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Before yesterday3. Hygiene

What we learned about handwashing from published research in 2017

13 June 2018 at 14:16
By: Bijan

This post originally appeared on FHI 360’s R&E Search for Evidence Blog, here

By Carolyn Moore

Every year, the Global Handwashing Partnership summarizes the year’s peer-reviewed evidence related to handwashing with soap. Our 2017 research summary includes 117 studies and brings together additional evidence for the benefits of handwashing, new information on hygiene behavior change, and some surprising results of handwashing programming.

The summary breaks down what we learned in 2017 into categories like access to handwashing facilities, handwashing compliance, approaches to behavior change and drivers of handwashing behavior. Here, I highlight five studies that stand out to me.

Access to handwashing facilities

A study by Kumar, et al. looks at data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe handwashing behavior in 51 countries. Using data from 51 surveys conducted between 2010 and 2013, the authors document the availability of soap anywhere in the home and access to a handwashing place with soap and water – both proxies for handwashing behavior. These proxies are ‘crude indicators’ of handwashing behavior, meaning that access to soap or a handwashing station in the home doesn’t necessarily mean that people are regularly washing their hands.

The study finds a wide range in access to both proxies between countries, with survey results ranging from less than 1 percent access (in Malawi and Western Kenya) to more than 90 percent (in places like Serbia and Iraq). Disparities appear within regions – for example, Bangladesh had 21.4 percent access compared with 78.7 percent in Bhutan. In nearly every country, wealthier and urban households are more likely to have soap available than less wealthy or rural households. The study, along with the 2017 WHO/UNICEF Joint Monitoring Report, helps us understand the scale of inequities in access to handwashing facilities.

Benefits of handwashing

A mixed methods study in Lofa County, Liberia, from Capps, et al. shows unanticipated long-term effects of water, sanitation and hygiene (WASH) behavior change programming. The study aims to understand Ebola cases reported in communities where the nongovernmental organization Global Communities conducted Community-Led Total Sanitation (CLTS), a community-based approach for eliminating open defecation and improving sanitation and hygiene.

During the 2014–2016 Ebola outbreak in West Africa, no cases of Ebola were found in communities that had engaged in CLTS and were certified as open defecation free. One CLTS community that had not reached open defecation free status did have cases reported. In focus groups, community members attribute their avoidance of Ebola to WASH behaviors learned from CLTS before the outbreak, especially handwashing with soap and disposal of feces. To me, this study shows how behavior change programming can protect communities in ways that may not be anticipated at the beginning of a project, and how good hygiene protects us against potential outbreaks.

Handwashing compliance

Multiple studies in our annual summary support an important distinction in handwashing behavior change: knowledge does not equal practice. Even when people have a high level of knowledge about the benefits of handwashing, when to wash their hands, and how, we still see low levels of compliance. This is an important reminder that behavior change programs cannot rely on knowledge alone to improve handwashing behavior.

For example, Demssie, et al. survey 251 mothers of children under the age of 5 years in Gotu Kebele, Ethiopia, using a semi-structured questionnaire delivered in person. While more than 99 percent of mothers know the importance of handwashing, their self-reported handwashing practice is much lower. Only 52 percent report washing their hands before feeding their children. Other studies in the summary show similar ‘knowledge-to-practice gaps’ in schools, health facilities and community settings.

Approaches to behavior change

One study by Dreibelbis, et al. featured in our 2016 research summary, looks at the effect of using nudges (simple, often subconscious cues) to increase handwashing behavior in a school in Bangladesh. That small study generated very promising results, with handwashing rates going from 4 percent to 74 percent, but also led to some open questions on how nudges work. I am excited to see more research on this approach in the 2017 literature.

In a study from The Netherlands, Caris, et al. use posters as nudges. The posters are displayed in hospital wards on or next to alcohol-based handrub dispensers. The findings show the poster nudge increases handrub use in one ward at all times and only during doctor’s rounds in another ward. Use of handrub does not increase at dispensers without a nudge, so there remains a need for further research to understand the extent to which nudges may or may not help develop habits even when a nudge is not present. The authors recommend similar poster nudges as an easy, inexpensive way to increase the use of handrub. You can learn more about handwashing nudges in our infographic and FAQ document.

Drivers of handwashing behavior

The RANAS (risk, attitudes, norms, ability and self-regulation) model is a formative research tool to help behavior change researchers understand what motivates people to wash their hands in a specific context. Seimetz, et al. use the RANAS model to understand drivers of handwashing behavior in primary school students in Burundi and Zimbabwe. The authors conduct interviews with more than 600 children in Burundi and over 500 in Zimbabwe; and they use regression analysis to understand the influence of the drivers in the RANAS model to the children’s handwashing behaviors. One of the authors, Dr. Hans-Joachim Mosler, presented details of the methodology in a 2017 webinar.

The authors find some similarity across the two settings. For example, self-efficacy and social norms are effective drivers of handwashing behavior in both the Burundi and Zimbabwe samples. However, the authors find there is a need for a handwashing promotion program to increase the perceived severity of consequences from diarrhea in Zimbabwe, but not in Burundi. They also recommend that a program in Zimbabwe address depression as an underlying factor for lack of handwashing. I am encouraged to see this level of context embraced in formative research for handwashing behavior change. Often, if we look only at factors we assume to be directly related to a target behavior, it’s easy to miss larger health and social issues that form determinants of multiple behaviors.

Looking ahead

The literature in 2017 provides exciting new ideas in handwashing behavior change. The volume, range and quality of the 117 studies show an increase in handwashing research as compared to previous years – and many of the papers are open access. Published literature helps us understand what motivates people to wash their hands, and contributes new ideas for how to change people’s handwashing behavior. However, it hasn’t answered every question. The Global Handwashing Partnership is already developing our 2018 research summary, and I’m looking forward to the new evidence to come.

Photo caption: At a rural primary school in Malda, West Bengal, India, children learn appropriate techniques of hand washing using soap from NGO volunteers. Photo credit: © 2015 Birabrata Das/www.rchss.in, Courtesy of Photoshare

Meet the Hygiene Heroes in Action

16 July 2018 at 17:37

Editor’s note: Throughout the High-Level Political Forum, we’re highlighting some of the ways that Global Handwashing Partnership members are contributing to progress towards SDG 6. Today, United Purpose shares the stories of Hygiene Heroes leading change in their own communities.

By United Purpose Nigeria

For the fourth consecutive year, United Purpose, in partnership with the PZ Cussons Foundation, organized Nigeria’s (and one of the world’s) largest Global Handwashing Day campaigns. In total, more than 46,000 people washed their hands with soap during our campaign activities, a unique achievement in Nigeria.

At events in nine Local Government Area (LGA) in Cross River and Benue States, children learned how they can avoid certain illnesses by handwashing with soap, by playing fun and informative games and performing to our Global Handwashing Day campaign anthem. Close to 200 schools commemorated the UN Global Handwashing Day. In each LGA, two enthusiastic and outspoken children were asked to volunteer to share their learnings and motivational stories with other school children. Using this peer-to-peer learning activity, also dubbed ‘Hygiene Heroes in Action’, the nominated Hygiene Heroes visited other schools in their area to share their enthusiasm about hygiene.

Meet three of the Hygiene Heroes working to promote good hygiene:

Isabella Isaac Magnus is a Hygiene Hero from Abi LGA, Cross River State. Isabella loves talking, singing and dancing, but her dream is to become a doctor: ‘’Because I understood that handwashing saves lives like the handwashing song [Wash Your Hands O] says, I have decided to tell and teach people how to wash their hands so that they can live long and live healthy’’. Her mission didn’t end there, as she visited another school in her area, where she taught her peers the five domains of hygiene, and showed them how to construct a tippy tap – a simple, low-cost handwashing station. She also showed teachers and pupils how to wash hands, and left them amazed at her boldness and expressiveness as a true ‘Hygiene Hero’ on a mission to save lives.

Sylvia Udokwu, one of our Hygiene Heroes from Ikom Local Government Area (LGA), Cross River State, attends Foresight Primary School.  She is an active member of the Environmental Health Club in her school. Why? In her own words: ‘’I want to save lives, I want to teach people about hygiene, I want to create awareness about keeping ourselves and our environment clean, to eradicate sickness and disease’’’.

Global Handwashing Day was an opportunity for her to spread the message. As a true Hygiene Hero she visited another school in her area, not only addressing other pupils but also school management. Her goal was to convince them that handwashing is important and should be practiced in the school environment at all critical times. She also demonstrated when and how handwashing needs to happen. Sylvia clearly transferred her enthusiasm – the school immediately decided to set up an Environmental Health Club!

This is Clifford Uchenna, a Hygiene Hero from Ikom LGA, Cross River State. As part of peer-to-peer learning activities facilitated by United Purpose as part of the Global Handwashing Day campaign, he delivered a speech and offered support to another school in his area. Where does his commitment to handwashing come from? In his own words, ‘’I want to teach people how to prevent diseases; diseases caused by bacteria and viruses such as pneumonia, diarrhoea, monkey pox, typhoid and other infections. The rate of children dying is too much and I don’t like seeing children die so if I spread this information, children will not die anyhow’’. He showed how handwashing can be made simple, by demonstrating proper handwashing, using locally available materials to construct tippy taps (fork sticks, wooden cross bar, nails, rope, plastic bottle), and setting up a Hygiene Corner for the school.

To learn more about United Purpose and our work promoting hygiene, watch our Global Handwashing Day video, and watch this video to hear the Wash Your Hands O song.

Hygiene Kits: thinking globally, acting locally

18 July 2018 at 12:50

Ed. note: This post continues our series on how our partners are contributing to SDG 6, with a post from International Aid on involving local communities in the US to solve the global hygiene challenge.

By Bryony Schultz, International Aid

For over 38 years, International Aid has worked to combat global health issues by providing medical equipment, health resources, and hygiene supplies to people suffering  from the impacts of natural disasters and  poverty in vulnerable areas of the world.

As an advocate of WASH and Sustainable Development Goal 6, International Aid understands that proper basic hygiene is the front line of defense against the spread of disease. Since the spring of 2014, we have invited our local communities from western Michigan to participate in our Hygiene Kit Packing Events. This has offered us opportunity to promote the basic practice of washing hands with soap and water and the positive impact this makes on global health.  This provides an opportunity for community groups to get engaged in working towards SDG 6 and solving the global hygiene challenge.

These events have produced hundreds of thousands of hygiene kits that we have distributed around the world.  Every hygiene kit includes full sized personal hygiene items: shampoo, bar soap, washcloth, comb, toothbrush and two mini toothpastes.  Since the spring of 2014 hundreds of thousands of hygiene kits have been distributed in 8 different countries around the world, including: Nepal, Ecuador, Guatemala, Kenya, Sierra Leone, USA, Jordon and Philippines.  They are an excellent resource immediately following natural disasters when the risk is high for spreading germs and disease. This work is  an integral part of International Aid’s mission to provide appropriate and sustainable medical equipment and health resources to global partners that serve people in need.

International Aid has celebrated Global Handwashing Day at our corporate offices, and on school premises, over the last 3 years.  We have held handwashing relays, glitter demonstrations that highlight how illnesses can be spread with our hands, and other fun activities intended to engage children in proper hygiene and handwashing.

Our Global Handwashing Day celebration allowed us to engage communities in fun activities that educate on proper handwashing. This works in tandem with our hygiene kits that contain soap and other personal care items. International Aid has even produced a fun and catchy song about the importance of proper handwashing.

Lifebuoy and Amref improve newborn health through handwashing with soap

20 July 2018 at 15:36

Ed. note: This post concludes our series on how our partners are contributing towards SDG 6. Read on to learn how Unilever and Amref Health Africa are working to improve handwashing practices in Kenya. 

By Lifebouy and Amref

More than 34,000 newborn babies in Kenya die each year. This startling statistic points to the vulnerability of the first 28 days of a child’s life in determining their survival. The good news is that handwashing with soap is a simple and cost-effective act that could help protect newborns and their mothers against life-threatening infections. Research has shown that when caregivers practice good handwashing in this critical period, newborn survival rates can increase by up to 44%.

In response, Lifebuoy, together with Amref Health Africa, launched a program aimed at improving the handwashing behavior of pregnant and new mothers in Migori County. Migori is one of the six counties in Kenya responsible for about half of Kenya’s maternal mortality burden. As part of a full-fledged campaign to raise awareness on the importance of handwashing with soap, Lifebuoy premiered a compelling film “Sherry”, which follows the journey of a pregnant mother in Migori County.

The pilot program was implemented in Kuria West, Migori County to educate mothers on the importance of handwashing with soap and raise awareness of the risks in handling their newborn with contaminated hands in order to motivate them to adopt behaviors. Community health workers were trained and equipped with skills in counselling, awareness creation and habit formation at three levels:

  • Households: Community health workers conducted up to four household visits to 160 new mothers over a period of 6 months. These visits took place from a mother’s last trimester up to the first month after her child was born. The visits were designed to drive behavior change through awareness, commitment, reinforcement, and reward, through interactive program materials such as Glow Germ demos, stories and provision of portable handwashing stations to support the behavior. Amref Health Africa and the County Ministry of Health included other key messages on maternal, newborn, and child health, and nutrition.
  • Community: 72 mother to mother support groups were formed to offer social support, and to enable engaging discussions and problem solving to reinforce and make handwashing with soap practice easier. These groups involved around 800 mothers of children up to 1 year of age.
  • Health Centers: The project worked closely with health facility staff and health workers to enable additional outreach to pregnant and new moms, and refer them to clinics for ANC services and safe delivery.

The program’s effectiveness was assessed on awareness of the program, attitude towards handwashing and knowledge on handwashing occasions relevant to new mothers. The results showed marked improvements with new mothers who underwent the program more likely to wash their hands with soap during three junctures compared to the control group – after changing nappies (26% vs 2%), before breastfeeding (42% vs 3%), and after visiting the toilet (39% vs 10%). In addition, 90% of the new mothers who were exposed to the program talked about it to their friends, family members, and neighbors, highlighting a positive ripple effect. The learnings from this partnership are being taken forward in several contexts globally.

Dr. Myriam Sidibe, Unilever Africa Social Mission Director highlighted “Reaching new mothers at this stage is crucial as their child is most susceptible to infections during the neonatal period and mothers are also most receptive to information and actioning steps for the health of their baby.” Lifebuoy aims to change the handwashing behavior of one billion people worldwide by 2020 under Unilever’s Sustainable Living Plan and Africa is a key focus for driving impactful maternal, newborn and child health intervention.

Introducing the Global Handwashing Partnership’s new Global Health Corps Fellows

27 August 2018 at 19:08

The Global Handwashing Partnership is excited to welcome two new members to our Secretariat team. We are hosting two fellows through our partnership with Global Health Corps. The Global Health Corps, now in its tenth year, develops a network of young changemakers and pairs them with placement organizations in the social impact space for a year. Read on to learn more about the fellows, their backgrounds and their new roles with the GHP Secretariat.

Aarin Palomares is serving as our Advocacy Technical Officer. She holds an MPH in Health Care Organization and Policy. She has previously worked with RESULTS and the United Nations Foundation on several advocacy initiatives.  As Advocacy Technical Officer, she will be managing the GHP’s advocacy efforts, particularly Global Handwashing Day, as well as coordinating partner outreach.

“I was interested in the Global Handwashing Partnership because of its mission and its unique approach to promoting handwashing with soap. By engaging organizations from different sectors, GHP can leverage each organizational strength and resource to holistically achieve its goal and prevent WASH-related issues worldwide.”

Aarin is excited to better understand the logistics behind a large campaign like Global Handwashing Day through her role as Advocacy Technical Officer.

“Often times, these events serve as the nudge a community needs to increase their efforts. As a community member, I know how influential these days can be, so I’m excited to be on the backend and help communities all over the world spread the message of handwashing with soap!”

Takeaways from her role so far:

“I was in New York City when the Sustainable Development Goals launched, and I remember being particularly excited to see a goal focused on WASH. I think it is important to note that while investments in access to water and sanitation are crucial in achieving this goal, it does very little without proper hygiene behavior. We must take a multi-faceted approach to ensure SDG 6 is met!”

When she’s not working, Aarin enjoys being outdoors and exploring the city.

“DC has such a dynamic and diverse culture, and I think it’s a great place to grow as a professional and expand my current skills. So far, I’ve enjoyed exploring different neighborhoods, museums, and workout classes, and I’m excited to see what this next year will bring!”

Ebuwa Evbuoma is the GHP’s Knowledge Management Technical Officer. She is a trained physician with interests that intersect communications, user experience design, data and policy for problem solving in global health. She has previously worked in design, research and publication capacities with nonprofits, design initiatives and community groups.

“The Partnership was a great space to work towards. The data shows the journey and gaps in handwashing, and how the implementation of proper handwashing can help girls stay in school, and reduce lost work hours. The GHP is nearly two decades old, and I wanted to be a part of an organization that has dedicated time and resources to thought leadership, to work with the team to bridge the past, present and future, and to steer knowledge management and effect sustainable improvements in health outcomes.”

She is vastly excited about the opportunities available in human-centered design and research to understand knowledge gaps and how to fill them. “Every day, I come to work and ask myself, ‘How might we…?’, and the knowledge design journey begins.”

Takeaways from her role so far:

“Everything matters. Integration will get us farther in our journey for cohesive action. The SDGs are a great example of the strength of cohesive action. The world united to effect a great reduction in the incidence of Neglected Tropical Diseases (NTDs). The magic we achieved with NTDs (Neglected Tropical Diseases)?  I want to see the world achieve that unity for all the issues interwoven around handwashing with soap.”

When she’s not working, Ebuwa can be found exploring cultural events, historical landmarks, or publishing essays and literature.

We’re excited to welcome Ebuwa and Aarin to our team! Please contact us to get in touch with our team, and watch this site for updates on their work in the year to come.





Moving toward Transformative WASH: Lessons Learned from the 2018 UNC Water & Health Conference

26 November 2018 at 15:41

By: Aarin Palomares, Global Handwashing Partnership

Every year, the UNC Water & Health conference convenes WASH (water, sanitation, and hygiene) professionals from civil society, government, research institutions, and the private sector to discuss successes in the field, identify current gaps, and ways to move forward as a sector. As a young professional working in hygiene advocacy, I found that the conference provided a platform for all voices to step up to the table, ensuring the sector is more innovative and inclusive in its approach to achieve SDG 6: universal access to sanitation and hygiene for all.

As we reflect on the future of the sector, transformative WASH remains an overarching goal for many WASH researchers and implementers. That is, how can we create enabling environments to not only provide access, but change overall WASH norms? Sessions throughout the conference pointed to the need to shift our work toward more ambitious approaches that go beyond the current status quo. Here are some common themes I heard throughout the conference to push us toward transformative WASH in the future:

Reflecting on “Less Successful Successes”

In recent years, there has been a greater push to present on less successful efforts within the WASH sector. “Less successful successes” were a major theme throughout the conference with Jamie Bartram, Director of the UNC Water Institute, reframing the concept of failure to adapt for learning opportunities that can be gained through missteps. For example, the WASH Benefits and SHINE trials were multi-arm cluster randomized control trials based in Bangladesh, Kenya, and Zimbabwe with the aim to measure the benefits of WASH interventions in improving child growth and development outcomes. Despite being well designed and executed, the trials reported little to no additional effect from WASH interventions on linear child growth compared with nutrition interventions alone.

While the overall body of evidence revealed positive impacts from integrative approaches, these results challenged current behavioral change messaging and highlighted the need to reevaluate our approach and next steps as a sector. A side event convened by World Vision, FHI 360, the Clean, Fed, & Nurtured Coalition, and the Global Handwashing Partnership hosted a discussion based off the WASH Benefits and SHINE trial results. The brief discussion emphasized the need for greater advocacy within the community, stronger governance, and greater frequency in delivering behavior change messages.

The discussion highlighted key considerations for future WASH research. For instance, studies that resulted in a more significant effect had more frequent behavior change messaging to target populations. The role of a community health worker in consistently delivering behavior change tools to target individuals, such as mothers in a community, is crucial and should be considered in future interventions. Based on the discussion, it was clear that these studies call for more integrative interventions with higher levels of intentional WASH needed to sustain impact. To achieve SDG 6 by 2030, we must draw on these conclusions and learn how to incorporate these reflections into future WASH programming.

Social Inclusion

SDG Target 6.2 calls for access to adequate sanitation and hygiene for all, yet it often goes unrecognized that the target emphasizes special attention for the needs of women and girls. WASH issues directly impact gender equality due to the traditional role women play in their homes and in society. As caregivers, women often prepare meals, feed young children, collect water, and manage bathing rituals. These responsibilities lead to a greater need for access to adequate WASH services.

An event convened by the London School of Hygiene & Tropical Medicine, Share, Emory, and Care hosted a discussion on how to create effective policy and practices based on gender-specific needs. While better access to WASH services may improve health and education outcomes, approaches to improve access must challenge the existing stereotype of the woman or girl. As we design programs, we must ask questions rather than make assumptions: What are her needs? Why does she play this role in her family? Does she find joy in what she’s doing? What barriers does she face?

Our discussion focused on gender-specific issues related to food hygiene and child feeding. In this context, a gender-transformative approach not only entails improving access to key WASH services, but also helps communities understand and challenge the social norms that perpetuate inequalities between men and women. This could involve engaging men and boys in ways that support women and girls’ decision making in WASH-related processes. To truly address health inequities, we must include strategies to foster progressive changes in power relationships between women and men moving forward.

Collaboration and Partnerships

Strengthening partnerships and collaboration is crucial to ensure WASH programming is locally appropriate and sustainable. The integrative nature of WASH requires new types of partnerships between research institutions, governments, and private organizations to meet SDG targets. Public-private partnerships, like the Global Handwashing Partnership, leverage different organizational networks and financing mechanisms to achieve one common goal. These collaborative efforts also empower partners to not only be accountable to each other, but to their progress toward SDG targets as well.

The importance of partnerships was further highlighted during several sessions throughout the conference. The plenary session on development effectiveness focused on the Sanitation and Water for All (SWA) collaborative behaviors with focus on planning, coordination, and financing. The integration of WASH with core country systems scales beyond project-based approaches and ensures sustainability. Thus, to achieve universal access to WASH and subsequently the wider SDG agenda, governments must take ownership and strong systems must be in place at the country level. A collaborative decision-making process with accountability mechanisms will ultimately lead to more sustainable, transparent, and transformative solutions.

Moving toward Transformative WASH

Reflecting on my first Water & Health Conference, a quote from Shabana Abas from Aqua for All resonates, “How can we bring different voices into the conversation? How do we get these voices heard at all levels?” If we want transformative WASH, we must first create an enabling environment to host these tough conversations, hold each other accountable, and brainstorm new, innovative ways to grow as a sector. Conferences like this allow stakeholders at all levels to be included in the conversation, bringing science, policy, and implementation actors into one space.

As a sector, we cannot expect different results if we continue business as usual. If we want to meet the SDG targets, we must shift the current trajectory to be more inclusive and create sustainable impact. This requires more practice-relevant research, communication innovations, new partnerships, and better systems management. As we enter a critical period in the SDG era, let us reflect on these lessons learned and move toward transformative WASH together.

Clean Hands Count for Frontline Health Workers

8 January 2019 at 22:02

December 21, 2018 Carolyn Moore and Ebuwa Evbuoma, Global Handwashing Partnership

This post was originally published on the Frontline Health Workers Coalition blog.

A nurse pours water from a pitcher to help the surgeon scrub for a cesarean section at St. Therese Hospital in Central Plateau, Haiti. © 2014 C. Hanna-Truscott/Midwives for Haiti, Courtesy of Photoshare

The ongoing Ebola response in the Democratic Republic of Congo is again drawing international attention to one of the most important things that health workers can do to keep themselves and others safe—wash their hands. Proper hand hygiene, as defined by the World Health Organization (WHO), can prevent the spread of infections, including health care-associated infections and ones that can lead to outbreaks.

Hand hygiene is a critical component of global health security.  However, an estimated 60% of health workers  globally are not adhering to correct hand hygiene practices. In many settings, the root causes include a lack of supplies and infrastructure (such as handwashing stations, piped water, and soap or handrub), high patient caseloads, and limited investments in hygiene behavior change. Only six of the 52 countries that reported water,  sanitation, and hygiene (WASH) expenditures in the 2017 GLAAS report provided data on expenditures specifically for hygiene,  and a 2018 study found that 66% of health facilities in low-and middle-income countries lack soap and piped water for handwashing.

In 2018, the UN Secretary General issued a call to action for WASH in all health facilities. stating, “A recent survey of 100,000 facilities found that more than half lack simple necessities, such as running water and soap —and they are supposed to be health care facilities. The result is more infections, prolonged hospital stays, and sometimes death. We must work to prevent the spread of disease.” This call has been followed by a global response from the WHO, UNICEF, and national governments to improve access to water, sanitation, and hygiene in all health facilities.

At the Global Handwashing Partnership’s Handwashing Behavior Change Think Tank in October, sessions highlighted the need for a realistic, context-based and empathetic approach to behavior change solutions. Robert Dreibelbis of the London School of Hygiene and Tropical Medicine called for handwashing behavior change initiatives to respond to factors that motivate health workers to wash their hands, in contrast to the frequently didactic methods currently in use. Read our 2017 Research Summary for more examples of provider-level behavior change initiatives.

WaterAid Malawi’s Clean Campaign Initiative, which employs participatory behavior change programs and knowledge exchange systems for government and health officials at national and subnational levels to effect hygiene behavior change in health facilities, is one example. At the Think Tank, Allison McIntyre with WaterAid showed how WASH improvements fit into a health systems-wide response. Urgent action for WASH improvements in the health system must include leadership and political will, governance and accreditation, monitoring and targets, research and learning exchange, as well as context-based, affordable technology solutions, such as mobile handwashing stations.

The 2017 global burden of disease study shows that only half of the world’s countries have a sufficient health workforce to provide quality care, but health workers increasingly need to respond to a wide and changing range of public health crises. Read this Lancet editorial for a quick but compelling look at the global health landscape and the  range of challenges that health workers are faced with. This shows that we need to be ready to take on new challenges while speeding up progress against long-standing health challenges.

To be prepared for the future, health workers need training, supplies, and support. They also urgently need something we often take for granted—water, sanitation, and hygiene. Access to WASH infrastructure and specific behavior change initiatives must be a core component of any support to health workers, particularly in emergency situations.

Learn more and contribute knowledge on handwashing in health facilities on the Global Handwashing Partnership’s resources hub.

The 2018 Handwashing Behavior Change Think Tank Through the Lens of a Hygiene Knowledge Manager

22 January 2019 at 17:25

By: Ebuwa Evbuoma, Global Handwashing Partnership

Participants at the 2018 Handwashing Behavior Change Think Tank in Manila, Philippines

The Global Handwashing Partnership’s Handwashing Behavior Change Think Tank events bring together multi-sector hygiene experts to drive learning and action in handwashing behavior change. The 2018 edition was held in the Philippines. It was the first Think Tank held in Asia and hosted 67 participants from 13 countries. The Think Tank presented a diversity of thought and resource potential for next steps in handwashing programming and problem solving.

I joined the Think Tank planning team as the GHP’s Knowledge Management Technical Officer and a Global Health Corps Fellow. In this post, I highlight my reflections of this event; as a young professional working in global health, and as a team member of the GHP Secretariat. I will provide an overview of core themes in this event, and the sessions I found most impactful in each of the three tracks.

Reflections on core themes at the Think Tank

Behavior change across settings

True behavior change requires desire and participation from the target population. This stood out to me from two sessions in particular – one on lessons across contexts, and one on handwashing in emergencies.

The session on Handwashing Behavior Change Lessons Across Contexts featured breakout poster presentations on four handwashing behavior change programs in the Philippines and Malawi. In all four case studies, involving the target community -preschoolers, teachers, healthcare workers and patients- in designing the intervention made a difference in program uptake and ability to scale. For instance, in the HiFive for Hygiene and Sanitation Program by the Center for Health Solutions and Innovations (CHSI) in the Philippines, the hygiene curriculum was co-developed with pre-school teachers, and this collaboration continued with feedback from the teachers during handwashing measurement in the implementation phase.

This track concluded with a session on Behavior Change Lessons in Challenging Contexts. The session defined program gaps in handwashing design for crisis regions, and innovations to address these problems. Field research with program managers revealed that the range of options for handwashing behavior change program design solutions in refugee camps and other settings was simply too broad, and the selection of a solution was often left to their discretion, influenced by previous crisis experience, or ease of availability.

The London School of Hygiene and Tropical Medicine (LSHTM) WASH’Em program aims to address this by tailoring program design to emergency setting needs. WASH’Em tools are hosted on an online platform that encourages hygiene program managers to select handwashing program designs based on evidence and the specific needs of their crisis context. I believe that the adoption of these programs rests strongly on the early involvement of the gatekeepers in the hygiene context under consideration. This ties in with the discussion on human-centered design, which I detail in the succeeding theme.

Design and innovation for behavior change

Modern development work asks implementers to think of target populations as participants and not beneficiaries. Human-centered design solidifies this thinking by asking designers to think only of the needs and desires of communities in achieving program goals. In a shift from traditional plenary style, the Think Tank also featured interactive workshops, one of which was built on these principles.  Designing a Better Handwashing Station explored traditional approaches to designing and delivering handwashing stations, and case studies of stations designed by the more collaborative human-centered design method. As a human-centered design enthusiast, it was rewarding to see representatives from different sectors roll up sleeves and attempt to think through typical biases in handwashing hardware interventions. Evidence-based concerns, such as soap availability and nudges for desired behavior remained motivators in the design cycle, but participants also weighed in practical considerations, such as household location, electricity, and water supply in their prototypes.

The largest highlight for me was the willingness of participants to view handwashing through the lens of target populations. For an event with attendees from over 13 countries, this multi-lens view was a great resource in the quality of engagement and prototype delivery.

Hygiene systems and integration

The successful scale-up of handwashing behavior change implementation has always relied strongly on partnerships and integrating systems. This theme appeared in two health and education sector-focused sessions, which explored policies and case studies in hand hygiene programming. An interesting example was the Department of Education’s program on hand and oral hygiene, rolled out in elementary schools across the country in partnership with UNICEF. GIZ’s WASH in Schools work in South East Asia was another highlight. GIZ uses the Three Star Approach, a standardized index, to measure policy and implementation of water, sanitation and hygiene structure and behavior approaches in schools.

The subsequent session, led by Dr. Robert Dreibelibis of the LSHTM’s Hygiene Center, explored research on hand hygiene behavior change among health care providers, with a case study from a tertiary health care facility in Nigeria. The evidence shows that knowledge has been proven to be insufficient to inform behavior change. Health care workers have knowledge of hand hygiene, but still struggle with balancing large caseloads and insufficient hygiene resources with the motivation to wash their hands at key moments. This point segued into a presentation from Ms. Allison MacIntyre, WaterAid Australia’s Technical Lead, on health systems strengthening for water, sanitation and hygiene behavior change in health facilities.

I found this session particularly interesting, as it resonated with my reflections on hospital WASH policy and practice when I worked as a medical doctor in tertiary care facilities in Nigeria. The hospital I had worked with launched an Infection Prevention and Control Committee (IPC) which was tasked with hand hygiene reforms, but the IPC simply could not maneuver around plumbing or hygiene supply delays. A healthy health system would make all the difference.

Reflections on participation and a pivot from hardware to behavior change

One example of how handwashing programs have shifted from hardware to behavior change was Dr. Om Prasad Gautam’s presentation of WaterAid’s work to change policies. This shift yielded measurable results in Nepal and Pakistan, including governmental collaboration, national level budget inclusion, and measurable behavior change in households. Further, Ms. Kristie Urich, World Vision’s (WVI) Knowledge Capabilities WASH Manager, highlighted learnings from WVI’s review of their over two-decade approach to solving WASH problems in developing countries. The core lesson of this sobering presentation was that participation and behavior change must be centered in the approach to WASH programming. The traditional focus on hygiene hardware, reflected in the large volume of environmental engineers in many WASH teams, must be pivoted to incorporate behavior change experts in program design and implementation.

The third day of the Think Tank featured a pleasant surprise- a collaborative Global Handwashing Day celebration. Over 150 pupils and staff of the Andres Bonifacio Elementary School in Pasay hosted the Think Tank participants at the event. With a school tour, musical performance (of a handwashing song), posters, learn-and-play sessions, and a communal meal called a Boodle fight, participants enjoyed the immersion into the school’s hand hygiene systems.

As a knowledge manager, this event presented a unique glance into the pains and gains of WASH researchers and practitioners, whom the GHP supports with tools, guidance and other knowledge resources. It was an opportunity to think with hand hygiene stakeholders, share experiences and make recommendations that can be carried into handwashing work in different regions.

The 2018 Global Handwashing Partnership Think Tank was co-hosted by the GHP, Procter & Gamble, and the Think Tank Planning Committee: UNICEF, GIZ, FHI 360, World Vision, USAID, WaterAid, and the Philippines Departments of Health and Education. Read more about the Think Tank and view the presentations here.

Amid Neglected Diseases is a Neglected Solution

4 February 2019 at 16:51

By Helen Hamilton. This post originally appeared on the Sanitation Updates blog, here.

Neglected tropical diseases (NTDs) are called neglected for a reason: they’re widespread, painful and debilitating and, at times deadly diseases that prey on the poorest people; yet most are preventable.

Soil-transmitted helminths – intestinal worms such as hookworm, roundworm and whipworm – infect 1.5 billion people, more than half of whom are children. Schistosomiasis is endemic in 70 developing countries, with the vast majority of individuals infected located in Sub-Saharan Africa. 190 million people are at-risk of developing trachoma – a disease that is the single most preventable cause of blindness worldwide and responsible for an estimated $2.9 to $6 billion in global losses in productivity annually. These are just three of over 20 diseases that make up this grouping of NTDs which take a devastating toll on human health, quality of life, livelihoods and national economies, particularly for those in the bottom billion, across 149 countries.

Amidst the devastation brought on by these neglected diseases is a neglected solution. Strong evidence shows that access to safe, sustainable and reliable water, sanitation and hygiene (WASH) interventions plays a critical role in preventing transmission.

For example, basic sanitation can reduce the prevalence of schistosomiasis by more than 75%. Access to WASH services can lower the prevalence of roundworm infections by 29% . Facewashing, in tandem with access to safe water and adequate sanitation, is vital in the prevention of trachoma, comprising the F and E components of the widely-used SAFE strategy: Surgery, Antibiotic treatment, Facial hygiene, and Environmental change .

Despite the recognition of WASH’s central importance in the prevention and treatment of NTDs, the WASH and NTD communities have historically remained silo’d, with few successful examples of collaboration and integration. We hope that is about to change for everyone’s benefit.

To bridge these two disparate communities, the World Health Organization and the NTD NGO Network’s (NNN) WASH Working Group have launched the first-ever WASH and NTDs toolkit, “WASH and Health working together: a practical guide for NTD programmes.”

Based on a range of experiences, the toolkit walks health and WASH practitioners through resource mobilization for joint programming, as well as the design, implementation and evaluation of such interventions with its 22 tools and practices. Now aggregated in one place, these tools have been shown to work in coordinated and integrated NTD control and elimination programs that support collaborative relationships between WASH and NTD stakeholders.

For example, in 2018, Ghana eliminated trachoma. They did so through the type of cross-sectoral action the WASH and NTDs toolkit will enable. The Ghana Health Service first introduced the National Trachoma Control Program and implemented the SAFE strategy in 2001, with the goal of eliminating trachoma in Ghana. Because latrines play a critical role in the long-term control of trachoma, the Program committed to constructing 5,000 household latrines each year to tackle the environmental improvement component of the SAFE strategy. Through a multi-sector and multi-agency partnership, over 12,500 household latrines were constructed in Ghana between 2001-2008. An impact evaluation in 2008 noted that water coverage improved from 50% to 80% and latrine coverage improved from between 0-1% to between 2-38% as a result of this project. The percentage of children with clean faces or faces without discharge rose from 70% to 93% in endemic areas in Ghana. Meanwhile the prevalence of active trachoma significantly reduced from more than 16% to less than 3% in the population. In June 2018, Ghana became the first country in WHO Africa Region to eliminate trachoma.

In northeastern Uganda, WaterAid joined the trachoma elimination programme to better environmental conditions and improve behaviours, such as facial cleanliness, that can sustain the impact of structural efforts. By collaborating with established and trusted WASH partners in the communities, trachoma programmes work alongside and benefit from the infrastructure (access to clean water, latrines, and hand/face washing stations) that these WASH organisations are putting in place, which enable the healthy behaviours connected to trachoma elimination. This work includes incorporating hygiene and trachoma messaging into existing WASH lessons, community meetings, and community-led total sanitation. Bespoke health and hygiene messaging that reflects the environments and communities, such as their lifestyle and dress in northeastern Karamoja, helps people relate to the images and integrate the messages into their daily lives. Integrating trachoma messaging into existing WASH strategies and materials is efficient and eliminates duplicate materials that would run parallel to the other health and hygiene work.

Ghana and Uganda are two of many great examples of cross-sectoral collaboration. The groundbreaking WHO and NNN toolkit promises increased collaboration and integration of WASH and NTD programming – and honors of the 7th anniversary of the London Declaration on Neglected Tropical Diseases and UN Water’s Leave No One Behind campaign. The NTD and WASH sectors share a very worthy goal: sustainable NTD control, elimination and prevention. As we approach 2030, increased collaboration is crucial so that we truly leave no one behind.

About the author: Helen Hamilton is Senior Policy Analyst for Health & Hygiene at WaterAid, UK

Handwashing with soap – where’s the real story?

14 February 2019 at 17:45

By Carolyn Moore, Global Handwashing Partnership

Because I work in handwashing advocacy, my friends, family, and colleagues love to alert me when handwashing pops up in the news. This week, I’ve received a flurry of emails related to a moment when  US-based news host, Peter Hegseth, claimed on air that he hasn’t washed his hands in ten years.

While it was disheartening to hear this from someone with such a large platform, it was an important reminder on why we’re so committed to advocating for handwashing. We can’t take for granted that everyone understands the importance of handwashing with soap. Handwashing is one of the most important things we can do – here are a few of the things I wish were talked about more.

Handwashing with soap prevents disease.

When we wash our hands with soap, the soap removes germs from our hands. This prevents those germs from entering our bodies and making us sick. Handwashing with soap can prevent a wide range of diseases, from the common cold to potentially life-threatening illnesses like pneumonia and the flu. It can also save lives – evidence shows that clean birth practices like handwashing with soap can give newborns a 44% better rate of survival

While there are still other ways to get sick, handwashing is a critical, and feasible, way to reduce our risks. The research base is unequivocal that handwashing protects our health (in 2017 alone, the GHP rounded up more than 100 studies on the importance of handwashing with soap).  When we bypass the sink after using the toilet or before eating, we miss out on those protective benefits.

Handwashing isn’t only to protect ourselves.

Even if we skip handwashing and manage to avoid getting sick- what about the other people in our lives?

Every day, most people have hundreds or thousands of opportunities to spread germs to others. Writing this in the morning, I have already lost track of all the times my hands may have spread germs to someone else. I high fived someone in my exercise class, held on to the same pole as someone else on the bus, shared breakfast with my husband, and shook hands with a colleague in a meeting. Most of us simply can’t remember everything we touch, but we can remember the critical times to wash our hands.

By washing our hands at these times, (for example after using the bathroom, and before cooking or eating), we can reduce the risk of everyday contact making us sick. This is a simple way to avoid infecting others and becomes particularly important when interacting with people at higher risk, like young children, older people, and people with certain health conditions.

Lack of handwashing can- and does- lead to very real losses.

While there has been a lot of news coverage about Hegseth’s unwashed hands, I often wish there were more coverage of the tragic losses that take place every day. Let’s look at just two of the diseases that handwashing is known to prevent – pneumonia and diarrhea.

According to the Global Pneumonia and Diarrhea Progress Report, pneumonia and diarrhea cause nearly a quarter of deaths of children under five. In 2017, nearly 5.7 million children died before their fifth birthday. This means that more than twice as many children died of pneumonia and diarrhea in a single year than there are people living in Washington, DC. This information is not common knowledge – in this year’s letter from Bill and Melinda Gates, even those global health leaders expressed initial surprise at learning how many children die from these causes.

Handwashing with soap can prevent 47% of diarrheal diseases, and 16% of respiratory infections like pneumonia. Hundreds of thousands of lives could be saved by ensuring that people know the importance of handwashing; have access to soap, water, and a place to wash their hands; and develop proper handwashing habits. At the Global Handwashing Partnership, we’re proud to bring together partners who work every day to make this a reality.

Handwashing isn’t a given, but we can change this.

Handwashing with soap simply isn’t happening enough. Around the world, only an estimated 19% of people wash their hands with soap after contact with excreta. Globally, rates of household access to a place to wash hands range from nearly 100% to less than 10%. Even medical professionals aren’t perfect– only about 40% are estimated to clean their hands at all critical times.

There are some immediate things we can all do to change this. First, wash your hands with soap at all critical times, and encourage others to do the same. Make sure that there is a good place to wash hands (stocked with soap and with water available), in your home, school, or workplace. Finally, public health and development organizations from all sectors should continue to promote effective handwashing behavior change in research, policy, programs, and advocacy.

To learn more about how to advocate for handwashing behavior change, visit our advocacy page and advocacy resources.

Leave No One Behind: Advocacy & Action for Universal WASH

22 March 2019 at 12:00

By: Aarin Palomares, Global Handwashing Partnership Secretariat

On World Water Day, the Global Handwashing Partnership is thrilled to announce that the 2019 Global Handwashing Day theme will focus on “Clean Hands for All.” We will continue advocacy efforts focused on leaving no one behind by emphasizing more equitable approaches, sharing success stories, and advocating for better hygiene for all. This is part of a year-long effort in partnership with advocacy days like World Water Day and World Toilet Day to highlight universal access to water, sanitation, and hygiene (WASH).

The goals set forth in the SDG agenda are abundantly clear. For SDG 6, that means water, sanitation, and hygiene for all by 2030. This World Water Day, we emphasize water as a human right, with special focus on marginalized groups, such as women, children, refugees, indigenous people, people with disabilities, and so many others who are often overlooked when addressing water issues. As we celebrate World Water Day, we must also think about how we use water and the key behaviors that can impact our health and well-being. Handwashing with soap is a simple, yet often neglected act. In order to achieve handwashing equity, access and behavior change messaging must reach those who are often overlooked or left behind.

What does leave no one behind mean?

When the Sustainable Development Goals launched, there was a commitment to universal access and to leaving no one behind. In committing to the realization of the Sustainable Development Goals, it is important to put these commitments into practice, recognizing that these targets must be met by all – all nations, all people, and all sectors. This is a testament to a more collective and shared process for development moving forward. This commitment means more than just a pledge; it means taking explicit actions to curb inequalities and confront discrimination to ensure progress for those furthest behind.

A discussion paper by the United Nations Development Program defines the key factors in addressing who is left behind. These include: discrimination, governance, socioeconomic status, geography, and shock and fragility. Accordingly, an individual’s gender, disability status, ability to access services, geographic setting, and other individual factors could make them more vulnerable to certain outcomes. For example, a project in Bangladesh found that 73% of women who worked at a factory missed an average of 6 days of work during their menstrual cycle. Failing to recognize gender dimensions often leads to policies and interventions that do not serve women’s needs, causing loss of productivity and economic challenges for these women. Likewise, only 23% of refugee adolescents attend secondary school compared to the world average of 84%. Transitional settings, such as refugee camps, make it increasingly difficult for these individuals to receive the education they deserve.

Access to WASH can vary by location (rural/urban), socioeconomic status, gender, and other factors. For example, while Angola has relatively high coverage for drinking water, there is a 65% gap between the richest and poorest individuals in the country. Likewise, in the slums of Jakarta, Manila, and Nairobi, individuals pay 5-10 times more for water than those living in high-income areas. Basic WASH coverage is also higher in urban schools compared to rural schools. In Tanzania, there is a 37% coverage gap in hygiene facilities between urban and rural schools. Groups who have lower access to adequate WASH facilities and behavior change programs have a higher risk for diseases that can adversely impact their health, education, and economic outcomes. We must prioritize and track the progress of the furthest behind if we want to address the drivers that create these disparities.

From pledge to practice

In 2010, the United Nations General Assembly explicitly recognized the human right to water and sanitation. While this pledge establishes an important step toward WASH equity, we must take action to address key barriers that perpetuate these inequities among certain groups.

Here are some practical examples of successful actions others have taken to address WASH equity:

1. Mum’s Magic Hands is a program developed by Oxfam and Lifebuoy (Unilever) to encourage handwashing with soap at key times in emergency affected communities. The program is customized to support community health workers in reaching mothers in camp settings, and utilizes storytelling, games, and nudges to increase handwashing behavior. In Nepal, the program saw a 45% increase in handwashing with soap after using the toilet, an 18% increase in handwashing with soap before eating, and a 17% increase in handwashing with soap before cooking. By focusing on motivating factors, such as nurture and affiliation, the program is able to change handwashing behavior among mothers in emergency settings.

2. In 2004, the Ethiopia WASH movement was launched under the Water Supply and Sanitation Collaborative Council (WSSCC). Ethiopia was ranked 105 out of 108 on the human poverty index with high rates of sanitation and hygiene-related diseases. The WASH Ethiopia Movement sought to promote improved WASH and gain political and social commitment within the country. It offers a good example of successful coalition building. Through the movement, WASH sectors were able to better coordinate with one another to gain attention from the government and other agencies. Through mobilization and strategic advocacy initiatives, the movement contributed to the development of a National Hygiene and Sanitation Strategy Protocol.

3. A program by Mougnousi, an association led by people with disabilities, along with its partners, World Vision and Messiah College, used innovative ways to overcome accessibility barriers for persons with disabilities in Mandiakuy, Mali. This included modifying water pumps, providing guides for those who are blind or visually impaired, and capacity building trainings around inclusive hygiene promotion messaging. The impacts of the project include accessible facilities in the community, allowing members of the association to become independent from their neighbors for many WASH matters. It was also successful in delivering WASH training that was inclusive to those with disabilities. Because people with disabilities were involved throughout every stage of the project, they were able to make decisions throughout the process, ensuring the community was more accessible to their needs.

Beyond a tagline

We are well into the Sustainable Development era, and thus far, several trends have stood out in this fight for equitable WASH. Focusing on marginalized groups, institutions, countries, and settings, and finding innovative ways to address unique needs is crucial in ensuring WASH for all. Now, we are at a turning point between stagnation and truly transformative progress. This year-long campaign focused on “leave no one behind” only reiterates the promise made when developing the Sustainable Development Agenda.

Global events, like World Water Day and Global Handwashing Day, present important opportunities for us to capitalize on this message throughout the year. However, this has to be more than a tagline. If we want to ensure we meet SDG 6, we must continue to make more ambitious goals, use more integrative approaches, and actively include those who are furthest behind in our work.

Join us in advocating to leave no one behind beyond World Water Day, and pledge to work toward inclusive WASH year-round. As Global Handwashing Day approaches, our Partnership will be releasing new materials to help support your advocacy efforts. Learn more at www.globalhandwashing.org.

Focusing on the H in WASH: New Insights into Why Handwashing and Hygiene are Key for Child Health and Growth

8 April 2019 at 16:00

By: Julia Rosenbaum, FHI 360

As handwashing advocates and programming implementers, we work to ensure that attention and funding go to the neglected ‘H’ in WASH, to handwashing and hygiene. However, we know that handwashing alone will not ensure the health and other gains we seek. A recent review provides a new perspective on one key set of practices that may need to be addressed alongside handwashing.

Emerging evidence and analysis suggest that household hygiene may play a much larger role in the growth of infants and young children that previously established. But unfortunately, the implications for hygiene programming aren’t yet too clear. In this post I review what we know so far, what we don’t know, and how we can begin to incorporate household hygiene into WASH work.

Why does stunting persist? What we know so far

Despite decades of nutrition and integrated interventions, about one quarter of children under age five are stunted, with the vast majority living in low- and middle-income countries. (UNICEF, WHO, & World Bank 2015). Inadequate diet and poor water, sanitation, and hygiene (WASH) conditions predispose infants and young children to a debilitating cycle of infections and undernutrition in early life. Stunting is not only low height for age, but also brings cognitive and developmental stunting affecting learning and earning potential later in life; and perpetuating cycles of poverty and misery.

But mounting evidence may shed light on why child growth stunting persists, even with comprehensive WASH and nutrition programming. Chronic exposure of infants to high loads of fecal microbes has been hypothesized to be a significant underlying cause of child growth faltering. This exposure causes environmental enteric dysfunction (EED), a condition where the lining of the small intestine becomes inflamed. EED shows that constant fecal assault on the gut of infants changes the shape and function of the intestine, making it harder to absorb much needed nutrients, and setting an infant’s body into overdrive to try and resist all the filth and infection. EED is thought to explain why even the most rigorous and comprehensive dietary interventions have only a modest effect on reducing child stunting.

Notably, EED and subsequent stunting can happening independent of the effects of diarrhea, so that an infant without symptoms may still suffer from EED. Risk has often been assessed using diarrhea as the primary outcome, potentially missing the key link between various exposures or interventions and growth. For nearly six decades, WASH interventions have been guided by a seminal “F-diagram”, which traces how uncontained feces work their way into water and food via fluids, fingers, flies, fields (floors, earth, dirt), fomites (surfaces) (Wagner & Lanoix, 1958). WASH interventions traditionally focused on “blocking” these transmission pathways through increasing access to an improved water supply, improving drinking water quality, and refining hand hygiene and sanitation measures.

But for infants and young children, the classic F diagram misses some key sources of fecal exposure, as well as pathways of transmission.

The USAID Water, Sanitation, and Hygiene Partnerships and Learning for Sustainability (WASHPaLS) project conducted a review of the scientific and gray literature, to synthesize the latest understanding of key pathways of fecal microbe ingestion specifically affecting infants and young children (IYC), the relative potential importance of the various pathways in terms of magnitude of pathogen transmission, and how to best mitigate them. The review included 160 articles, and was complemented by dozens of key informant interviews with researchers and field implementers. The full text of the review can be accessed here.

What is New? Key Findings on Neglected Sources and Pathways of Transmission

Domestic animal waste: The abundance of uncontained animal feces in developing countries is an important and historically underemphasized source of pathogens and fecal microbes in the domestic environment and water supply sources. Domestic animal husbandry is common among rural populations, and multiple studies document significant sources of animal fecal contamination in the domestic environment, including both poultry and ruminants, spanning South Asia, East Africa, and South America. However, animals also bring nutritional benefits from increased food access as well as the increased household income. The data are inconclusive about the overall impact when positive and negative are weighed.

The ingestion of soil (geophagy) and mouthing of household objects: Infants and young children ingest dirt and feces through exploratory mouthing of soiled fingers, toys, and household items as well as by directly ingesting contaminated soil and/or feces. Babies learn about their world by putting almost everything that they can reach into their mouths, and this exploratory mouthing also assists cognitive and motor development and provides comfort. Soil ingestion among IYC has been widely observed and associated with increased risk of both disease (diarrhea and worm infection) and growth faltering.

Unsafe disposal of infants and young children’s feces: The highest levels of unsafe child feces disposal are found among poor, rural households; among the youngest children; and where other household members were practicing open defecation. However, unsafe practices are found even in households with improved sanitation. Unsafe management of child feces is linked with growth faltering and higher odds of detecting E. coli in areas where children play.

Based on existing evidence, we suggest that traditional WASH measures aren’t enough to address the exploratory mouthing behaviors that are a key part of early childhood development, nor to address exposure to domestic animal feces.

So, what then, are appropriate measures?

As advocates and evidence-based implementers, we need to beat the drum to get more attention towards a hygienic environment for infants and young children. But current evidence doesn’t yet suggest a clear programmatic pathway forward.

A revisioning of the F diagram illustrating sources of exposure to fecal pathogens, transmission pathways, and measures to block transmission

Emerging Interventions

Our review identified 17 service delivery programs employing measures that fall within the scope of protecting infants and young children from exposure to feces. These included the distribution or sale of playmats and playpens and promotion of behavior change interventions directed at corralling animals away from children and generally keeping courtyards clean. Several researchers have also turned their sights to the effect of various products and behaviors at reducing exposure. Current interventions fall into three general categories:

Barriers: Efforts have been made to construct barriers to keep animal feces out of the home environment, and to prevent associated ingestion of soil and animal feces. These barriers include finished flooring; improved animal husbandry practices; playmats for immobile infants; and a playmat/playpen combination for crawling and mobile infants.

Animal Feces Management: Interventions to protect infants and young children from pathogens in animal feces have focused generally on day- and/or nighttime separation of children and animals, improved corralling, and courtyard cleaning.

Safe Disposal of Child Excreta: Existing interventions promote the safe disposal of feces using approaches ranging from general “safe disposal” messaging to age cohort-specific behavioral programming targeting feasible but improved disposal practices, such as locally-crafted reusable diapers, sani-scoops, potties, and child-friendly latrines.

Assessing the true potential of these interventions requires a better understanding of the behavioral feasibility of the intervention, as well as the biological plausibility or effectiveness. To date, we know little about thresholds of exposure as they affect disease and child growth. For instance, if an infant is placed in a playpen instead of on the ground for four full hours in the day, but then comes out, crawls to her father’s cast-off gumboot and starts mouthing the shoe, did those four hours help at all?

As with any behavior-centered programming, we also need to better understand the behavioral feasibility of the practice. Cooping chickens during the day time may not be feasible given the dependence on free-range feeding and preference for meaty yard hens, for instance. Do households consider the proposed behaviors feasible and appealing?

Likewise, current interventions to protect infants and young children from exposure to pathogens found in animal feces focus on disposal of animal feces, when in fact many households value these feces as fertilizer, fuel and building material. Additional research is required to explore the safe management of productive feces in the household.

Beyond behavioral feasibility and effectiveness, additional research is also needed to investigate the adoption, constraints, and scale-up potential of these and other measures to reduce exposure to fecal pathogens. Researchers are starting to address these questions from a variety of angles and will provide much needed data to guide programming.

What does this mean for handwashing and hygiene advocates?

It is well documented that infants and young children will go hand to mouth with soiled objects, suck on their fingers, eat handfuls of contaminated dirt and even chunks of poultry excreta. However, we don’t have consensus on whether it is behaviorally feasible or biologically effective to promote handwashing for infants and young children. Damp hands will pick up more dirt, that will then be licked off; drying is often done with contaminated towels or clothing that may introduce more pathogens than washing eliminates. At the same time, in addition to reducing pathogens on hands, washing the hands of infants and young children gives an early start to handwashing habits throughout life, and sets a clear social norm. Despite a lack of clear consensus, most BabyWASH activities include periodic washing of young children’s hands, particularly before feeding.

The emerging research clearly points to the need to address the neglected pathways and focus on assuring a more hygienic environment. This shift to more comprehensively addressing the environment cannot be underestimated if we are to begin to address these neglected sources and pathways. We know that clean hands are important but not sufficient, and we are learning more about what is required to establish and maintain an environment where children can explore and develop without the devastating consequences of sickness and stunting. Monitoring a child’s environment, clearing areas of visible feces, taking action when the child reaches for dirt and feces, maintaining the cleanliness of toys and any object within reach of the child, and other measures are all essential components of such a hygienic environment.

Editorial Note: This post is part of our #AsktheGHP series. Learn more about #AsktheGHP here. To submit a question, e-mail the Global Handwashing Partnership Secretariat at contact@globalhandwashing.org or use #AsktheGHP on social media.

Let’s Make Water, Sanitation and Hygiene Inclusive!

11 April 2019 at 14:00

By: Kristin Hughes Srour, Special Olympics International

In Malawi, a group learns how to build a tippy tap and about the practice of washing hands with soap and water. In Nigeria, family members are provided Packs H2O backpacks to carry and store water. In Indonesia, Red Cross provides handwashing education to community members. In UAE, people at health education stations organized by Special Olympics hum the “Happy Birthday” song twice to help time washing their hands thoroughly with soap and water for 20 seconds.

What these examples have in common is an often neglected group – people with intellectual disabilities (ID). In each one of these instances, they received an opportunity to learn about water, sanitation and hygiene or WASH.

The Problem

Nearly 2.1 billion people alive today lack access to safe drinking water and 4.5 billion people are without access to safely managed sanitation.[i] Globally, diarrhea is the second leading cause of death among children under five, killing more children than malaria, AIDS and measles combined.[ii] It is estimated that 88% of diarrheal disease is caused by poor water, sanitation and hygiene.[iii] Yet, handwashing with soap alone can reduce incidence of diarrhea by more than 40%.[iv]

Although access to safe water and sanitation is a right included in the UN Convention on the Rights of Persons with Disabilities (CRPD) (Article 28 focuses on the right of people with disabilities “to an adequate standard of living for themselves and their families; this includes State Parties duty to ensure equal access to clean water services.” ), it is widely accepted that people with disabilities face particular challenges accessing safe water and sanitation.[v][vi] Not only are people with ID at increased risk of WASH-related disease, they are also less likely to receive the necessary treatment and care. This inequality in terms of access to safe water is an unjust life-and-death risk for people with ID.

There are a number of barriers that prevent people with ID from accessing water and sanitation resources, including stigma and discrimination, physical/structural barriers, and poor access to appropriate health and WASH education. On the rare occasion that disability is factored into WASH infrastructure designs, adaptations tend to focus on the needs of people with mobility issues. Very rarely does planning consider the needs of people with ID, especially tailored health literacy and education programs designed to reach individuals with ID, a disability subset with one of the lowest access-to-education rates in the world.[vii] As a result, people with ID may not receive the education or awareness on the need to practice hygiene and require outreach outside of schools and resources that can be understand by all, despite literacy levels.

In addition, since 1998 UNICEF and partners have promoted the WASH in Schools model. Considering an estimated 90% of children with disabilities in developing countries do not attend school , they are excluded from the benefits of these interventions.[viii]

Although much has been achieved in WASH programming over the past two decades, great disparities in water and sanitation access still exist and there is much to be done to reduce inequity among the poor as well as individuals and families of people with disabilities.

Finding Solutions

With inclusive programming in over 170 countries, and engaging over 5 million athletes, Special Olympics is a global inclusion movement using sport, health, education and leadership programs every day around the world to end discrimination against and empower people with intellectual disabilities.

Special Olympics Programs in Nigeria, Malawi and Uganda have used innovative programs to ensure sustainable WASH education for individuals with ID and their families. In Nigeria, in partnership with the UNICEF Nigeria Country Office, UNICEF specialists attend Special Olympics’ Family Health Forums and offer didactic and practical education programs for families on proper hygiene, proper sanitation, and ways to share this important information with their children. Special Olympics Uganda has held similar Family Health Forums on hygiene and cholera prevention. In partnership with the national Ministry of Health and village elders, Special Olympics Malawi has used the leadership and expertise of community health workers (CHWs) to provide ongoing WASH education and practice to children and adults with ID and their families. Special Olympics Malawi has also partnered with Catholic Relief Services and the Ministry of Education to deliver WASH education to children with ID and their family members at special schools in Lilongwe. At Special Olympics Healthy athletes events across the globe, handwashing is a core component to the health promotion education offered.

As we reflect on World Water Day and all the incredible progress being made globally, how will you do your part to ensure that people with disabilities are part of the solution? Will you join Special Olympics in our goal of #inclusivehealth?


[i] WHO/UNICEF Joint Monitoring Programme (JMP) Report 2017 update – See more at: https://www.who.int/news-room/detail/12-07-2017-2-1-billion-people-lack-safe-drinking-water-at-home-more-than-twice-as-many-lack-safe-sanitation

[ii] UNICEF/WHO, Diarrhoea: Why children are still dying and what can be done (2009).

[iii] Black RE, Morris S, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361(9376):2226-34.

[iv] Curtis V & Cairncross S. Effect of washing hands with soap on diarrhea risk in the community: A systematic review. The Lancet Infectious Diseases 2003;3:275-81.

[v] Convention on the rights of persons with disabilities and optional protocol (2006). http://www.un.org/disabilities/convention/conventionfull.html

[vi] The state of the world’s children (2013): Children with disabilities. http://www.unicef.org/disabilities/files/Final_Flyer_WASH.pdf

[vii] Briefing note: What the Global Report on Disability means for the WASH sector (2013). https://washmatters.wateraid.org/publications/what-the-global-report-on-disability-means-for-the-wash-sector

[viii] http://portal.unesco.org/education/en/ev.php-URL_ID=32969&URL_DO=DO_TOPIC&URL_SECTION=201.html.

Photos courtesy of Special Olympics International.

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.

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.


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.

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.


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.

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.