.

The way we approach the current extraordinary global health crisis can be no different. Tackling new and existing inequalities must be central to our emergency response to coronavirus. During the global COVID-19 pandemic, life-saving clean water for hygiene, safe sanitation and basic healthcare is more critical than ever. And delivering equitable, empowering WASH responses for all is fundamental.

In our support of COVID-19 responses through WASH we are both drawing on what we already know and learning new ways to reach the most marginalised and the most burdened.

What we already know about tackling inequalities in WASH and emergency contexts

1. Gender inequality is exacerbated in health emergencies and economic crises, so must be tackled in all response efforts

As schools close and families head into lockdown, domestic chores and caring responsibilities increase greatly. At the same time, increased calls for washing hands, as well as for cleaning and sanitising, multiply the need for water. Because of gender divisions of labour, it is women and girls who will have to collect this extra water, perform more labour and do more caring for people who become sick.

For the 29% of people who do not have water inside their home, the additional long journeys to water sources caused by increased demand for water will mean more chances of contact with others at waterpoints or kiosks. And for many it will mean spending more of their already scarce resources on buying water at an unaffordable cost.

WaterAid/ Ronny Sen

Women queue up to collect water from the common water source in Anna Nagar Basti, Hyderabad, India.

Meanwhile, an estimated 70% of the global health and social care workforce are women. As the coronavirus pandemic spreads, these frontline workers face increased pressure and exposure to the virus, often with little personal protective equipment. This in the context of two out of every five healthcare facilities globally lacking handwashing facilities, and 55% in least developed countries lacking basic water supplies.

Health crises also increase risks of violence and harassment of frontline health workers, particularly women nurses. Amid the Ebola outbreak in the Democratic Republic of Congo, for example, the World Health Organization documented attacks on more than 300 healthcare facilities in 2019, leaving six workers and patients dead and 70 wounded.

During times of enforced isolation and closure of many public facilities, women and girls’ ability to manage menstruation can be compromised in communities and households. Finding a clean and private space to change and wash while remaining indoors for much of the time with their family, and accessing menstrual materials and water, can be difficult.

Finally, isolation measures, the inability to access previous social support systems and increases in financial and other stresses are increasing the risks of violence against women everywhere (download report PDF). Although not directly connected to WASH, this has implications for women’s ability to access essential services, and must be factored into our response, to ensure people’s safety and security when accessing WASH and other services.

You can read more about the gendered impacts of the COVID-19 pandemic in this article published in The Lancet.

2. Marginalised people become even more vulnerable during a crisis

People with chronic health issues, such as HIV, or other health conditions are dealing with increased fear of acquiring COVID-19, while often already experiencing social stigma and exclusion based on their health status. In an environment where misconceptions around HIV transmission or general discrimination might already prevent them from using communal WASH facilities, crises have the potential to exacerbate the situation, making handwashing and maintaining treatments even harder. Additionally they face the real risk of disruption to essential life-saving services, and concerns over whether they will be able to access treatment for COVID-19 on an equal basis to others.

More than a billion people globally live with disabilities, the rates higher in low-income countries and among those living in poverty or belonging to ethnic minorities. Once again, the health and social inequalities they already face are intensified in crises. For someone with a physical impairment, accessing clean water frequently can be a challenge because of distance, inaccessible infrastructure or reliance on others.

People with disabilities are often already isolated from the outside world, missing out on public health campaigns geared towards people who move around. And public health and information campaigns are rarely targeted to their specific requirements. Those who rely on a carer to help them with daily tasks face either the risk of added exposure to the virus through their carer, or an inability to get the help they need more than ever in challenging times.

WaterAid/ Ahmed Jallanzo

Reuben J. Yankan, Director of the Disable Camp 17th Street Community, who is visually impaired, is helped down the steps from a public toilet by Timothy Kpeh.

Equally, public health messaging and calls to stay inside are hard to follow for people who have little or no access to WASH facilities; those who rely on daily wages to survive; those living in densely populated informal settlements or refugee camps; and street dwellers. This puts them at greater risk of not only COVID-19, but also harsh punishment by authorities. For example, we are already seeing a response that includes clearance of informal markets and housing in the name of ‘sanitisation’ in some places. The Ebola crisis in Monrovia in 2014 set a precedent for quarantining entire informal settlements that were deemed a ‘health risk’. This a deep injustice.

Our response efforts can mitigate both existing and new vulnerabilities

While the poorest and least powerful are likely to be worst affected in crisis situations, we can work to alleviate the inequality through our response:

  1. Support governments and other WASH actors to deliver the human right to water and sanitation as a central part of response efforts, provided in a way that is non-discriminatory and accessible to all.
  2. Develop crisis responses alongside the affected communitiesrather than for them, to ensure solutions meet cultural, social and religious challenges. Disability rights, women’s rights and indigenous rights groups, to name a few, are best placed to help us shape our response in a way that is empowering, does no harm and responds to real requirements.
  3. Tackle and confront any discrimination and stigmatisation in response efforts, related to factors such as age, gender, race, ethnicity, socio-economic status, livelihood type and caste. We must closely monitor our messaging, images and approaches to ensure they are not inadvertently fuelling discrimination.
  4. Promote collection of water, cleanliness of water and sanitation facilities and practising of hygiene as the responsibility of all – not just women.
  5. Recognise the obligations and responsibility of government and sector actors to respond; do not make this an issue of individual action or responsibility.
  6. Ensure we are collecting and disaggregating data to understand differing impacts on all parts of the population. At minimum age, disability, gender and location disaggregation is needed.

Read UNICEF’s COVID-19 Considerations for Children and Adults with Disabilities (PDF) guide.

Our simple list of dos and don’ts

As initial responses, including ours, rely heavily on visual and mass media public communications, it is vital that these are respectful and do no harm. Our list of actions to take and avoid can help.

Do: Use images and messaging that show responsibility for hygiene behaviours can be equally distributed.

  • Ensure images are gender balanced.
  • Include males in images of household & community hygiene practices to show collective responsibility.


  • Do not reinforce gender or other stereotypes – i.e. do not show only women doing washing, cleaning or looking after children.

Do: Frame messaging that builds community spirit, support and collective action.

  • Use terms like ‘us’, ’we, ‘together as a community’, ‘altogether we can, etc.
  • Use images that show people helping each other.
  • Demonstrate sector/government response and duties, not just individual responsibility.


  • Do not focus only on individualistic messages, which reinforce individualistic responses and actions.
  • Do not use emotional triggers such as shame, guilt or fear – we have a responsibility to avoid promoting further hysteria or blame.
  • Avoid emotional or negative language.

Do: Portray people in all their diversity.

  • Communities are made up of women, men, children, people with impairments, people of different ethnic or religious identifies, etc – reflect this reality in your communications to improve uptake.


  • Do not blame or associate individual factors such as gender, ethnicity, religion, age, impairment, health or poverty status with reasons for infection or contagion.
  • Avoid messaging, images or implementation approaches that unintentionally stigmatise, ostracise or cause abuse for certain people.

Do: Acknowledge and respond to the diverse needs of communities.

  • Demonstrate how assistive devices can be used.
  • Demonstrate solutions that are relevant in low-income settlements, in rural and water scarce areas.
  • The Compendium of accessible WASH technologies has illustrations and descriptions you can adapt.


  • Avoid blanket approaches that suggest that everyone can change behaviours without any specific adaptations.
  • Do not direct messaging or responsibility for ‘change of behaviour’ at one group of people, e.g. mothers, instead talk about parents caring for children.
  • Do not misrepresent the number of people who have a clean water supply or access to soap.

Do: Adapt communications to suit different target groups.

  • Consider the communication and learning abilities of all people, including people with visual, hearing and intellectual impairments.
  • Plan channels for information to reach all, especially those doing caring duties, sanitation work, etc.
  • Takeaway materials can reinforce messages and make up for some short-term memory loss among older people or people with disabilities.
  • These should be easy to read, large script, high contrast between text and paper, on non-glare/glossy paper, in local languages/dialects, highly visual​​​​.


  • Do not exclude anyone. Not being inclusive of all can lead to fear, shame and blame.
  • Do not portray informal settlements or slum areas as ‘vectors of disease’, or poorer areas of the city as being unable to keep clean. This reinforces stigma and increases the chance of a negative reaction. For example, there have already been cases of informal housing being cleared in the name of ‘sanitisation’. The solution lies in guaranteeing adequate and safe levels of service for all, rather than reinforcing stigma towards certain parts of the population.

Do: As part of our do no harm approach, do a risk assessment before and throughout communications campaigns

  • Monitor backlash on social media, such as racist comments and immediately delete as needed.
  • Check that it does not amplify or put blame on one group (or if audience is interpreting it that way).
  • List who is likely to miss out on the communication because of language, ability, culture or gender, and come up with strategies for how they could be included.


  • Do not ostracise or promote ‘calling out’ of people or parts of the population. This may encourage vigilante tactics or backlash.
  • Avoid terms such as ‘victim’, ‘infecting’ or ‘spreading to others’.
  • Do not tolerate any racist, bigoted or blaming comments on social media and have a strategy for monitoring these.

Priya Nath is Equality, Inclusion and Rights Advisor and Louisa Gosling is Senior WASH Manager – Accountability and Rights, both at WaterAid UK.

Collapse of hygiene management in hospitals in Bangladesh

20 March 2020 at 13:51

By: Rashad Ahamad

This article was originally posted by New Age Bangladesh. 

Patients are treated in corridors at Shaheed Suhrawardy Medical College Hospital. — New Age photo

Cleanliness, poor quality supply water, sanitation and hygiene as well as unsafe management of medical wastes in hospitals in Dhaka and elsewhere in Bangladesh together paint a dismal picture of hygiene practice in Bangladesh.

Appallingly ignored and neglected, hygiene management in health care facilities are potentially dangerous factors for spreading infectious diseases, said experts.

Even during the COVID-19 pandemic that has already killed more than nine thousand people across the world and infected many more in at least 170 countries, the hospitals seem reluctant about making any improvement in their hygiene and cleanliness practices.

Considering the practices and practical situation of the hospitals, experts said that people were in high danger of nosocomial infection.

New Age reporter visited at least four hospitals in the capital from March 15-19 and observed that hospital staffers, infrastructures, patients and their relatives all were very reluctant about maintaining hygiene.

None of the Dhaka Medical Collage Hospital, Dhaka Shishu Hospital, Shaheed Suhrawardy Medical College and Hospital and National Institute of Traumatology and Orthopaedic Rehabilitation was found clean. In terms of maintaining hygiene, they all fall far short. Especially when one is using their toilets, the realisation dawns that even in hospitals cleanliness is not a priority.

The appalling state of the toilets could hardly described. Bad smell filled the air in the dark, damp, filthy toilet in which garbage is scattered on the floor. The experience is gut wrenching as toilets are seen flooded with faeces.

There was no sign of soaps and tissue papers though those are things necessary in toilets that are used by patients, their relatives and  junior staffers of hospitals.

Toilets in the public hospitals are all squat toilets and no modern flushing system is there.

The above descriptions apply only to the toilets used by the public while the toilets for doctors and senior official are off limit to the public.

DMCH director Brigadier General AKM Nasir Uddin admitted that the allegations against the hospital are true and said that the hospital authority tried time and again to provide hand washing soaps but failed.

He said that every time we provides the soap, it would soon get stolen by as unidentified people.

He said that hygiene in hospitals was very much important than any other places and urged the patients to maintain their hygiene of own accord.

He said that the hospital management put up a number of posters and festoons for creating awareness about hygiene among the patients and visitors.

‘We urge visitors not to come to the hospital if they did not have any emergency. Visitors are the main challenge for hygiene in hospital,’ he said.

During multiple visits to Shaheed Suhrawardy Medical College and Hospital at Sher-e-Bangla Nagar in the capital the toilet floor of male medicine ward was found under water.

Four waste bins were kept there at a corner where different types of disease-carrying vectors were thriving.

Patients and their relatives were collecting water and washing their dishes there while bathroom water regularly kept a portion of the ward under water.

A number of patients admitted to the hospital amid acute seat crisis, also took shelter on floor mats.

Rafiquel Islam, a relative of a patient said that he was staying with his father since March 2 but did not find any soap for a single day in any of the bathrooms.

Mitford Hospital in Dhaka without ensuring proper hygiene and cleanliness. — New Age photo

Rafiquel is from Brahmanbaria and hge was admitted to the hospital as his father’s leg had to be amputated after an infection.

SSMCH director Uttam Kumar Barua’s mobile phone was found switched off after repeated attempts at contacting him. Following two subsequent visits at his office on Wednesday and Thursday, he was found absent.

New Age contacted the other officials but they declined to comment on the issue.

The scenario at Dhaka Shishu Hospital was not much different. There is no hand washing facilities with soap even after defecation.

Abdul Hakim, public relation officer, and also spokesperson of the hospital, said that they could not provide soaps as soaps get stolen within hours after they are supplied.

About cleanliness, he said that the hospital had no sufficient cleaners of its own so they leased out the work to Nepcons Cleaning Service, a private company.

Nepcons cleaning in-charge Ajay Kumar Nipu said that the hospital provide them with Tk 4.9 lakh each month for cleaning purpose under an agreement signed three years ago.

‘It is very insufficient to ensure high-quality cleanliness but regular cleaning is monitored done,’ he said.

He added that buying equipment and providing salary of 150 cleaners was very challenging within the budget.

It was not only that the inside of the hospital building looked dirty and unhygienic, but also the entire premises was dirty.

Aynal Hossain, father of a patient at the specialised hospital for children made a complaint that mosquito menace was acute at the hospital even when the city people were living in acute fear of dengue.

Mohammad Abdul High, admitted to Dhaka Medical College Hospital for lever infection, said that the hospital was very dirty and hygiene was hardly maintained.

He said that all visitors, doctors and staff members enter the wards without any protection.

Public health expert and country director of WaterAid Bangladesh Khairul Islam said that hygiene situation could be improved manifold if hospital authorities developed a pragmatic management system.

Bangabandhu Sheikh Mujib Medical University public health and informatics department associate professor Romen Raihan said that there was no alternative to controlling visitors in hospitals to check hygiene.

He also emphasised that trained sweepers should be employed and proper management of medical waste should be maintained.

He urged the hospital authority to follow guidelines and safe management of hospital linen.

Experts said that management of health-care waste was an integrated part of hospital hygiene and infectious disease control. The waste should be considered a reservoir of pathogenic microorganism, which can cause contamination and infection.

If hospital hygiene is not maintained properly, these microorganisms can be transmitted by direct contact through air and a variety of vectors, putting the health of hospital personnel and patients at risk.

Dirty toilets and murky hand-washing basins, which are hardly functional, are not only restricting peoples’ access but also affecting their hygiene practices at hospitals.

Furthermore, the overall environmental safety of a public hospital is compromised due to the lack of the collection, segregation and safe disposal of hospital waste.

Various studies revealed that proper WASH provision and practices could reduce disease transmission.

Globally, hospitals maintain special hygiene compared to residences or offices because people with diseases are admitted there.

As part of hygiene maintenance, they put emphasis on cleaning, sterilization, disinfestations and hand washing, doctors said.

Cleaning is one of the basic measures for the maintenance of hygiene and particularly important in the hospital environment. The principal aim of cleaning is to remove visible dirt. It is essentially a mechanical process. Soaps and detergents act as solubility promoting agents. The efficacy of the cleaning process depends completely on mechanical action as cleaning will remove 90 per cent of the microorganisms.

Sterilisation is another process which can be achieved both physical and chemical means. Physical method based on heat includes autoclaving, dry thermal or wet thermal sterilisation. Chemical mean gas sterilisation with ethylene oxide or other gases are also effective.

There is no ideal disinfectant and the best method should be chosen according to the situation.

More than 90 per cent of the transient microorganisms can be removed through hand washing with adequate safe water and soap.

Experts said that Bangladesh lack all measures of hygiene in most of the hospitals as its staffs were not trained.

Although waste management is the key responsibility of the City Corporation but none of the city corporations in Bangladesh have the capacity to treat medical waste.

Medical waste frequently found dotting open spaces including drainage and wetland.

The essential requirements like safe drinking water, water for hand washing, basic sanitation facilities, safe health-care waste management facilities, clean floors and fittings and hygiene messages need to be provided to the staff, patients and attendants for maintaining clean and healthy environment in the hospital.

The World Health Organisation guideline ‘Essential Environmental Health Standards in Health Care’ and government’s ‘Medical Waste Management Rules-2008’ remained on paper in case of hospitals in Bangladesh.

World Health Organisation referred to a study that showed that patients infected with diseases accounted for 50 per cent of in-patient and 33 per cent of out-patient consultations adding an extra burden to hospital services that were often already overstretched.

Providing access to sufficient quantities of safe water, adequate and sound sanitation facilities, proper health-care waste management systems and introducing sound hygiene behaviour communication systems could reduce the amount of disease transmission, the study said.

Icddr,b reported that nosocomial infection can cause severe pneumonia and infections of the urinary tract, blood stream and other parts of the body and often are difficult to manage by antibiotics which in turn can increase the emergence of resistant strains of antibiotics.

These kinds of infections were commonly spread when hospital officials became complacent and did not maintain correct hygiene practice on a regular basis like maintaining sanitation protocol regarding uniforms, equipment sterilisation, washing, and other preventative measures.

From April 2007 to March 2008, Icddr,b conducted a low-cost surveillance in three hospitals to identify the onset of new respiratory symptoms in patients hospitalised for more than 72 hours and in health care workers in medicine and paediatric wards.

During 46,273 patient-days of observation, 136 episodes of hospital-acquired respiratory diseases were recorded, representing 1.7 per cent of all patient hospital admissions.

The ward with higher bed occupancy rates poses an increased risk to patients.

Twenty five per cent of hospital-acquired respiratory disease occurred in patients hospitalised for cardiovascular disease, stroke, and myocardial infarction which is concerning, because acute respiratory illness in this group, particularly influenza, is associated with increased risk of complications and poor health outcomes and patients leaving with respiratory infections pose a health risk to others in the communities.

Of the 226 heath care workers who worked on the surveillance wards, 27 per cent experienced a respiratory illness during the study period. Thirty of the 40 health care workers on the adult medicine ward experienced respiratory illness compared with 6-24 per cent of staff members on other wards.

Incorporating nudges into COVID-19 Communication and Prevention Strategies

31 March 2020 at 21:36

By: Julia Rosenbaum, USAID WASHPaLS Project (FHI 360)

Nudges are physical cues that influence people to behave in a certain way, without particular messaging or promotion of any behavior. Nudges avoid direct instruction, mandates or enforcement. The term “nudge” became popularized starting in 2008, after publication of Thaler and Sunstein’s book by that name. Nudges engage audiences at a subliminal level and work ‘reflexively’, rather than providing information to audiences to ‘reflect’ upon and then act. Nudges are reflexive not reflective.

Nudge theory operates by designing elements or ‘architecture’ in the environment which encourage positive or improved behaviors. Nudge principles have been applied for social good as well as in commercial marketing. For example, when searching for a hotel room on priceline.com, the pop-up saying, 5 people are looking at this hotel right now! nudges browsers to not lose the opportunity and book now! At an airport or food court, bakeries intentionally emit sweet cinnamon scents to spur you to buy donuts or cinnamon buns. Nudging has also been successfully used for traffic safety, recycling and toilet etiquette.

In what has now become the iconic handwashing nudge example, cheerful footsteps in demarcated pathways led Bangladeshi school children from school latrines to handwashing stations brightly decorated with handprints. These nudges were found to be an effective way to nudge children to wash their hands after the toilet. Without additional handwashing education or motivational messages, handwashing with soap among school children increased from 4% at baseline to 68% the day after nudges were completed, and 74% at both 2 weeks and 6 weeks post intervention. (Dreibelbis et al, 2016). A second, larger trial showed nudges to be as effective as intensive health education without the intensive or expensive effort. (Grover, Hossain, Uddin, Venkatesh, Ram & Dreibelbis, 2018). The findings generated high interest in integrating nudges into behavior change programs; including, handwashing in health facilities (INudgeyou, 2016), schools (Thrive Networks, 2017), and communities.

While not explicit to nudge theory, easy access to any required supplies or equipment (called ‘enabling technologies’ because they remove obstacles to action) also facilitates the practice of behaviors. Linking nudges with access to flowing water and soap further facilitates behavior change, which is why nudges are often placed near handwashing stations with soap and water.

As we scramble to respond to the COVID-19 crisis, we suggest one effective approach, which is to incorporate nudges into COVID-19 communication and prevention strategies.

Key COVID-19 prevention strategies include:

  • Frequent handwashing, including when returning home from trips outside;
  • Avoid touching your nose, mouth, or eyes; and
  • Social distancing by maintaining two meters or six feet apart.

Handwashing nudges have been elaborated and evaluated, primarily in school contexts. Footpaths, footprints, hands, and ‘watching eyes’ successfully nudge handwashing, as do mirrors (calling audiences to check their appearance in the glass). Again, placement of the nudges matters.

Nudges for other COVID-related prevention behaviors have not yet been defined, but collective brainstorming will help to develop possible nudges for different contexts.

As a start, we suggest nudges to spur social distancing might include painting six-foot rulers at the entrances to parks and markets. When walking or waiting in small groups, a two-meter (six foot) string or bright ribbon kept taut to assure the ideal distance is maintained. Others seeing the string — whether taut or flaccid — will be reminded to keep the safe distance from others.

There is some debate as to the effectiveness of various types of facemasks, particularly home-crafted masks, at protecting against aerosols that transmit coronavirus. Nonetheless, in addition to any partial protection offered by masks, the use of masks may nudge AWAY from bringing hands to your mouth or nose. Wearing one at the supermarket the other day, I stopped myself from wetting my finger to open a plastic produce bags (commonly used in US supermarkets). Gloves might also nudge ‘hands off’, however the effect could wear off as the wearer becomes more accustomed to the feel of the gloves.

As we enter into an unprecedented time, it is important to consider the use of nudges in our response strategies to assure swift and sustained preventive action.

“WASH Viruses Away” on World Water Day

20 March 2020 at 22:26

In honor of World Water Day, the Global Handwashing Partnership is pleased to announce our WASH Viruses Away campaign, which will run throughout 2020. The campaign will promote handwashing with soap to protect against the coronavirus and other respiratory diseases with the aim to catalyze good handwashing habits in the long-term.

The growing coronavirus (COVID-19) pandemic has resulted in public officials and mainstream media encouraging people to wash their hands with soap regularly. In an outbreak, people tend to wash their hands more frequently and thoroughly because they perceive themselves to be vulnerable to a dreaded disease. Yet there are often challenges and misconceptions in sustaining handwashing as a habitual practice beyond an outbreak, such as coronavirus.

In some parts of the world, knowledge around proper handwashing may be low, or access to proper handwashing facilities is lacking. According to the JMP Baseline Report, national averages of access to soap and water in households range from below 10% to nearly 100%. The more accessible water is, the more likely individuals are to wash hands with soap and water. Access to necessary supplies can facilitate handwashing practice. Likewise, the placement of such supplies can serve as a reminder to wash hands. Easily accessible handwashing infrastructure can make people 60% more likely to wash their hands.

Proper hand hygiene practices are especially critical in controlling viral infections, like COVID-19. As the name of the campaign states, handwashing with soap can literally wash viruses away. With the support of several partners, the Global Handwashing Partnership has released a new handwashing poster in time for World Water Day. Learn how to protect yourself and others from COVID-19 by downloading the poster here.

Join us on World Water Day by using the hashtags #SafeHands and #WASHVirusesAway. The Global Handwashing Partnership will continue to release materials as part of our WASH Viruses Away campaign throughout the year. Learn more at www.globalhandwashing.org.

How a Swiss scale-up is taking up the fight against the spread of infectious disease worldwide

10 March 2020 at 19:33

By: Emilie Barnasconi, Smixin

As part of its ongoing advocacy efforts, Smixin AG. a Swiss cleantech scale-up, is engaged in comprehensive research led by the Massachusetts Institute of Technology (MIT), UC Berkeley and the University of Cyprus. The preliminary results of the research can be found here. This research proves the strong impact that hand hygiene behavior among the airport population can have on the diffusion of infectious and bacterial diseases worldwide. Through this study, 10 airports were identified in playing a key role with regard to the spread of global disease. When handwashing engagement increases at these airports alone, the impact of disease spreading worldwide would decrease up to 37%. Ongoing research by the team demonstrates that handwashing with soap whilst air travelling can reduce the risk of a pandemic outbreak by up to 65%.

This study is the first time academic researchers have investigated the direct link between the outbreak of a pandemic and handwashing behavior of airport populations. “We observed that by increasing the handwashing frequency of the airport population, the spreading power of infectious disease worldwide reduces significantly”, says Dr. Christos Nicolaides, coordinator of the study from University of Cyprus and MIT. With that, is it now possible to define a target handwashing ratio for airports to limit the spread of disease worldwide.

The fact that people do not wash their hands with water and soap costs tens of thousands of lives per year. While handwashing is a cornerstone of public health, actual rates of proper handwashing around the world are quite low and vary widely: on average, handwashing with soap is only practiced 19% of the time after contact with feces. At Smixin, we are constantly working towards smart solutions that make handwashing accessible for everyone, everywhere. Building on the clear preliminary results of this research, we will continue to engage authorities and airports to create more opportunities to wash your hands at airports.”

Smixin is affiliated with the Global Handwashing Partnership, alongside partners like Procter & Gamble, the World Bank and Unilever. Also, Smixin is donating 10.000 liters of fresh drinking water per handwashing system they install in the field via Made Blue. Smixin, dedicated to reinvent the handwashing process completely, is proud to be joining these renowned companies in their efforts to increase awareness for handwashing.

For media inquiries and visuals of Smixin, please contact Emilie Barnasconi, Smixin AG, info@smixin.com

For in depth questions about the research, please contact Christos Nicolaides, Unieversity of Cyprus, Nicolaides.christos@ucy.ac.cy

Photos curtesy of Smixin AG. 

Harnessing the power of WASH in the fight against NTDs

30 January 2020 at 13:10

By: Yael Velleman, SCI Foundation

While in Uganda last week, I had the unique opportunity to sit down with the Ugandan Ministry of Health’s National Program Officer for Trachoma Control, Gilbert Baayenda. Trachoma is a devastating bacterial infection and the world’s leading infectious cause of blindness. It is one of 20 Neglected Tropical Diseases (NTDs) that cause extreme pain, disability and even death. Yet NTDs are preventable. They are diseases of poverty and marginalization that affect over one billion people across 149 countries globally.

Access to safe water, sanitation and hygiene (WASH) is essential for the prevention, treatment and care of NTDs. Recognizing this, the World Health Organization (WHO) and the NTD NGO Network (NNN) developed, “WASH and health working together: A ‘how-to’ guide for Neglected Tropical Disease programmes,” the first step-by-step guide for building successful WASH and NTD partnerships. Since its launch last year on what is now World NTD Day, the toolkit has been utilized in a number of countries across sub-Saharan Africa and Asia, including Uganda. As the lead on collaboration with the WASH sector on behalf of Uganda’s National NTD Control Program, Gilbert has championed greater coordination between WASH and NTD partners, and is now in the process of adapting the innovative WHO and NNN toolkit to meet national and district-level needs.

What motivates you, as a healthcare professional, to be a WASH champion?

GB: I have lived and worked at the community and sub-national level for about 15 years and have seen what it means to have access to water and sanitation. I’ve worked in nomadic communities where WASH is non-existent – where there is no safe water, no latrine, no hygiene facilities, and water is scarce. Even where we believe that access is relatively good, we hear communities complain that there is only one water source and they must travel far to access it.

What motivates me is the decisions we make and their impact on the community. If even one family that currently has difficulties in access can say that the WASH problem has been resolved, then I would be relieved. If we solve half of the cases of disease within the next couple of years, I would be motivated to scale up to as many homes as we can get to.

What challenges have you faced in addressing WASH and NTDs?

GB: One challenge is that service providers, as well as communities, are not aware of the connection between WASH and NTDs. We must get the message out that without improvement in WASH, we may not be able to sustain the gains we have made in the fight against NTDs. This is clear when you compare progress on trachoma and schistosomiasis; while we have eliminated trachoma in most endemic districts, we have seen progress on schistosomiasis reversed despite added treatment. The only way we can address this is if we improve WASH. In terms of achieving this improvement, we are challenged by natural disasters such as floods, poor soil conditions that make latrine construction difficult, and long distances to water sources. When we conduct health education, we try to emphasise the vital role of WASH.

Getting all the players to sit at the same table and view themselves as part of one WASH community instead of medical, engineering, NGO, social science or hydrology specialists, and initiating collaboration, has been a challenge. Another challenge is that Uganda has a decentralised government system, so whatever we do at the national level has to also reach all 126 districts if we want to make an impact.

Coordination of the collaboration itself is also a challenge as it is important to ensure that one sector does not appear to dominate the others – we’ve therefore tried our best to get everyone together and this is expected to improve as the concept of WASH and NTD collaboration gets more buy in.

How have you begun to overcome these challenges and improve cross-sectoral coordination?

GB: We decided to adopt the WASH and NTDs toolkit [“WASH and health working together”] and customise it to the Ugandan context. We have held meetings at the national level and we would like to hold specific WASH and NTDs meetings with district officials in which we can explain the toolkit and the expected results, to get them to appreciate that collaboration and partnership with WASH stakeholders and relevant ministries is vital. WASH is a very big challenge and we cannot do it alone.

What difference can collaboration make?

GB: Even if we come up with one innovation that can ensure coverage in fishing communities, which are right on the water, yet they have no access to safe water, that will be a huge success. If the communities that are very far from the water source can benefit from innovation to resolve this problem, I would be proud to have been a part of this effort.

For more information:
https://www.who.int/water_sanitation_health/publications/wash-health-toolkit/en/ https://www.infontd.org/cross-cutting-issues/wash-and-ntds

About the author:
Yael Velleman is the Director of Policy & Communications at SCI Foundation, and co-chairs the NNN WASH Working Group

Can a toolkit make a difference to WASH and NTDs collaboration?

30 January 2020 at 13:00

By: Yael Velleman (SCI Foundation) and Leah Wohlgemuth (Sightsavers); WASH Working Group Co-Chairs, Neglected Tropical Disease NGO Network

One year on from the launch of the first-ever practical guide on WASH and NTDs collaboration, the co-chairs of the NNN WASH Working Group reflect on its impact.

WHO/NNN toolkit cover

A year ago today, Dr. Mwele Malecela, WHO Director for the Department of Control of NTDs, unveiled the first-ever step-by-step guide for building NTD and water, sanitation and hygiene (WASH) partnerships to a crowded auditorium at the London Centre for Neglected Tropical Disease (NTD) Research. “WASH and health working together: A ‘how-to’ guide for Neglected Tropical Disease programmes” is the culmination of more than two years of collaboration between the World Health Organization and the NTD NGO Network (NNN), incorporating real-life program perspectives and tools to improve coordination between the NTD and WASH communities. On this inaugural World NTD Day, the toolkit is celebrating its one-year anniversary and the significant headway made since its launch.

2019 saw a burst of activities to disseminate the toolkit far and wide; it was translated into French and Spanish, transformed into an interactive online version, and featured in two webinars for the NTD and WASH communities. Blogs by WaterAid and the NNN highlighted the mutual benefits of the toolkit to the WASH and NTDs communities, and the toolkit was highlighted in a USAID Water Currents issue on the importance of WASH and NTD integration. Interviews with The Carter Center’s Kelly Callahan, Director of the Trachoma Control Program, and Dr. Wondu Alemayehu, Technical Advisor at The Fred Hollows Foundation, demonstrated the value of the resource in the eyes of those who have worked towards NTD control and elimination for many years. The toolkit also made a splash at a number of WASH and global health convenings, with workshops delivered at Stockholm’s World Water Week, UNC’s Water and Health Conference, and the 10th Annual NNN Conference.

More importantly, however, the approach set out in the toolkit was implemented in a number of countries. Inspired by this resource, the Ethiopian Ministry of Health, which was also a major contributor to the toolkit’s content, developed a national framework to guide all government and non-government stakeholders on resourcing, planning and monitoring joint interventions, along with a woreda-level WASH and NTDs coordination toolkit. Various tools including the situation analysis protocol and planning workshop were also utilized in Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Ghana, Guinea, Kenya, Liberia, Niger, Nigeria, Senegal, Tanzania, Zambia and Zimbabwe. More recently, the Government of Uganda formally adopted the toolkit as a whole and has begun a process of coordination, and adaptation of the toolkit to the national and local context. The toolkit has also informed the design of WASH activities with the UK Aid funded Ascend programme in West and Central Africa, including coordination structures and joint planning processes.

As we look ahead to 2020—with the anticipated launch of the 2030 Global NTD Roadmap and complementary Global Strategy on WASH and NTDs, as well as renewed commitments to be made in Kigali this summer—nothing is clearer: cross-sector collaboration is essential to sustainably beating NTDs. This World NTD Day, we’ll celebrate the progress made in 2019 following the launch of “WASH and health working together”, but know that as a global community, we still have much to do to build successful partnerships. This will mean taking collaboration to the next level, by convening and supporting capacity building initiatives at the regional and national level, by supporting the development of country and local tools, and by documenting the use of the tools to ensure that the toolkit is continuously enhanced to achieve the ultimate aim: end the scourge of NTDs by 2030.

Crossing the Finish Line: Sustaining Behavior Change for the Prevention and Elimination of NTDs

19 November 2019 at 14:22

Shelmel Terefa, a school teacher, demonstrates face washing to students at his school in Aware-Golje village in the North Shewa Zone, Oromia, Ethiopia. Photo credit: Michael Amendolia/The Fred Hollows Foundation

By: NNN WASH Working Group

Access to water, sanitation and hygiene (WASH) is a fundamental human right. Improvements in health and increasing life expectancy across much of the world can be attributed to investments that improve environmental conditions and healthy behaviors. However, inequities in accessing services mean that many of the world’s poorest and most vulnerable communities still lack sustained access to WASH infrastructure of sufficient quality. This leads to ill-health, including neglected tropical diseases (NTDs), which exacerbate social and economic challenges and can trap entire communities in a cycle of poverty and marginalization.

The presence of NTDs is an indicator of the need to improve access to WASH. Many NTDs, such as trachoma, soil transmitted helminths and schistosomiasis, are preventable through practicing the same behaviors, such as reducing open defecation, maintaining sanitation facilities, and hand and face washing with soap. Other NTDs require WASH access to treat the symptoms caused by the disease, such as personal hygiene to reduce the occurrence of acute attacks in people with lymphedema due to lymphatic filariasis.

How can WASH programs support NTD programs?

Ensuring access to clean water and sanitation facilities, such as working toilets linked with safely managed sanitation services and continuous water supply for hygiene purposes, is a critical first step, but is not enough. WASH infrastructure must be complemented by cross-sectoral integrated programs that bring health, education and WASH stakeholders together to raise awareness about the link between good health and hygiene and shift long-held cultural norms. In a nationally representative survey recently conducted in Uganda, researchers found that improved access to WASH facilities alone did not lower the prevalence of intestinal schistosomiasis. Rather, lower prevalence of the disease was associated with changing attitudes to open defecation and increased toilet use.

However, sustained behavior change is challenging. The complicated nature of disease transmission, which is influenced by both environmental and psycho-social conditions means that effective strategies are often extremely context specific. This is evidenced by the fact that systematic reviews have been unable to demonstrate replicable efficacy of any given approach.

So, what can we do?

The NTD community needs to invest in a coordinated program of research that investigates the determinants of healthy behavioral practices and designs and tests approaches that create and sustain change. Forums like COR-NTD and ASTMH provide platforms for NTD stakeholders to share research outcomes and identify research questions for sustained behavior change.

Several theoretical frameworks have been developed in recent years to guide the design of effective interventions and ensure they are contextualized and appropriate to the communities they are designed to benefit.

The Behaviour Centered Design framework is one such tool, developed by London School of Hygiene and Tropical Medicine and adapted by trachoma stakeholders to improve facial cleanliness and environmental improvements as part of the delivery of the World Health Organization endorsed SAFE strategy for trachoma elimination. The framework draws on psychology and marketing principles in order to explore and define the causes of behavior, including cognitive processes and the way individuals interact with their environments.

By using the framework’s environmental and psycho-social determinants checklist, those designing behavior change interventions can analyze behaviors that often go unexamined. For example, a study to understand the behaviors associated with trachoma transmission in Ethiopia found that communities practiced open defecation, in part, because open defecation was viewed as acceptable, comfortable, convenient and beneficial to agricultural productivity. In contrast, experiences with latrines were largely negative, with latrines perceived as smelly, unhygienic and dangerous for small children, leaving participants feeling poorly after their use.

Partnerships to achieve WASH and NTD targets

In January 2019, the World Health Organization and the Neglected Tropical Disease NGO Network (NNN) published WASH and Health Working Together: A ‘How-To’ Guide for Neglected Tropical Disease Programmes. Recognising that cross-sectoral collaboration is essential to achieve global targets, the toolkit provides step-by-step guidance for partnerships at all levels, including working with health ministries, the private sector, and local and national WASH agencies, and is adaptable to different needs and local contexts.

The toolkit, which is available online and in print, was developed using real life program experiences and is continuing to be refined and updated by the NNN WASH Working Group to ensure the tools provided respond to the challenges of cross-sector collaboration such as differences in objectives and priorities, and budgetary and capacity constraints.

The road to 2030

To achieve Sustainable Development Goal 3.3 by 2030, WASH investments and interventions must be prioritized in NTD endemic areas. This will require greater understanding of effective behavior change interventions, increased cross-sectoral collaboration between NTDs and WASH actors and the ability to adapt to specific environments.

Cross-sectoral collaboration is required at all levels, from ministries of health and water, down to municipalities. The upcoming WHO NTD 2030 Roadmap, recognizes that meeting its targets is impossible without cross-sectoral collaboration. A new cross-cutting indicator has been added, in which all NTD endemic areas must reach universal WASH access by 2030. The WHO’s 2015-2020 global strategy on WASH and NTDs—which will be updated in line with the NTD 2030 Roadmap— will provide the vision and strategic objectives to ensure that this cross-cutting target is met.

Significant progress towards NTD elimination in recent years has demonstrated what can be achieved when all stakeholders work together in support of our shared vision of a world free of NTDs. It is possible to end the disability, poverty and marginalization faced by the 1.6 billion people affected by NTDs by 2030, but only if all NTD stakeholders work together and support national programs

This article was written by NNN WASH Working Group members:
• Angelia Sanders – Co-Chair WASH Working Group, Vice-Chair International Coalition for Trachoma Control, The Carter Center
• Kelly Bridges – NNN WASH Working Group Communications Task Team Co-Chair, Global Water 2020
• Sarity Dodson – NNN WASH Working Group Behaviour Change Task Team Co-Chair, The Fred Hollows Foundation
• Tim Jesudason – NNN WASH Working Group Communications Task Team Co-Chair, International Coalition for Trachoma Control

Note: This article has been cross-posted on the NTD NGO Network website, COR-NTD, Sanitation Updates, and the ICTC website.

How handwashing behaviour change programmes can save lives in an emergency

28 August 2019 at 19:34

By: Claudia Codsi, Private Sector Partnerships, Oxfam

As World Water Week started this week, I was reminded of a shocking statistic. In an emergency setting, diarrhoea is responsible for 40% of child deaths – 8 out of 10 of those children are under the age of 2. This appalling rate can be reduced by up to 50% with the simple act of handwashing with soap, an easy, effective and affordable method to protect and prevent disease transmission. Yet too often, this simple intervention is not prioritised in humanitarian responses despite its potential to save lives.

This is why Oxfam and Unilever joined forces, because we both realised that there was an existing problem and that our organisations had the combined expertise to solve this; Oxfam’s vast humanitarian and public health response experience with Lifebuoy’s marketing and behaviour change expertise to better understand what motivates mothers to wash their hands.

Oxfam conducted research with emergency-affected mothers in the Philippines, Pakistan and Nepal which showed that mothers share two universal motivators 1) nurturing their children so that they succeed in life and 2) desire to be affiliated to a community of people.

Based on these results we created a programme called ‘Mum’s Magic Hands’ drawing on emotional motivators, nudges and triggers to drive sustained behaviour change. The results had a positive effect on mothers’ handwashing practice, increasing both awareness and practice of handwashing with soap.

At World Water Week this past Sunday, Alma Migens Cuenta, Oxfam, Aarti Daryanani, Lifebuoy and Murray Burt, UNHCR presented a sofa session, convened by the Global Handwashing Partnership, calling on all WASH and Humanitarian actors to prioritise handwashing behaviour change programmes in emergencies. They provided examples of how ‘Mums Magic hands’ has been applied across various contexts and why it is unique and more effective than functional communication, which has focused on health benefits. Listen to the recording here.

They called on donors to give more attention and investment to handwashing behaviour change programmes like Mum’s Magic Hands that have proven health outcomes, advocating for this to be a minimum standard in the sphere. The programme is also freely available to practitioners working in the humanitarian sector and downloadable on the Oxfam policy and practice website.

All actors – donors, NGOs, government, civil society, private sector – have a collective responsibility to achieve SDG 6.2 (access for all to sanitation and hygiene). The evidence exists and shows what it takes to sustain improved handwashing behaviour change in an emergency context. We can and must work together to protect those most vulnerable to disease from avoidable illness and death.


Thoughts and Reflections from the 72nd World Health Assembly

25 July 2019 at 17:39

By: James Stix, Partnerships & Strategy, Wellbeing Foundation Africa

The World Health Assembly is somewhat of a yearly family reunion for the international health community. After seventy-two of them, plenty has changed while some aspects have remained the same. The first Assembly took place in 1948, shortly after the WHO’s inception, when the key decisions for the governance and development of the Organisation were still pending and 48 member states attended. It was still over a decade until the WHO actioned on the 1959 proposal towards a global initiative to eradicate smallpox and it was acting upon the importance of “enlisting the co-operation of governments and of non-governmental organisations in the collection and distribution of information”.

Today, the World Health Organisation has 150 country offices with multiple liaison offices and the ‘World’ in its name seems much more appropriate. Between the 20th and 28th May 2019, complementing the main functions of the World Health Assembly – to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget – representatives from organisations across the world travelled to Geneva to host, join or collaborate on side events and sessions during the Assembly.

For the Wellbeing Foundation Africa, a maternal and newborn health-oriented NGO, the appeal of the Assembly brings in opportunities to connect, reconnect, expand and develop in a number of ways, some obvious and others more elusive. An early notion in planning to attend the Assembly is that convening globally-spread organisations, messages and impact to assess progress is difficult and so attendance has the benefits of being surrounded by the people we want to see, the partners we want to meet with and the leaders and decision-makers that bring about change.

This year, a primary focus of the Assembly for the Foundation was to join the water, sanitation and hygiene (WASH) in health care facilities resolution, which was unanimously approved and address a high-level meeting at the World Health Assembly on how to better align solutions to Women’s, Children’s and Adolescents’ Health and Well-being in Humanitarian and Fragile Settings, alongside meeting with partners, Ministers, world leaders and members of the international development community to further existing programmes and design new avenues for collaboration.

If it is not obvious from the above, the Assembly week becomes a whirlwind of activity and a flurry of movement. Aside from the larger implications (environmental, logistical, funding) of a legion of representatives and organisations travelling to Geneva for the Assembly, there is a conference fatigue which kicks in at around day two or three, especially if the Assembly comes off the heels of another conference of relevance to your organisation – which could have been anywhere from nearby Zurich to Sydney. This is where the efficacy of the Assembly comes into question and recent scrutiny has achieved some introspection – Devex wrote a great piece on the cost of development conferences for budgets and the environment – with some veteran attendees, such as executive director of the advocacy ONE Campaign, David McNair, making the point that today “I find you can save money, time, and cut your environmental footprint by following conferences on Twitter.”

Therefore, attending the World Health Assembly in 2019 happens at somewhat of a crossroads for the development community. There is a tangible, electric energy when you are in the room where progress becomes materialized at the global level, such as when Member States committed to developing national roadmaps, setting and monitoring targets, increasing investments in infrastructure and human resources and strengthening systems to improve and sustain Water, Sanitation and Health (WASH) services in health care facilities. That 32 countries spoke and highlighted the “fundamental role of WASH in Health Care Facilities (HCF) for achieving universal health coverage, improving quality of care and in preventing the spread of antimicrobial resistance” (UN Communiqué) truly feels like the culmination of combined efforts – it is both a humbling and empowering experience to cross eyes with partners and friends who you have worked with – sometimes programmatically on the frontlines and other times remotely – as Dr. Tedros walks in with a mop and turns the room to a cheerful celebration of progress made and the impact of an honest realisation from the WHO leadership of the work that remains to be done.

Reminiscing over such experiences reinforces the impression that the Assembly becomes logged in memory as more of a broad-stroke blur than a fine brush caricature. The meetings blend in, the sessions could have happened on Tuesday or Wednesday, was it in May again? There is only so much the brain can log in an organised manner. This, however, is not to say that concrete outcomes do not bear fruit out of all these interactions and the Assembly is certainly a conference where both seeds are planted and fruits are harvested. This is where the surface chaos takes form onto the intricate, nuanced resolutions that are woven in the fabric of such a large-scale conference. The examples of outcomes vary widely: maybe you wanted to arrange a first meeting with a potential collaborator, or with the UN or WHO official responsible for the area of remit of you or your organisation, or maybe you wanted to attend a particular session that could strategically bolster your mission or work. The Assembly, beyond what’s on paper long before the first session inside the United Nations headquarters or at a nearby hotel hosting side meetings, is truly what you make of it.

Therefore, the 2019 World Health Assembly was, if one aspect stands out for the Wellbeing Foundation Africa and its attending representatives, it was the Assembly on WASH. A year ago, at the 71st Assembly, we were setting up the meetings that we thought would lay the groundwork for work that could go on for years or decades in this area. A year later, having established partnerships with the WHO WASH teams, the World Bank, global corporations and advocacy groups and local implementing partners, we see the results of collaborative effort and a mass drive across the development sector – or the WASH-focused parts at least – towards greater investment and attention in providing water, sanitation and hygiene to healthcare facilities where most of our programmes take place. In an ever-changing environment where progress in impact is palpable but also assessing what the best way to structure the international development conference agenda is becoming a priority, we guess the fondue will have to wait until next year and the 73rd Assembly.

Innovations in Combating the Hand Hygiene Crisis: A Lesson in Getting Creative

22 May 2019 at 16:01

By: Lindsay Denny

This post was originally posted on the WASH in Health Care Facilities website.

What do you do when there aren’t enough working sinks in the hospital and the infrastructure situation won’t be improved anytime soon? Sometimes, you need to get creative.

Walking through a packed hospital in rural Cambodia, I saw the same problem yet again: this facility cared for more than 100 patients per day, but the building that housed the pediatric and post-surgery wards had no water access. Standing between rows of beds, I observed the patients and their caregivers and wondered how the staff could possibly do their job well without a sink to wash their hands.

Simply washing hands with soap has been shown to prevent nearly 40 percent of neonatal deaths. It is fundamental to patient care and worker safety. The importance of handwashing cannot be overestimated, and soap and water and the ability to dry hands are imperative for infection prevention and control.

Staff at this hospital cared for patients who had just had major surgery; yet they needed to walk to the building next door to access a functioning sink and soap. One of the nurses told me she and her colleagues sometimes used hand sanitizer, but because they had to purchase it themselves, it was used sparingly. In addition to being cost-prohibitive, hand sanitizer isn’t always the best option to decontaminate hands. For example, the WHO says hands need to be washed with soap and water when covered with blood, a common occurrence in a health facility. Neither walking 100 meters nor using hand sanitizer intermittently was ideal for ensuring proper hand hygiene for every patient.

This absence of handwashing facilities inside healthcare facilities puts entire communities at risk of health epidemics and the spread of infectious diseases; and it is by no means unique to Cambodia. A series of recent reports have confirmed what should be incomprehensible: billions of people are served by healthcare facilities that lack adequate hygiene facilities. Forty-three percent of hospitals and health centers globally do not have materials for handwashing at points of care. That’s the conclusion of the first global report on water, sanitation and hygiene (WASH), based on data from over 560,000 healthcare facilities in 125 countries, recently released by WHO/UNICEF. These findings follow a landmark 2018 report that analyzed data from 129,000 healthcare facilities in 78 low- and middle-income countries: 50 percent of healthcare facilities lacked piped water, 33 percent lacked basic toilets, and 39 percent lacked soap.

What then do you do when there aren’t enough working sinks in the hospital and the infrastructure situation won’t be improved anytime soon? Sometimes, you need to get creative. WaterSHED, a local Cambodian NGO, is no novice when it comes to finding innovative, yet simple solutions. They started by looking at ways to improve hygiene in rural communities across the Mekong, focusing on households and how to motivate families to consistently wash their hands. With insights from Vietnamese and Cambodian mothers, they designed a portable sink and tested it in rural homes with young children. The end product: the “HappyTap”, an affordable, mobile, and easy-to-use way to encourage everyone to stay healthier by maintaining better hand hygiene.

Photo Credit: WaterSHED Asia

It may sound like an obvious solution, yet there were no low-tech, low-cost alternatives to sinks on the market in Cambodia. But could it function in the more demanding healthcare setting as an acceptable alternative where water infrastructure is not available? Through funding from the General Electric Foundation, Emory University partnered with the team at WaterSHED to bring Happy Taps to GE project hospitals where Emory was working. While hospital staff were keen to try it out, they made it clear that they wanted their own designated sinks, separate from patients and caregivers. Four portable taps were placed in critical handwashing areas that lacked water access, on carts so they’d be mobile. A mirror and a poster about handwashing were hung on the wall above and staff members were assigned to refill the water.

Our initial visits were encouraging. The Happy Taps were intact, functional and most important, in regular use thanks to their proximity to points of care. But we know sustainability notoriously plagues water solutions. With the best of intentions, equipment and infrastructure is installed, but with no funding, training and plans for on-going maintenance, faucets crack, pipes snap, and far too many sinks gather dust. Even with this low-tech innovation, we didn’t know what we’d find.

The real test was what we’d find when we returned a year and a half later. Not only were all the taps fully functioning and being used, they’d been placed in preferred locations and staff had rigged them with add-ons, like attachments for liquid soap purchases. During staff training on infection prevention, the portable sink in the middle of the training room was perfectly suited to demonstrate proper handwashing technique. Several staff even inquired about purchasing handwashing stations for their homes.

Is a portable tap a long-term solution? Probably not, because they require a staff member to fill up them with water and empty the discharge. When discussing their ideal handwashing situation, the hospital directors in Cambodia described a normal sink, piped in from outside.

But providing healthcare workers with the ability to clean their hands is absolutely vital. Until hospitals have access to piped water and permanent sinks in critical locations, particularly the point of care, and are kept operable with on-going maintenance, our experience in Cambodia demonstrates that portable handwashing stations may be one acceptable, cost-effective way to help close the global gap in the hand hygiene crisis within healthcare facilities. And that is the definition of one very happy tap. do you do when there aren’t enough working sinks in the hospital and the infrastructure situation won’t be improved anytime soon? Sometimes, you need to get creative.


Typhoid, Water and Buried Pipelines: A Call for Better Health-WASH Integration

17 May 2019 at 16:06

By: Laura Kallen, Scientific Communications Officer, PATH

Handwashing with soap and clean water prevents diseases from spreading from the hands to the mouth. Vaccines save lives by preventing pathogens from causing illness.
For a disease such as typhoid, where bacteria from hands can contaminate food and water and cause illness, we need both water, sanitation, and hygiene (WASH) and vaccines to control it successfully. But to ensure these tools reach all communities and effectively control disease transmission, we need more coordination.

Children drinking from well pipe. Photo: PATH/ Monique Berlier

Typhoid: A disease of sanitation

Spread via the fecal-oral route through contaminated water and food, typhoid is estimated to have caused nearly 11 million cases and more than 116,000 deaths worldwide in 2017. It used to be a global disease, but after improvements in water and sanitation infrastructure in high-income countries during the last few centuries, the typhoid burden is now mostly found in low- and middle-income countries in Asia and sub-Saharan Africa. Typhoid thrives in settings where water and sanitation infrastructure—e.g., sewer systems, water treatment facilities, and well maintained pipelines—are in disrepair or lacking completely. Typhoid continues to spread when communities struggle with a lack of access to clean water and sanitation facilities, which makes handwashing and other hygiene behaviors difficult to employ consistently. Eroded, insufficient, and overused pipes, wells, toilets, and sewage systems allow contaminated fecal matter to seep into pipelines and water supplies, forcing families to use unsafe water for drinking, cooking, and bathing.

Vaccines work

Improving WASH infrastructure is a complicated and expensive. This problem has led many typhoid control experts to support a readily available and effective solution: typhoid vaccines. During the last two years, momentum for typhoid vaccination has accelerated with the availability of a new WHO-prequalified typhoid conjugate vaccine(TCV), a huge step forward for the protection of young children against the disease.
Vaccines offer a necessary near-term solution for typhoid control while governments and communities continue to work on WASH improvements. But the opportunity to introduce TCV doesn’t mean we can forget about WASH. Typhoid will continue to lurk in the pipes.

Merging sectors

In order to take on typhoid, diarrheal disease, and other waterborne pathogens, we need both vaccines AND improvements in WASH. While vaccination can save and improve lives now, long-term investments in WASH infrastructure will create a future where typhoid and other diseases are removed from the water altogether, effectively ending the risk of falling ill.
That future needs to start now. The momentum for new typhoid vaccines provides an opportunity to start building a more integrated approach for typhoid control. By integrating WASH behaviors into vaccination programs, encouraging diverse sectors and government ministries to collaborate, and advocating for integrated solutions, we can start to change the paradigm—not just for typhoid, but for diarrheal disease, cholera, and other waterborne diseases. Health is comprehensive and multifactorial, and health solutions need to be, too.

A pipeline of promise

By identifying opportunities to strengthen the coordination between the health and WASH communities, we can develop new, innovative solutions to tackle diseases of poverty. One imminent example is the current initiative for WASH in health care facilities, which is the subject of a resolution at this year’s World Health Assembly. The resolution will encourage all countries to assess and develop plans to improve the availability of clean water and sanitation in health care facilities—a goal that will require coordination between the health and WASH sectors.
Yes, we need to improve actual water and sewer pipelines. We also need to continue to strengthen the development and introduction pipeline of vaccines for waterborne diseases. But to start building a more integrated approach to health, we need to create, strengthen, and reconnect the figurative pipeline of collaboration between the health and WASH communities. It has remained fractured and buried for far too long.