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Before yesterdayGHP Blog

Manila Water Foundation Helps Bring Hand Hygiene for All

October 26th 2020 at 19:32

In the Philippines, Manila Water Foundation (MWF) is the only local organization that is a member of the Global Handwashing Partnership (GHP).  MWF is the social development arm of Manila Water, a water utility subsidiary of the Philippines’ oldest conglomerate, servicing over seven million people in Metro Manila. Founded in 2005, MWF aims to enable change through sustainable water access, sanitation, and hygiene (WASH) education in marginalized communities in the Philippines.

In celebration of the 2020 Global Handwashing Day, MWF continues to build on its parent company’s strengths to contribute to the global campaign, using a participatory, responsive and holistic approach. Through its Health in Our Hands (HiOH) Program, MWF furthers the advocacy of handwashing with soap and clean water as a way to prevent communicable diseases and illnesses such as COVID-19.

Anchoring on this year’s theme, “Hand Hygiene for All”, MWF highlights inclusivity with its wide-ranging campaign, reaching as many people as possible, even in a time of restricted movement and physical distancing.

MWF embarked on a month-long celebration of Global Handwashing Day with several initiatives in October, aimed at addressing the issue of water access, sanitation and hygiene, and providing access to the information, supplies, and facilities needed for safe handwashing across the three island groups in the country – Luzon, Visayas, and Mindanao. This includes the construction of handwashing facilities across the National Capital Region, starting last October 12 with the installation of a 10-faucet hygiene facility at the Ramon Magsaysay High School in the City of Manila, followed by turnover of hygiene facilities at the Marikina Sports Center, and more installations at the La Mesa Ecopark and at the Tahanang Walang Hagdanan, an institution providing services to persons with disabilities.

On October 15, MWF organized a virtual celebration bringing together collaboration partners from the public and private sectors such as the GHP, the Department of Health, Department of Education and UNICEF Philippines. MWF partnered with Procter & Gamble, Safeguard Philippines and PHILUSA Corporation, for the distribution of thousands of hand hygiene supplies to city jails, orphanages, homes for the elderly, indigenous communities among the Mangyans in Mindoro and the Dumagats in Sitio Calawis in Antipolo City, Rizal. Hygiene supplies and information and education materials will also be provided to public institutions in Boracay, Cebu City, Davao City and Zamboanga City.

For more information about this year’s MWF Global Handwashing Day celebration and HiOH program, you may refer to the website here.

 

Global Handwashing Day Interview with NNN Vice-Chair, Arielle Dolegui

October 16th 2020 at 14:02

This interview was originally posted on the Neglected Tropical Disease NGO Network website.

Combining hand hygiene and broader water, sanitation and hygiene (WASH) interventions with NTD programs is one of the most cost-effective ways to improve public health. WASH, including hand and face washing, prevents NTDs like trachoma, soil-transmitted helminthiasis (STH), schistosomiasis and Guinea worm disease, and is needed for safe and dignified treatment and care. Hand hygiene is also effective at preventing other infectious illnesses, such as COVID-19. To commemorate Global Handwashing Day 2020, the NTD NGO Network (NNN) has committed to ensuring hand hygiene for all. It strives to support cross-sectoral political leadership, create an enabling environment, and promote sustainable and inclusive programming at scale.

Cross-sectoral partnerships are nothing new for NNN’s Vice-Chair, Arielle Dolegui. As a Technical Advisor for Health Systems Strengthening and Cross-Sector Coordination at World Vision, supporting the USAID-funded Act to End NTDs | West program, Arielle brings to the NNN a wealth of experience at the intersection of WASH, NTDs and education.

For Global Handwashing Day today, NNN WASH Working Group Chair and Director of Policy and Communications at the SCI Foundation, Yael Velleman, interviewed Arielle for her insights on the challenges and opportunities for coordinated programming, as well as the role of the NNN in driving this work forward and at scale as to realize hand hygiene for all.

As a Technical Advisor to World Vision, you’ve worked at the intersection of WASH, NTDs and education. Please tell us about your experience, and the impact you’ve seen on-the-ground from such coordinated programming.

In my role at World Vision, supporting the USAID-funded Act to End NTDs | West program, we have supported the institutionalization of cross-sector coordination of NTD programs. For example, we have supported the Ghana Health Service/National NTDP with the revamping and relaunch of their multi-sector coordination mechanism–the Intra-Country Coordinating Committee (ICCC)–to facilitate integration of NTDs into the national health systems’ priorities and policies and engage key sectors such as WASH and education for joint planning and implementation to sustain the elimination and control objectives of NTDs in Ghana. This has been a tremendous achievement on-the-ground as streamlined cross-sector collaboration remains the cornerstone strategy for effective NTD programming and a testament to country ownership and political will to move the NTD sustainability agenda forward. In Senegal, Sierra Leone, and Niger, we have also supported the Ministries of Health leadership in restructuring their multi-sectoral interventions, leveraging existing robust partnerships with the education sector while building and strengthening the nascent collaboration with the WASH sector to support both service delivery integration as well as behaviour change strategies and interventions.

The WASH UP! Initiative you lead teaches children proper hygiene practices to prevent NTDs via muppet ambassadors, Raya and Elmo. What additional innovations are needed to promote and sustain behaviour changes? How can the NNN promote such best practices?

WASH UP! is a school-based program that World Vision implements in over 11 countries in collaboration with Sesame Workshop and Ministries of Education. This program was expanded to include NTDs, specifically schistosomiasis and STH, as a pilot in Ghana and Niger. The play-based curriculum aims to promote positive WASH attitudes and behaviours among children and their school communities, including those with disabilities, with a focus on vulnerable populations. Targeted behaviours in the WASH UP! curriculum include safe water and food practices, increased latrine use, improved waste management, consistent handwashing, good personal hygiene, and kindness to all, including those who are sick and/or disabled.

World Vision has a long history of providing clean water and access to sanitation for millions of children and their families, a critical element in the prevention of NTDs. World Vision’s WASH programs focus on five key aspects: capacity building, sustainable water supplies, hygiene behaviour change, sanitation, and strengthened networks and management capacity among various stakeholders, including both government and communities. Recent projects include constructing and rehabilitating community latrines, digging wells, mobilizing communities to be declared Open Defecation Free, and promoting handwashing. In Zambia, World Vision supported the School Health and Nutrition Program, operated by the Ministry of Education in collaboration with the Ministry of Health, to leverage infrastructure and financial resources for NTD-focused health education curriculum. Other projects in Malawi and Uganda have also contributed to reduced prevalence of blinding trachoma through increased uptake of hygiene and sanitation practices and strengthened capacity in planning, coordination, and monitoring of trachoma control programs.

As for the NNN, via the WASH Working Group we are currently surveying the community of practice to identify WASH and NTD research priorities, from WASH-related determinants of NTDs to implementation research for improved coordinated programming to evaluating impacts of such joint efforts. Plans to develop a technical resource on behaviour change are also underway. These are only some of the examples of how the NNN is promoting best practices for NTD elimination and control.

Your career has focused on developing cross-sectoral partnerships, which will be critical toward achieving the goals laid out in the WHO 2030 NTD Road Map. What challenges persist for WASH and NTD coordination, and what role do you see for the NNN in helping the NTD community overcome these barriers?

While WASH is critical to NTDs, current major WASH providers are not seen as NTD players as they are not participating in NTD control or elimination activities in most countries. There is also a lack of interest in partnership due to limited funding and capacity. Across countries, barriers in effective NTD-WASH coordination and collaboration include: 1) siloed program design and insufficient joint implementation; 2) limited advocacy and communication strategies on NTDs and missed opportunities to raise awareness of NTDs and their impact on public health and economic growth among WASH partners; 3) coordination mechanisms largely driven by donor funding and priorities; and 4) limited coordination and planning with relevant partners from the WASH, education, and health promotion sectors to leverage on their existing platforms to support NTD program activities.

Fortunately, The BEST framework–Behaviour, Environment, Social inclusion and Treatment and care–launched by the NNN in 2016, provides a guide for the NTD community in terms of advocacy messaging, coordinated action and funding. In addition, the NNN and WHO toolkit released last January in English and French, provides a number of tools for WASH and NTD practitioners to work better together. As it is Global Handwashing Day, I’ll emphasize two such tools: a resource on NTD-related behaviours and a guide to understand behaviours for developing behaviour change interventions. Addressing behaviour change is core to our efforts to beat NTDs, both in terms of prevention through hand and face washing, as well as the promotion of care-seeking behaviours.

COVID-19 has been immensely disruptive to many public health programs, including delaying mass drug administration activities. At the same time, however, it has also created unprecedented momentum for WASH. How is the NNN responding to this urgent need, while also strengthening coordination with the WASH sector to ‘build back better’ toward 2030?

Last month, the NNN convened its annual conference, the theme of which was building resilient NTD programs in a changing world. COVID-19 was but one focal point at the conference, during which attendees noted the resulting challenges, but also this opportunity to ‘build back better’ against future existential threats. WASH was a thread throughout the conference, including exceptional workshop sessions on behaviour change programming and evidence-based, cross-sectoral programming. The NNN, through the annual conference and monthly WASH Working Group meetings, provides a unique knowledge-sharing and action-based platform to strengthen coordination between WASH and NTD stakeholders.

Individual NNN members have also led the way on WASH and NTD coordination in response to COVID-19. The NALA Foundation, for example, with the support of The END Fund, is scaling up its WASH efforts in NTD-endemic areas to address both NTDs and COVID-19. This has included the construction and placement of 100 handwashing stations in public areas, including healthcare facilities. Additionally, several members recently pitched the Bill and Melinda Gates Foundation and other partners at the NTDs Idea Forum–launched at our recent NNN conference–on the opportunity to integrate WASH messaging and programming with COVID-19 and NTDs efforts.

World Vision has also leveraged its NTD partnerships to provide technical assistance to Ministries of Health, such as the Ghana Health Service/Ministry of Health (MOH/GHS) and the Senegal Ministry of Health and Social Action (MSAS), on their COVID-19 responses to enhance their cross-sector collaboration with WASH Ministries. In Ghana, the MOH/GHS is working with the Ministry of Sanitation and Water Resources and the Ministry of Education on policies, strategies, and programs for the provision of safe water sources, rehabilitation of environmental sanitation facilities, and dissemination of hygiene promotion messages. For instance, the Community Water and Sanitation Agency provided free water access to all Ghanaians in rural areas for 3 months to help stem the spread of COVID-19. In Senegal, the national response coordination platform for COVID-19 is led by the Centre des Operations d’Urgence Sanitaire mandated by MSAS. Implementing partners, including World Vision, constructed and rehabilitated WASH infrastructure and sensitized community actors at healthcare facilities, Daaras, mortuaries, and households on hygiene practices to reduce COVID-19 exposure and transmission.

To mark Global Handwashing Day this year, the NNN has issued a statement reaffirming and even expanding upon its commitment to WASH. What message do you want to send to the NTD community regarding hand hygiene for all?

The NNN is committed to hand hygiene for all and WASH more broadly as to sustainably eliminate and control NTDs. Our commitment to this issue covers political leadership for cross-cutting WASH and NTD policies, budgets and coordination mechanisms; an enabling environment that fosters collaboration between our sectors and a lively exchange of experiences and best practices; and, finally, sustainable, inclusive programming at scale through our work to develop technical resources and a research agenda for behaviour change interventions. The NTD community, including and beyond the NNN, has and will continue to be an effective partner to the WASH sector; however, as we look to the next decade and the Sustainable Development Agenda, it is evident that we must identify new and better ways to work more effectively together as to fast-track progress. I call on NNN members and the wider NTD community, including NTD-endemic countries, development partners, donors and the WHO, to prioritize critical WASH investments and interventions in NTD-endemic areas, reinforce hygiene behaviours for NTDs and promote joint leadership at the local and ministerial levels toward these ends. This collaboration is needed to achieve hand hygiene for all and a generation free from NTDs by 2030.

Maximizing Handwashing Behavior Change Through Multiple Community Engagement Tactics

October 14th 2020 at 22:13

By: Sona Sharma and Armelle Sacher, Action Against Hunger

To promote hygienic behaviors, we must communicate and engage with communities across a variety of communication channels. In Uganda’s Kyangwali refugee settlement, Action Against Hunger’s social and behavior change efforts went beyond the simple dissemination of messages through multiple channels to also include specific tactics for enhanced engagement with communities. The efforts bore fruit, bringing about changes in handwashing behaviors.

Photo Credit: Sona Sharma, Action Against Hunger

Action Against Hunger, as a member of a project consortium supported by the European Union, aims to address immediate basic needs and increase resilience through an approach that puts people at its heart. Our efforts to improve access to clean water, safe sanitation, and good hygiene includes a variety of activites, including a ‘Cash for Latrine’ intervention and behavior change interventions to promote critical behaviors around handwashing, use of latrines, and safe disposal of child feces.

When the project began, just 43% of households in Kyangwali had handwashing facilities and only 32% of the household could list three critical moments for handwashing. Action Against Hunger conducted formative research to identify the main factors influencing hygiene behaviors in addition to the community’s preferred communication methods.

Based on our findings, we implemented a social and behavior change (SBC) strategy that included strategic engagement with communities through multiple platforms and channels, such as group sessions and home visits, community-based video shows and dialogues, drama shows, radio spots and talk shows, and rigorous follow up through hygiene promoters.

“The drama shows were very well done, and we learned that it is not good to use a latrine without a hand washing facility because the family members fell sick when they used the latrine and did not wash their hands after doing it.” – Caregiver for child under two years old

One unique aspect of this intervention was that every activity was planned in great detail to ensure it is connected with other activities for better recall, that there is two-way communication with communities and they are followed up to track behavior change. For example, a community-based participatory process was adopted, where community members, hygiene promoters, and local drama groups collaborated with professional actors and filmmakers to create and produce two video shows about handwashing and good hygiene. This tactic benefitted the video shows, since the audience related to known settings and were excited to see people they knew in the film. It also benefitted the drama shows as people recognized the actors from the film, thereby resulting in better engagement of the audiences.

“Videos taught us to use water and soap to wash hands when we are going to eat and that if we eat food without washing hands we shall get diseases as we saw on the video show” – Community Leader

The videos were screened in public venues and used to spark interactive discussion around hygiene. Every activity with the community members, whether a video show, a sensitization session or a drama show included interactions with people and ended with a request for commitments to adopt the promoted behaviors. Hygiene promoters then followed up on these commitments during their home visits. People from the community also participated in radio talk shows, by serving on panels or calling in to ask questions and clarify doubts.

Communities were not just passive recipients of messages, but active participants in every SBC activity. The results, within a short intervention time, reveal the potential of such a participatory approach.

In March 2020, a qualitative assessment of the effectiveness of the SBC component reported that project beneficiaries had very good knowledge of the five hygiene behaviors promoted through the intervention. The most prominent motivating factors for adoption of handwashing were the facts that handwashing prevents diseases such as cholera and Ebola and that families, especially those with young children, would be healthier with regular handwashing.

“Hand washing is easy because of the installation of the tippy tap and safe disposal of feces because I have a latrine.” – Mother of child under 5 years old

Photo Credit: Sona Sharma, Action Against Hunger

The video and radio shows had the ability to reach men, who are often left out from hygiene promotion activities. Additionally, many households had equipped themselves with simple home handwashing stations (tippy taps) and were regularly using them. Mothers, fathers, and other caregivers reported that handwashing was easy to practice, but that using soap was still a challenge as many people couldn’t afford it and the practice of handwashing before cooking was still not widely used. Finally, Action Against Hunger produced and shared guidance on radio programming, which continues to be used by partners to engage communities from a distance during the COVID-19 pandemic.

“It’s the hands that do everything in the home, and also it’s the hands that bring everything to the mouth, so hand washing is very important” – Mother of child under two years old

Several recommendations were made to improve the interventions, such as using music during the drama show to make it more attractive for a Congolese audience in the refugee camp; providing nylon rope for tippy taps, as ordinary rope often broke; equipping community leaders with radios to increase audience coverage; giving promotors tablets and speakers to show the video during door-to-door activities; and advising community members on how to prevent termite damage to tippy taps.

Action Against Hunger made a conscious effort to plan and synchronize our SBC activities to maximize overall impact. Activities were rolled out strategically, focusing on one topic at a time with simultaneous capacity-strengthening among hygiene promoters. With access to quality technical SBC support, trainings, and a detailed facilitation manual, the implementation team had every support they needed too.

In these difficult times, we know that promoting handwashing with soap is a dire necessity. We hope that these valuable lessons from our SBC intervention will lead to large-scale changes in handwashing behaviors.

How Eco-Soap Bank is tackling COVID-19 in partnership with the #Sweat4Soap Campaign

October 12th 2020 at 20:08

By: Samir Lakhani, Eco-Soap Bank

Eco-Soap Bank, a global nonprofit organization employing women to recycle leftover soap from factories, and Mina Guli, a longstanding water advocate, are teaming up together to tackle COVID-19 and raise awareness about the newfound importance of handwashing with soap. Together, the partnership will donate 50,000 bars of soap to schools this week in 5 developing countries.

Right now, we’re washing our hands, our clothes and the surfaces around our home more than ever. For most of us, the process is relatively straightforward – we do it without a second thought: tap on, hands underneath, apply soap and sing happy birthday while we scrub.

But for the 3 billion people on our planet that don’t have access to adequate handwashing facilities, it’s a very different story.

The world is in the midst of a global COVID-19 pandemic that is threatening to destroy the life and health of vulnerable groups and devastate the economies of the developing world.

After months of lockdowns intended to contain and mitigate the spread and effects of the deadly COVID-19 virus, the developing world is now beginning to reopen its schools. This new phase is fraught with risk, especially in the developing world where resources are few and children and elderly people often live close together in the same household.

To prevent further escalation of the COVID-19 pandemic, it is crucial that as many as possible of these reopening schools are provided with basic access to soap and handwashing education. Handwashing with soap constitutes the most cost-effective method to combat the detrimental effects of COVID-19 and other hygiene-related illnesses, but lacking soap availability and hygiene awareness represents a significant obstacle to current mitigation efforts.

The #Sweat4Soap campaign is simple and lifesaving: for every kilometer that is run or walked from October 10-17, 2020 using the hashtag #Sweat4Soap, a bar of soap will be donated to a community in need. Participants have already logged 5,500 kms equaling 5,500 bars of soap! So grab your running or walking shoes and #Sweat4Soap to save lives!

About Eco-Soap Bank

Eco-Soap Bank employs disadvantaged women worldwide to recycle leftover soap from hotels and factories and redistributes it to impoverished communities along with hygiene education to reduce disease and save lives.

To date, the organization employs 154 women who have provided more than 9 million bars of soap and education to over 3 million people in 15 developing countries, supporting over 2,500 schools, health clinics, and refugee settlements.

Eco-Soap Bank and Soap Manufacturers

Eco-Soap Bank maintains a diversified recycling and sourcing strategy through partnerships with medium-sized and large global FMCGs, which generate millions of bars of usable discarded soap each year. We collect those waste volumes and help these companies become zero-waste manufacturers and achieve their social impact goals. Since January 2020, we’ve sourced 400 metric tons of soap waste—and we estimate that we’re currently collecting only a small fraction of the global volume of waste. Please get in touch to collaborate to recycle surplus soap and save lives: samir@ecosoapbank.org.

COVID-19 as an awakening for hand hygiene access

October 13th 2020 at 10:09

By: Team DefeatDD

In the time of COVID, the future is in our hands. Literally. Photo: PATH/Gareth Bentley

When the COVID-19 pandemic first began and little was known about the novel coronavirus, one of the World Health Organization (WHO)’s first recommendations was a simple, tried-and-true public health measure: handwashing. This advice persists today as one of the most important ways, alongside masks, to prevent COVID-19. Just twenty seconds of scrubbing with water and soap, or with an alcohol-based hand sanitizer, can wash away the novel coronavirus—in addition to other common infectious diseases such as typhoid, cholera, and diarrheal pathogens like rotavirus, E. coli, and Shigella.

As the pandemic unfolded around the world, hand sanitizer and handwashing stations became as in-demand as toilet paper. But in too many places around the world, a preexisting lack of access to safe water, sanitation, and hygiene (WASH) resources makes handwashing impossible. In fact, 40% of the world’s population does not have access to a basic handwashing facility.

For health care workers who cannot practice safe handwashing due to a lack of safe water or soap in health care facilities, this issue can have dire consequences for spreading infection. In a COVID-19 guidance document sent to Member States in April 2020, WHO wrote:

“Although awareness of the importance of hand hygiene in preventing infection with the COVID-19 virus is high, access to hand hygiene facilities that include alcohol-based hand rubs as well as soap and water is often suboptimal in the community and in health care facility settings, especially in low-and middle-income countries. WHO and UNICEF estimate that globally 3 billion people lack hand hygiene facilities at home and two out of five health care facilities lack hand hygiene at points of care.

WHO recognized WASH in health care facilities as an urgent global health crisis in 2019, before COVID-19 began. The World Health Assembly Resolution urges countries to address the issue and seeks commitments from governments, partners, organizations, and individuals in line with the Resolution.

Another critical location for hand hygiene access is in schools. For families without handwashing facilities at home, schools can be a lifeline of hygiene access for children. With many schools currently closed due to the pandemic, this lifeline is shut off. But in too many other schools, WASH was already lacking before the start of COVID-19.  A recent WASH in Schools report from UNICEF found that, in the 60 countries at the highest risk of health and humanitarian crisis due to COVID-19, 3 in 4 children lacked a basic handwashing service at their school at the start of the outbreak. As schools begin to reopen, UNICEF and WHO urge governments to implement WASH in schools. These steps will not only help stop the spread of COVID-19, but also protect children from other WASH-related diseases such as diarrhea and typhoid that can interrupt education and have lasting health consequences.

Of course, installing handwashing facilities is just the first step to improving access and uptake. As with all public health interventions, there also is a human behavioral component. The latest research on behavior change highlights the utility of simple environmental “nudges” such as signs, communication that is empowering rather than fear-inducing, and the importance of infrastructure. More behavior change research is needed, but one thing is clear—behavior change can only go so far without policy change. It’s impossible for people to make good choices when they have no good choices. In the same COVID-19 guidance document, WHO acknowledges findings from research:

“When hand hygiene is provided free of charge and is made obligatory by public health authorities, acceptability and adherence to hand hygiene best practices are improved.”

In order to make access to hand hygiene a universal reality, it is crucial for country governments to support hand hygiene through policies and funding: something that WHO and UNICEF formally called for in their Hand Hygiene for All call to action. The pandemic makes this call especially urgent, but long before COVID-19, the everyday crises of cholera, pneumonia, typhoid, and diarrheal diseases revealed the consequences of inadequate WASH in homes, schools, and health care facilities. We’ve learned a lot from the efforts to combat these diseases and their cascading impacts, so we know what needs to be done.

Perhaps COVID-19 can serve as the wake-up call to prioritize hand hygiene—along with safe water and sanitation—now and long into the future.

WASH practitioners stand on the frontline of Nigeria’s COVID-19 response

July 16th 2020 at 19:39

By: Olajide Adelana

This article was originally posted on WSSCC’s website. 

ABUJA, Nigeria – The role of water, sanitation and hygiene (WASH) practitioners in Nigeria’s response to the COVID-19 pandemic cannot be overemphasized as working on the front line of the fight against the coronavirus requires both courage and commitment.

Mr Benson Attah, National Coordinator of the Society for Water and Sanitation (NEWSAN) – an umbrella body for civil society organizations (CSOs) working in the WASH sector – is a WASH practitioner, whose commitment has been unwavering in implementing and monitoring Nigeria’s COVID-19 response framework.

When Mr Attah heard about the number of COVID-19 cases in the country, his first action was to alert NEWSAN’s state chapters to immediately commence community sensitization and ensure compliance with the safety protocols of the World Health Organization and Nigeria Centre for Disease Control (NCDC). With his colleagues at NEWSAN, Mr Attah also created an action plan for the pandemic at various state levels, which became a vital tool for awareness creation and COVID-19 prevention activities at the community level.

“The COVID-19 pandemic didn’t come as a surprise and my experience with professional emergency management equipped me for this type of emergency,” he says. “We had thought the N1H1 virus between 2008 and 2009 was going to be a pandemic but it was not. It was just a matter of time.

Nigeria’s coronavirus cases have begun to soar with no less than 29,286 laboratory confirmed cases as of 7 July 2020. Mr Attah states that the ongoing community spread of the disease is concerning, but more worrisome are Nigeria’s hygiene and sanitation statistics.

According to the 2018 WASH Norm Survey findings by Nigeria’s Federal Ministry of Water Resources, only 11 percent of the entire population has access to complete basic water, sanitation and hygiene services. 16 percent of schools have basic water and sanitation services, and 47 million people still practice open defecation.

Mr Attah explains that these statistics expose worrying gaps both in light of COVID-19 safety protocol’s insistence on personal hygiene and Nigeria’s growing population, which is currently estimated at 200 million people.

Also of significant concern is the impact of these statistics on rural and hard-to-reach communities in Nigeria, where the likelihood of misinformation about the disease is high and medical interventions can be challenging.

The pandemic has overstretched Nigeria’s already weak healthcare sector, which suffers from a shortage of manpower and equipment, requiring many to step in as frontline workers to support the fight against the virus.  Despite the challenges, Mr Attah, who is a member of Nigeria’s Federal Capital Territory’s COVID-19 task force team, says he is not scared to be on the frontline.

I would not be part of the team if I was scared. I keep myself safe and sane by making sure that I don’t compromise my safety and I religiously follow preventive protocols.

WSSCC has been providing support to the Nigerian government in response to the pandemic by tailoring one of its flagship initiatives, Rural Sanitation and Hygiene Programme in Nigeria (RUSHPIN), and supporting organizations like NEWSAN to address COVID-19 related issues.

RUSHPIN has been effective in breaking down scientific information into graspable formats, and debunking myths concerning COVID-19, sanitation and hygiene in rural and hard to reach areas in Nigeria. Meanwhile, NEWSAN has continued to provide necessary administrative support to the Nigerian government down to the State and Local Government levels.

Coronavirus brings several points of reflection for WASH experts in Nigeria.

“In NEWSAN, we have always regarded WASH as the ‘gateway to development’ as it affects every aspect of development, health, education, economy, labour and productivity. In Nigeria, the WASH sector should be more professional in its set up and outlook,” explains Mr Attah.

“Government across different levels should take immediate responsibility by recognizing the prominent role of the WASH CSOs in ensuring that coronavirus does not spread beyond its present point and, this should be allowed to gradually transit and consolidate into an all-round development that is sustainable.”

Sustaining Sanitation and Hygiene in Madagascar: the Impact of the Pandemic

July 14th 2020 at 19:28

By: Hoby Randrianimanana

This interview was originally posted on WSSCC’s website. 

ANTANANARIVO, Madagascar – Dr Fano Randriamanantsoa is the Community Mobilization Specialist at the Fonds d’Appui pour l’Assainissement (FAA), WSSCC’s Global Sanitation Fund programme in Madagascar.

A medical doctor by training, Fano Randriamanantsoa has worked in the WASH sector for over ten years. His role with FAA is to coordinate and monitor sanitation and hygiene activities in communities that have been declared open defecation-free (post-ODF activities). He spoke with us on how his work has been impacted by COVID-19.

WSSCC: Could you tell us about your work?

Dr Fano Randriamanantsoa, Community Mobilization Specialist at the Fonds d’Appui pour l’Assainissement: I coordinate and monitor the post-ODF activities of the implementing agencies we fund. For that, I first define specialities needed to support these agencies in their post-ODF activities, and then I recruit consultants for each speciality, including, among others, sanitation marketing, capacity building and Village Saving and Loan Association (VSLA) expertise.

A key aspect of my work is going in the field to collect feedback, learn and share knowledge, and test with partners the approaches we have developed.

According to WSSCC’s “EQND” handbook, post-ODF activities refers to any structured activity taking place in a community after they have been certified as ODF, with objectives ranging from sustaining changed sanitation and hygiene behaviour to promoting the use of more hygienic and sustainable facilities and addressing other aspects of environmental hygiene, including safe water treatment and solid waste management.

WSSCC: Based on your experience, what are some of the challenges to sustainability for ODF communities in Madagascar?

Dr Randriamanantsoa: I can give four prevailing challenges in our work:

Behavioural challenges arise when residents are not fully convinced that they don’t want to eat “shit” anymore. It is the result of using the wrong approach. Implementers often tend to be either too strict or too easygoing. Sometimes, they get too involved in the community, preventing the population from taking full responsibility for improving their own sanitation and hygiene.

Economic hardship is a challenge we often encounter in the field, where the majority live on less than 2 dollars a day. It automatically excludes the poorest as they are unable to afford even the most basic sanitation and hygiene services.

Non-access to resilient and sustainable infrastructure is tied to economic hardship. Due to limited resources, communities cannot build durable facilities and instead resort to using cheaper local materials, which are not sustainable and tend to become non-functional either because of weather conditions or overuse.

Environmental challenge includes external factors that aren’t necessarily sanitation and hygiene-related but potentially affect them, such as weather conditions, soil type, political atmosphere, unsupportive local leaders, and crowd-gathering cultural events.

WSSCC: When communities are having difficulty sustaining their ODF status, what support does the programme provide to address the situation?

Dr Randriamanantsoa: We have seen many cases of slippage over the years, and what we do is provide implementing agencies with tools and approaches to tackle them.

For instance, when a community is experiencing slippage due to behavioural issues, we facilitate the establishment of the Local Community Governance (GLC), where residents are trained in methods to uphold changed behaviours. Where it is caused by economic hardship, we guide the agencies in the creation of a VSLA to help community members, especially the poorest, maintain or upgrade their facilities.

As for slippage originating from non-resilient infrastructure, we encourage agencies to promote sanitation marketing with local technicians, who have been trained to build durable latrines.

Slippage is used to describe the return to previous unhygienic behaviours due to the inability of some or all community members to continue to meet all ODF criteria.

WSSCC: Again, based on your experience, can you talk about the difference between working in rural areas and sub-urban/urban areas?

Dr Randriamanantsoa: We have seen that working in rural areas is more productive thanks mainly to our ability to use what is called continuum community-led total sanitation (CLTS) —implemented from the beginning until long after ODF certification—without any disruption.

CLTS is more effective in rural areas because of existing socio-cultural norms such as tight-knit communities, respect for elders and handcrafting skills. Most rural communities are also more open to innovations from outside as long as those innovations don’t contradict their values. On the contrary, the closer you move to urban settings, the more challenging post-ODF work becomes. We usually combine various approaches in these areas and sometimes request the help of other partners to carry out activities.

WSSCC: How has COVID-19 affected your post-ODF activity programming?

Dr Randriamanantsoa: Because of the lockdown, we have suspended most activities in our 19,000 ODF-certified communities. We have, however, a few implementing agencies carrying out post-ODF activities while adhering to COVID-19 prevention rules. In other cases, the agencies follow up remotely by connecting with members of Local Community Governance (GLC) and Local Institution Governance (GLI).

In Nigeria, Doctors Turn to Basic Hygiene to Slow Covid-19

July 3rd 2020 at 19:50

By: Elena Bruess

As the coronavirus pandemic spreads through Africa’s most populous country, a health foundation pushes for better access to water, sanitation and hygiene.

Members of Wellbeing Foundation Africa speaking about their Clean Hands for All initiative © Wellbeing Foundation Africa

Otun Adewale recounts the story of two doctors in a private hospital in Abuja, Nigeria. One who washes his hands after he is with a patient, the other who does not. One who contracts Covid-19 and one who does not.

Adewale is a senior medical officer in maternal and child health. Since the beginning of the year, the doctor has been working with Wellbeing Foundation Africa (WBFA), an organization that focuses on women’s and children’s health in Nigeria through education, advocacy, and better care. For the past few months, Adewale and the team at WBFA have had a new mission: breaking the transmission of Covid-19 by improving water, sanitation, and hygiene practices.

“This story actually got me interested,” Adewale told Circle of Blue, referring to the parable of the two doctors. “That as simple as handwashing can be, as simple as observing these precautionary measures can be, it can actually save you from the dangers of Covid-19. The other person who takes it for levity is facing the music now.”

Members of Wellbeing Foundation Africa present clean water for handwashing. Photo © Wellbeing Foundation Africa

Though it had a late start, the disease is spreading through Nigeria with increasing speed. As of June 30, Nigeria had more than 25,000 confirmed Covid-19 cases, the second highest number in Africa. Forty percent of the cases were recorded in the last two weeks. Vulnerable populations such as frontline healthcare workers are at a greater risk without proper water or hygiene.

That is where organizations like WBFA step in. The foundation notes that hospitals and clinics often have inadequate water supplies and lack soap to prevent disease transmission. According to Rita Momoh, a midwife with WBFA, expecting mothers might be scared doctors will bring Covid-19 to their homes when they have a checkup, or the mothers may not be comfortable going to the healthcare facility when they need to.

“The atmosphere surrounding handwashing and personal hygiene in response to Covid-19 [in Nigeria] can be rated very, very low.” Adewale explained. “A majority of Nigeria still believes Covid-19 isn’t real. Some believe it is a scam.” He added: “People will only take responsibility for their health when they are convinced of Covid-19.”

‘It All Comes Back to WASH’

A leading organization for water, sanitation, and hygiene before Covid-19, the foundation has since intensified its educational outreach due to the virus. WBFA workers teach classes to healthcare facility employees and engage with hospital officials to install handwashing stations. The foundation holds meetings with community leaders and passes out flyers in the local language so residents can understand and value the information. WBFA also has a virtual program for adolescents across states, to educate and demonstrate how to wash.

Most rural communities do not have easy access to clean water, and residents will often travel long distances to find wells or creeks. Urban Nigeria has better water and sanitation access rates than rural areas, yet cities face their own challenges with the virus. The expansion of unplanned settlements such as slums puts more lives at risk because of crowded living conditions and inadequate water, sanitation, and hygiene, known collectively by their acronym WASH.

A member of Wellbeing Foundation Africa speaks with villagers about WASH and Covid-19. Photo © Wellbeing Foundation Africa.

According to WaterAid, 57 million people in Nigeria do not have access to clean water, and 130 million do not have basic sanitation or hygiene. This is in a country of about 200 million people. Nigeria operates as a federation of 36 states, each with a different institutional framework. The fragmentation has its drawbacks. According to Alero Roberts at WBFA, the water board that is responsible for clean water and sanitation in every state is often aging and ineffective.

“What this pandemic has taught us is how easily our health system can be stretched beyond capacity,” Roberts told Circle of Blue. “We’re talking infection prevention and control, but with infection prevention and control we’re talking water and sanitation hygiene. It all comes back to WASH.”

For now, WBFA will continue to educate individuals and advocate for healthcare adaptation in Nigeria. So when a patient needs a checkup, there’s no doubt about handwashing and proper procedures.

“Because what we need to do is change hearts and minds,” Roberts said.

 

How I Found My Way to Advocating for Safe Water and Sanitation in Nigeria and Beyond

June 23rd 2020 at 20:37

By: Her Excellency Toyin Saraki, founder-president of Wellbeing Foundation Africa

This article was originally posted on Global Citizen. 

In African traditional folklore, we have a proverb: “Every dance starts with a clap.” Just watch us and you’ll find this proverb is indeed true. We clap at least once from a primordial pre-instinct, to find our rhythm and set the tone, before we begin to dip, sway, and swirl.

But we have another African proverb that says, “You cannot clap with one hand.” And so I embarked on clapping with two hands, advocating on behalf of women, girls, and children around the world.

In hindsight, the roots of my global work are found in my baby’s nursery. I was expecting twins but tragically, only one child would survive. I returned home with my new baby daughter and replicated in the nursery what I had seen in the neonatal intensive care unit. I quickly had water pipes installed so her nursery would have a handwashing basin just inside by the door. I knew for my newborn to be safe, I needed two clean hands.

In 2003, I became a very young and very new First Lady to the north-central Nigerian state of Kwara, where my husband was elected governor. I took time to get to know the people, their needs, and the basic services that existed for Kwara’s 3 million inhabitants. I would visit dilapidated hospitals and schools, untouched since 1974. Whenever I wanted to shake hands or hold a baby, and wished to wash my hands, water was not available and there was invariably a 10-minute or more delay while someone would have to fetch a bowl of water from a well, borehole, or tank.

Photo Credit: Wellbeing Foundation Africa

I continue to encounter the inability to wash hands in places of critical care. In April 2018, I visited my Wellbeing Foundation Africa’s MamaCare Midwives Antenatal and Postnatal Session at a Primary Health Care Centre in Abuja, Nigeria’s capital. I was there to encourage mothers to allow their infants to receive oral polio vaccinations during World Immunisation Week. When I asked to wash my hands, I again faced that delay while a bucket of water was fetched.

At home that evening, I looked into current data and found that only 5% of health facilities in Nigeria have combined basic water, sanitation, and hygiene (WASH) services. The absence of WASH during birth plagues 17 million women across least-developed countries every year. It is clear that we are still trying to clap with one hand.

Now the need for two clean hands is being recognized as more urgent than ever — and perhaps that’s the only good news to come from the coronavirus pandemic. The handwashing that the WASH community has so long advocated for has come out of its echo chamber, and become a thunderous resounding clap for global health.

COVID-19 has made “wash your hands” a daily adage and has reinforced the need to invest in safe and dignified health care. This renewed urgency calls us to ensure that the WASH and health communities unite indivisibly to activate, actualise, and accelerate WASH investments to match the behavioural change.

Image: Courtesy of Wellbeing Foundation Africa

I see this need in my country. Despite the slower pace of COVID-19 across the African continent, Nigeria’s eventual burden could be one of the worst in Africa. Reality on the ground is showing weak health systems already stretched to a breaking point, according to reports from medical and public health officials.

Valuable programs are gaining needed steam, like WaterAid’s “Clean Nigeria” campaign for homes and hospitals, and the London School of Hygiene & Tropical Medicine’s global “Teach Clean” campaign, to achieve infection prevention and control, and prevent maternal and newborn sepsis.

Our midwives persevere. As our “WASH for Wellbeing” midwives work every day, teaching over 8,000 young pregnant and nursing mothers and their medical colleagues in hundreds of health facilities, they are my frontline warriors for WASH. Too often, the photos they send me still show a water tank in the far distance, and a bucket of water on a table.

In this inaugural UN Year of the Nurse and Midwife, we must ensure that health care workers everywhere have access to WASH. Hands, all around the world, are working tirelessly. Let’s be sure they can do so, safely.


Join the momentum tomorrow! From the mountains for Nepal to leadership at USAID, Water.org, the Vatican, and funders:  


About the Author

As Founder-President of Wellbeing Foundation Africa (WBFA), Mrs Toyin Saraki is a Nigerian philanthropist with two decades of advocacy covering maternal, newborn and child health, gender-based discrimination and violence, improving education, socio-economic empowerment and community livelihoods in Africa.

Without WASH, Health Workers Can’t Do Their Jobs

June 16th 2020 at 18:11

By: Lindsay Denny, Global Water 2020

This post was originally posted as a Frontline Health Workers Coalition blog. 

The hospital—a referral hospital in Bahir Day, Ethiopia—served a population of 25 million. Dozens of mothers gave birth daily, some of whom were sent from other facilities in order to deliver by emergency Cesarean section. It was a bustling institution, yet it was without some of the most basic amenities—I saw broken water taps, unsanitary toilets, and no soap or other supplies for cleaning. The nurses of the neonatal intensive care unit, where there were no sinks for handwashing, recognized what the conditions meant. Their job is to care for the most vulnerable, yet they were unable to drop the spread of infection within their unit.

The neonatal intensive care unit at the referral hospital in Ethiopia lacked soap and water for health workers to wash their hands. Photo courtesy of Lindsay Denny.

This hospital isn’t the exception in low- and middle-income countries. According to a recent report from WHO and UNICEF, two billion people must rely on health facilities that lack basic water services and 1.5 billion people visit facilities without toilets. Without these basic amenities, it is impossible to provide safe care and live up to the doctrine of “do not harm.”

Nearly 1 in 6 patients in developing countries acquires an infection inside a health facility. Handwashing alone can cut deadly diarrheal disease by 45%, but not if hands cannot be washed due to inadequate soap and water, or if hygiene behaviors are not fully adopted. Some 61% of health workers do not adhere to recommended hand hygiene practices. Hygiene behavior change is needed. As is soap and water.

Learn about WASH in health care facilities during a virtual event on June 24, 2020.

The lack of water, sanitation and hygiene (WASH) services also endangers health workers. Consider the 2014 Ebola outbreak. Ebola not only killed some 11,000 people, it was 103-fold higher in health workers in Sierra Leone than in the general population, 42-fold higher in Guinea health workers, and Liberia lost 8% of its health workforce. These losses were in part due to that fact that health workers did not have access to adequate WASH. The situation has not improved. In the Democratic Republic of the Congo, where Ebola killed thousands, 50% of facilities have no water, 59% have no toilets, and just 62% have soap and water or hand sanitizer at points of care. Now global health care staff addressing COVID-19 face similar challenges and threats. Additionally, given that the majority of midwives, nurses, and cleaners are women, the lack of WASH disproportionately affects women. For example, without proper toilets, female health workers may be forced to hold their bladders through their shifts—a recipe for a urinary tract infection.

This problem of WASH in the health facility has long been neglected, but it is solvable and momentum is building. UN Secretary-General António Guterres issued a global Call to Action in 2018 to get WASH into health facilities; WHO Member States then unanimously adopted in a 2019 World Health Assembly Resolution that includes eight practical steps towards successful implementation by 2030. WHO and UNICEF responded with metrics to chart progress by governments, and dozens of national governments are now exploring concrete plans and resource requirements. In 2020, WHO prioritized the absence of WASH in HCFs as among the most urgent global health challenges in the coming decade for the first time.

Last June, 92 diverse organizations announced commitments to WASH in health facilities. In the past year, these organizations have been translating commitments into action. At the same time, the COVID-19 pandemic has brought the global need into even sharper focus. Now more than ever, WASH in health facilities must be a foremost priority for governments, funders, and development assistance organizations alike. Progress demands an adequate level of support for sustainable, and accountable, WASH services in health facilities, regularly monitored by professional authorities.

On June 24, 2020, Global Water 2020 and Global Health Council are hosting a virtual event recognizing the first anniversary of these commitments. Global health and WASH leaders will come together to reflect on efforts to reach every health facility with WASH services. We urge our global health colleagues, in particular those working on the front lines of health care delivery, to join the discussion. It is critical that we continue to drive progress towards WASH in all health facilities, everywhere. And in the process, we must elevate the voices of frontline health workers, for whom this deficit has the greatest impact.

NGO provides sanitary pads to girls in Nairobi slum during COVID-19 lockdown

June 16th 2020 at 18:06

By: Kevin Mwanza

This post was originally posted on WSSCC’s website. 

NAIROBI, Kenya – In Nairobi’s Korogocho slums, the sudden closure of schools in March was a double tragedy for 15-year-old Consolata. It meant she would lose out not only on learning, but also on free access to sanitary towels provided under a government scheme to promote menstrual health and hygiene.

As the global lockdown occasioned by COVID-19 has forced people to stay home and live on reduced income, she and millions of girls around the world who live in informal setlements are struggling to access sanitary pads.

The form-two student says she is lucky to get menstrual pads from a local non-governmental organization known as Miss Koch that empowers young girls and women in Korogocho slums.

“We can’t access these (government) pads until we go back to school. Our mum cannot afford to buy us pads and also provide for food. So we mostly depend on what Miss Koch provides,” Consolata said.

“We are five girls in our house, and the pads are usually not enough for all of us. Sometimes we ask our brothers to chip in.”

The Kenyan government, through the State Department for Gender Affairs, runs a programme to provide free sanitary towels to some 3.7 million girls in public primary schools, special primary and secondary schools in the country.

The scheme is essential in a country where over 65% of people who menstruate cannot afford sanitary towels, according to figures cited in the 2016 report Menstrual Health in Kenya, published by non-profit consulting firm FSG.

It also showed that 6 out of 10 girls in Kenya had never heard about menstruation until their first period.

The government-funded sanitary towel program was initiated in 2011 and has so far benefited over 11.2 million girls, mostly in marginalised and slum areas, according to the ministry.  The closure of schools in March due to COVID-19 halted pad distribution.

Mentorship

Consolata is one of 600 children in Korogocho slum that benefit from a mentorship programme by Miss Koch that seeks to support child-parent relationships, said Emmie Erondanga, the organization’s executive director.

The NGO also distributes sanitary towels donated by well-wishers to girls through private and apex schools within the informal settlements that do not benefit from the state scheme.

“But with COVID-19, things have changed. Schools closed abruptly and these girls are out of school,” Erondanga said.

“Sometimes we get short of supplies, which means the girls that we have not reached will go for alternative avenues. These could lead to dropping out of school or even teenage pregnancies.”

According to a UNESCO report, Puberty Education & Menstrual Hygiene Management, one in ten girls in sub-Sahara Africa misses school during their periods, losing up to 20 school days a year and increasing their chance of dropping out altogether.

Patricia, one of Consolata’s four sisters, says that while she benefited from the free sanitary pads while in school, it has become harder to afford them after she finished her secondary school education in 2019.

“Sometimes we have to use rags or borrow from friends,” Patricia said.

“Girls here end up having sex with men so that they can get money to buy pads. Some of my friends have even ended up pregnant just because they could not afford pads.”

Inadequate knowledge of sexual and reproductive health among adolescents has meant that over 3.9 million school-going girls aged between 15 and 19 undergo unsafe abortions annually, according to the World Health Organization.

For Consolata and girls and women across the country, there is hope for more robust support as they continue to face their menstrual challenges. On this year’s Menstrual Hygiene Day (28 May), the Government of Kenya launchd a landmark stand-alone policy dedicated to menstrual health and hygiene.

The Menstrual Hygiene policy 2019-30 will create an enabling environment for implementation of menstrual hygiene and management interventions in Kenya. It will also ensure women and girls have access to safe and hygienic products.

No regrets: integrating hygiene and immunisation on the frontlines of disease prevention

June 5th 2020 at 13:50

By: Julie Truelove and Katie Tobin, WaterAid

This post was originally posted on WaterAid’s WASH Matters. 

WaterAid/ PATH/ Chileshe Chanda

As global health donors gather virtually for Gavi’s Global Vaccine Summit on 4 June, hosted by UK Prime Minister Boris Johnson, Julie Truelove and Katie Tobin make the case for why they should be talking about investing now in improving access to hygiene services, and how this should go hand in hand with investing in vaccines.

Hygiene is a first line of defence against COVID-19

While the world waits for a vaccine, we collectively rely on critical measures of prevention to control the transmission of COVID-19 – and to avoid future health crises caused by the disruption of key global health interventions during the pandemic.

One of the most effective methods of disease prevention, hand hygiene is at the core of public health advice from the World Health Organization (WHO). Evidence suggests handwashing with soap can reduce cases of pneumonia by 50% and acute respiratory infection by 16–23%, while reducing risk of endemic diarrhoea by 48%.

Neglecting investment in hygiene undermines health system strengthening

Governments and donors have long neglected to invest adequately in the basics of clean water, soap and decent toilets. Even now, hygiene investment to bolster weak health systems is largely absent from COVID-19 national responses and donor support. (Gavi is a notable exception to this trend, having enabled recipients of its funding to reallocate up to 10% of health system strengthening budgets – including to hygiene and infection, prevention and control – to address the COVID-19 crisis.) We recently called on governments and donors to take seven critical actions to accelerate hygiene investment, including by initiating mass public health information campaigns at nationwide levels, and to urgently increase financial support for hygiene services for communities and frontline health workers.

The pandemic has disrupted public health programmes

Compounding the challenges of minimising the impact of COVID-19 on global health, immunisation services have been delayed or disrupted since the pandemic began, in part to avoid spreading disease at crowded clinics and putting frontline health workers, carers and patients at risk. According to UNICEF, Gavi and WHO, this has put 80 million children under one year of age at risk of vaccine-preventable diseases including measles, diphtheria and polio.

While many countries grapple with restarting immunisation services, the Global Task Force for Cholera Control has emphasised the need for adequate water, sanitation and hygiene (WASH) services as one of six critical steps required to resume preventative oral cholera vaccinations in hotspots.

The case for joint delivery of hygiene and vaccines

To mitigate the long-term impacts of COVID-19 on global public health, joint delivery of hygiene and immunisation services is essential. Because immunisation programmes reach more people than any other health intervention does, they are a crucial entry point to integrate WASH – with particular emphasis on hygiene behaviour change. Hygiene-integrated approaches must become the new normal for vaccine delivery.

Our recent research with SHARE and numerous partners presented the case for integrating WASH and context-specific hygiene behaviour change interventions into immunisation sessions. The research showed potential positive outcomes from this hygiene-integrated model to include:

  • Improving cost effectiveness and operational efficiency – an important factor in resource-constrained settings for both service providers and to reduce time demands for service users across vital health services.
  • Reaching underserved populations to support them to attend and complete immunisation sessions, increase trust in health services and engage in hygiene behaviour change practice.
  • Synergistic effects of increasing demand for and uptake of immunisation and other child health services, while increasing success of child caring behaviours such as exclusive breastfeeding and food hygiene.
  • Potential for improved vaccine performance, based on emerging evidence that supports the biological plausibility that improved hygiene, sanitation, clean water and soap could increase oral vaccine performance through improved gut health – a key area for further research.

Global guidance from WHO emphasises that linking prevention and control efforts for diarrhoeal diseases could lead to greater health outcomes compared to results from single interventions, including preventative measures like improved living conditions and WASH. Context-specific planning, budget allocation, implementation and evaluation can establish robust, integrated platforms for hygiene and immunisation.

In Nepal, we worked with the London School of Hygiene and Tropical Medicine (LSHTM) to undertake a scoping study to assess the feasibility of incorporating hygiene behaviour change into the country’s already successful immunisation programme. The intervention improved key hygiene behaviours (related to exclusive breastfeeding, handwashing with soap, food hygiene, faeces management and water and milk treatment) from 2% at baseline assessment to 53% after one year. The project also increased immunisation coverage and led to a 10% decrease in diarrhoea prevalence in those who took part in the pilot.

Based on this successful intervention, the integration of hygiene promotion with routine immunisation will be scaled up to national level with the introduction of a rotavirus vaccine, scheduled for June 2020. Despite the COVID-19 pandemic, massive training programmes for these interactive sessions have already taken place across health offices in Nepal. Watch our short film about the project, below.

‘No regrets’ actions for disease prevention

Investing in hygiene-integrated approaches now is a no regrets action to confront COVID-19, help maintain the essential provision of vaccines, and build resilience against subsequent health crises related to preventable diseases. Building towards longer-term strategies, urgent action must start now, at all levels:

Local actions:

  • Ensure every immunisation clinic has basic handwashing facilities with water and soap, accessible to all staff and patients.
  • Build on a ‘do no harm’ approach to actively promote hygiene and handwashing through immunisation platforms, clinics and with clinic staff through visual cues and behaviour nudges, alongside radio, music and mobile messaging platforms.
  • Accelerate development of context-specific integrated intervention packages, drawing on national guidelines and hygiene behaviour change science.
  • Initiate training of frontline health workers for integrating hygiene and immunisation.

National actions:

  • Ministries of health and related line ministries for WASH and social development should actively promote hygiene behaviours embedded with immunisation communications.
  • Include in health and immunisation budgets ringfenced funding for immediate improvements to handwashing and hygiene practices for immunisation clinics.
  • Make best use of Gavi’s flexibility to reallocate up to 10% of health system strengthening funding to prioritise hygiene integration and infection, prevention and control training.
  • Accelerate collaboration across sectors to develop national guidelines and action plans for hygiene-integrated approaches for immunisation, including readiness plans for launch of a COVID-19 vaccine.

Global actions:

  • Key allies for immunisation and WASH should champion a hygiene-integrated approach to immunisation as a ‘no regrets’ action for global health.
  • Donors to Gavi should voice support for a hygiene-integrated approach to immunisation, and amplify Gavi’s flexibility to reallocate up to 10% of existing health system strengthening funding to prioritise investment in hygiene integration, hand in hand with immunisation, as a critical preventative measure in the COVID-19 response.
  • Accelerate actionable global guidance on integration of hygiene and immunisation, on the basis of existing evidence and ‘no regrets’ actions for hygiene and handwashing, to inform Gavi’s health system strengthening strategy.

WaterAid/ Mani Karmacharya

A hygiene-integrated immunisation approach: a female health volunteer conducts a hygiene session with parents and children who have come to the district hospital for immunisations. Jajarkot, Nepal.

Prioritising investment in hygiene now will ready plans and mechanisms for joint delivery of hygiene and immunisation

Prioritising joint delivery of hygiene and immunisation programming, including critical funding for integrating hygiene with immunisation, is essential to establish a new normal – and particularly vital in this period of vulnerability before a COVID-19 vaccine is universally available. The pandemic has exacerbated inequalities along lines of income, gender, age, location, disability and health status, and these factors of discrimination – which already play out in terms of who has access to clean water and soap and to sanitation – will likely also be manifest in who has access to a vaccine and when.

Supporting the call by UNAIDS, Oxfam and more than 150 world leaders for a People’s Vaccine, we emphasise the need to act now to prevent the continued spread of the pandemic. Prioritising hygiene now will ready national plans and delivery mechanisms across ministries for health, immunisation and WASH; help strengthen critical routine and mass immunisation services with hygiene interventions for the long term; and prepare hygiene-integrated approaches to improve the effectiveness of the eventual roll-out of a COVID-19 vaccine. We hope to hear Gavi and its donors supporting this call when they make their commitment on 4 June.

Julie Truelove is Senior Policy Analyst for Health and Hygiene at WaterAid UK. She tweets as @JulieTruelove. Katie Tobin is Advocacy Coordinator at WaterAid. She tweets as @travelingKT.

The hospitals where doctors can’t wash their hands

May 19th 2020 at 12:31

By: Rebecca Root

This article was originally posted on Devex.

Salimata Dagnogo, matron at a health center in Mali, washes a piece of equipment in the delivery room. Photo by: Guilhem Alandry / WaterAid

BELFAST, Northern Ireland — Hand-washing is the first line of defense against COVID-19 and many other diseases. Yet 1 in 4 health care centers around the world has no hand-washing facilities, and in the lowest-income countries, almost half have no clean water.

A lack of facilities means over 2 billion people are forced to seek care in a place where there is no clean water and 1.5 billion people visit health care facilities with no sanitation services at all.

Advocates say that needs to be understood in order to help low- and middle-income countries control the virus.

“The vital role of good hygiene in preventing hospitals [from] becoming breeding grounds for disease is being woefully overlooked as part of the global response to COVID-19,” said Tim Wainwright, chief executive of WaterAid.

In a statement for WaterAid, Rhoda Phandama, a nurse and midwife in Malawi, added that the Katimbira Health Centre in Nkhotakota, where she works, doesn’t have enough soap.

“We need to have enough supplies so that we are protected and that the clients who come here with issues like injuries and other diseases do not end up catching coronavirus,” she said.

Aside from hand-washing, soap and water are needed to clean floors, operate some medical devices, and deliver babies, said Lindsay Denny, health advisor at Global Water 2020, an initiative focused on water access and security. Over 1 million deaths annually are associated with unclean births.

“We’ve heard stories of people using swamp water because it’s the only water available and that causes infection in the lungs of newborns,” Denny added. “And can you imagine being told ‘oh there’s an outbreak but you can’t wash your hands?’ If anyone needs to have access it’s nurses and doctors,” she said.

As well as patients, the lack of hygiene puts health care workers themselves at risk.

“We know of midwives who don’t go to the toilet on a 12-hour shift because the toilets are on the other side of the freeway from the health center or because it’s not safe,” Denny said, which can lead to infections.

Salimata Dagnogo, matron at a health center in Mali, collects dirty water from an open well. Photo by: Guilhem Alandry / WaterAid

At last year’s World Health Assembly — the annual governance forum for the World Health Organization — ministers of health signed a water, sanitation, and hygiene in health care facilities resolution. The agreement committed to developing national roadmaps, setting targets, increasing investments, and strengthening systems around the issue. In 2018, United Nations Secretary-General António Guterres also made a global call to action for achieving WASH in all health care facilities.

But in many places, this is yet to happen.

Ahead of this year’s World Health Assembly — which is taking place online due to the pandemic, on May 18 — WaterAid issued a call for change.

“As leaders meet virtually at the World Health Assembly we want to see rapid commitments that will mean that no nurse, midwife, or doctor has to work without somewhere to wash their hands,” Wainwright said.

In the Democratic Republic of the Congo, health care workers in rural areas often have to travel long distances to collect water from the nearest well or river, which means less time providing care, according to Amuda Baba Dieu-Merci, a former community health worker and director of the Panafrican Institute of Community Health.

Dieu-Merci blamed an absence of water companies focused on rural areas and the costs being higher than many facilities can afford.

For Denny, the siloed approach to global health and WASH is the main culprit. “When you have a breakdown of water in your health care facility you don’t necessarily have the expertise there to solve these problems. Similarly, the people working in the health system have a health perspective and they may not see water as important to the work they’re doing,” she said.

Zoe Pacciani, country director for Uganda at Freshwater Project International — an organization that provides WASH to villages, schools, and health centers — said many rural health centers were built years ago when building hand-washing facilities outside of the operating rooms wasn’t thought of.

Of the facilities that once had a water supply, many have deteriorated due to a lack of operation and maintenance, Pacciani explained, “rehabilitation on its own is not enough.” Mechanisms to enable district governments to maintain new water systems and local operators to perform routine operations and minor maintenance are needed alongside more funding, she said.

Just 3% of Uganda’s national budget is allocated to water and environment, and that figure drops to 1.5% in Malawi. Pacciani hopes the pandemic will highlight the need to prioritize water supply and hand-washing facilities in health centers.

“It’s shining a light that we’ve ignored this issue for so long. It’s been such a neglected crisis,” Denny agreed. “The outbreak will help countries and major organizations reprioritize and think about how we really focus on what the key elements of a health care facility are.”

In the meantime, Dieu-Merci hopes NGOs will step in, especially in places like DRC where conflict and displacement remain higher priorities for the government.

WaterAid constructs water tanks, towers, and toilets for health centers in several countries including Malawi, Ghana, Zambia, and Mali, while also working to put plans in place for their maintenance. In partnership with Engineers Without Borders, Freshwater Project International is also upgrading and replacing pumps, tanks, sinks, and taps in health care facilities in Malawi.

But this is not something that the WASH sector can solve alone, Denny said. “It’s about coming together, prioritizing, and budgeting. If we don’t have the money for it, it’s never going to be something that’s prioritized,” she said.

Visit the Duty of Care series for more coverage on how health systems can function better so that health care workers are supported and protected. You can join the conversation using the hashtag #DutyOfCare.

The most momentus day in a century for the midwives: We must applaud midwives with WASH

May 5th 2020 at 12:25

By: H.E. Toyin Saraki, Wellbeing Foundation Africa

Today, on 5th May, we celebrate the most momentous day in a century for the midwifery profession, the International Day of The Midwife, in the first ever Year of the Midwife, as the world is currently at a standstill fighting the coronavirus pandemic, an invisible enemy that has claimed hundreds of thousands of lives. It cannot be a coincidence that today we also celebrate World Hygiene Day, a day set aside to focus on hand hygiene: that simple act of handwashing with soap. Hand washing was originally propagated by the 1840 Physician Ignaz Semmelweis to midwives at his maternity wards, as the best means to prevent and control childbed fever infection—as puerpural sepsis was then known. Thus, midwives and their clean hands have established and led life-saving and life-enhancing infection prevention and control protocols for centuries. They are at the very frontlines of health, safely guiding new life, as the first eyes to see and first hands to touch a newborn child, as they stand by women all over the world in their hours of labour, delivery and need.

And they are not alone.

Health care workers, midwives, nurses, doctors, and the entire medical profession are at the forefront to save lives because they took an oath, an oath to serve regardless of the situation. They risk their lives to save the world in these unprecedented times. It is sad that during this crisis we have pushed to the background the work that we have put in over the years in various development aspects. I fear that this progress of prominence on the work we have put in reducing maternal mortality through they essential role of the midwifery profession in standing with women to ensure safer births will be threatened by a recession of recognition, and subsequent key investments as the focus shifts.

My thoughts and prayers are with the families of all the nurses and midwives who have lost their lives to Covid-19. Their deaths are a tragedy and I join their colleagues standing with midwives around the world in mourning their beautiful souls. Each and every one of them will be remembered in our hearts as a heroine.

As always in times of crisis, the most vulnerable among us will be the ones hit hardest. Women and girls will suffer the most from this disease which has already seen a rise in gender-based violence, and rights violations of pregnant women forced into giving birth alone. Some will face child-birth complications risking the lives of both the mother and child, some will have stillbirths and some others will successfully give birth to the future leaders that will hold us accountable for the lives of their mothers lost during child birth.

The repercussions will be a constant reminder that for years we have failed and continue to fail women and children where public health is concerned.

While the world grapples in its response to COVID-19, we must be mindful that everything else still functions as before. We still require access to SRHR, women will continue to require prenatal care and safe spaces to deliver in order to reduce maternal mortality.

For years midwives have joined the battle and reduced maternal mortality ensuring that even in the poorest communities, women still had access to safe births. This is most likely one of those challenging situations for midwives in various communities.

Midwives continue to be an essential service in this crisis and we should do more than just applaud their hard work and dedication. How are we ensuring their access to protective clothing and reaching women in need. This is why on this International Day of the Midwife we are launching the We Must Applaud Midwives with WASH campaign that seeks to remind people on the importance of washing hands. As well as protecting frontline healthcare workers, WASH plays a vital role in stopping disease transmission yet two out of five healthcare facilities still lack hand hygiene facilities at points of care.

Ten Immediate WASH Actions in Healthcare facilities to Respond to COVID-19

  1. Handwashing: Set up handwashing facilities, like a bucket with a tap with soap, throughout the facility. Prioritise the facility entrance, points of care and toilets, as well as patient waiting areas (and other places where patients congregate). If the facility is piped, repair any broken taps, sinks or pipes.
  2. Water Storage: Consider the water requirements to perform WASH/IPC activities with an increased patient load. If inconsistent or inadequate water supply is a concern, increase the water storage capacity of the facility, such as by installing 10,000L plastic storage tanks.
  3. Supplies: Solidify supply chains for consumable resources, including: soap (bar or liquid), drying towels, hand sanitiser and disinfectant. Ensure cleaners have Personal Protective Equipment (PPE) for cleaning. If ingredients are available locally, produce hand sanitiser at the facility (or at district-level) – see WHO protocols.
  4. Cleaning & Disinfecting: Review daily protocols, verifying based on national guidelines or global recommendations for resource-limited settings and noting additional levels and frequency of cleaning in clinical areas with high numbers of COVID-19 cases, including terminal cleaning. Ensure adequate supplies of cleaning fluids and equipment, making allowance for additional cleaning requirements. Ensure handwashing stations and toilet facilities are cleaned frequently.
  5. Healthcare Waste Management: Strengthen healthcare waste management protocols by making sure bins are located at all points of care, that they are routinely emptied, and waste is stored safely.
  6. Staff Focal Points: Assign staff member(s) – cleaners, maintenance staff, or clinicians — whose job it is to oversee WASH at the facility, including: refilling handwashing stations, auditing availability of supplies in wards, reporting on WASH maintenance issues, monitoring cleaning and handwashing behaviours of staff and communicating updates to the director daily.
  7. Training: Organise training for all staff on WASH as it relates to their role at the facility, including a specific training for cleaners based on the protocols reviewed above.
  8. Daily Reminders: Remind staff of WASH protocols during morning meetings. Post hygiene promotion materials throughout the facility, particularly next to handwashing facilities.
  9. Hygiene Culture: Encourage a culture of hygiene at the facility. Emphasise that all staff members, including cleaners and maintenance staff, are part of a team working to prevent the spread of infection. Recognise individual WASH champions in the HCF.
  10. IPC Team: Work with the Infection Prevention and Control (IPC) team at the facility to make sure efforts are reinforced and aligned, avoiding duplication. Encourage WASH focal points/partners to participate in IPC meetings. Coordinate WASH/IPC activities based on plans to isolate COVID-19 patients.

BONUS – Preventative maintenance: Check on WASH infrastructure and undertake any necessary preventative maintenance, such as repairing possible disruptions to the water supply, storage, distribution or treatment.

There is much work to be done to ensure that the focus on WASH lasts beyond this crisis and translates into a radical change in how we understand and prioritise water, sanitation and hygiene. A key part of achieving that will be demonstrating that without good WASH standards, global health security is impossible.

Clean water is health and security, and clean hands save lives.

The ripple effect of COVID-19 runs far beyond the disease itself. We must stand in support of midwives, and the entire medical profession, to build a strong bridge between the global health community and WASH, in order to mitigate and heal the scars of this modern-day pandemic on medical workers, women, our newborns and humanity for the many years to come.

My prayers are thus reinforced as 2020 marks not only the Year of the Midwife but also heralds the Decade of Action and Delivery, designed for us to take deliberate steps towards the 2030 Sustainable Development Goals. Because midwives have supported women for centuries by delivering routine maternity care and counsel on a daily basis, we must use this opportunity to advocate louder and stronger together. We must mobilise women and policymakers to stand with midwives as midwives stand with women, newborns and their families. We must stand for the midwifery profession around the world to be recognised, respected and remunerated, and routinely provided with whole-system support.

What key principles should we use to guide our coronavirus hygiene programming ?

April 29th 2020 at 21:14

By: Sian White, London School of Hygiene and Tropical Medicine

This article was originally posted on the COVID-19 Hygiene Hub. 

There is not one standardised approach to coronavirus response and context adaptation is important. Irrespective of what your organisation decides to do we recommend that you use these three principles to guide your work and ensure it remains relevant and that you minimize harm.

Stay informed

It is complex to stay up to date on coronavirus during this pandemic. SARS-Cov-2 is a new virus. There are still many things we are learning about this virus and the disease it causes (COVID-19 or coronavirus disease). Because so much new information is being produced, our first key principle for guiding coronavirus hygiene programming is: stay informed.

With so much new rapidly emerging information, it can be hard to stay up to date. Below we include some advice for staying informed:

  1. Identify key information sources: We recommend regularly checking the websites of your National Ministry of Health, World Health Organisation, and the Centres of Disease Control and Prevention. Following these organizations on social media (Facebook, Twitter) will also allow you to stay up to date on recent news and updates. The COVID-19 Hygiene Hub will continue to update all our briefs and resources based on the latest information too.
  2. Check information before you act on it:  If you see a surprising news story; don’t immediately assume it is true. Take time to look at the sources it is using and see whether that same information is reported elsewhere. If you are unsure it’s best to rely on major international media sources as these will have had to have gone through a range of validation checks prior to publication.
  3. Plan to adapt your programme: When designing a COVID-19 response programme you will need to make decisions without perfect evidence to back it up.  It’s important to continue to pay attention to new information and adapt your programme based on this.

Involve others and stay connected 

The scale of the COVID-19 pandemic is unlike anything we have ever seen before. In order to reduce transmission we need to act fast and at scale. To do this, we need as many people and organisations involved as possible. Our second principle is: involve others in the coronavirus response.

Below we recommend some practical actions for involving and coordinating activities where possible:

  1. Identify people in your existing networks who you could partner with. This could include businesses, community leaders or social and religious organisations. Remember that for businesses their most important asset is their staff, and that social groups couldn’t exist without their members. This is the time where they can show that through clear actions.
  2. Identify where partners can add value: When you are working with different stakeholders get them to focus on their employees or community first by setting up handwashing facilities at the entrance to buildings and in places where they meet. Then get them to think about the various ways they could contribute to your work. Local groups and businesses can provide financial support if that is what is needed but partners can also contribute to your response through skills sharing. Examples of useful skills could include graphic design, media development, IT skills, and website design.
  3. Set up communication channels: When you are working with others make sure to set up communication channels for you to stay in touch should it not be possible for you to meet in person or work from an office. Mechanisms may already exist to support this in your country. For example countries commonly affected by crises often have a National WASH Cluster and the Global Handwashing Partnership is working to establish national handwashing partnerships in many countries. Establishing localised communication channels to bring together key leaders within your community is advised so that you can continue to learn about what is working and share information.
  4. Learn from and build on local community action: Communities will develop their own coping mechanisms in response to COVID-19. Make sure you take time to establish mechanisms to learn from your communities about what is working well and use this to shape and adapt your organisation’s work.

Align your work with the national response

At the moment many organisations and individuals are motivated to play a role in COVID-19 response. However it is important that all efforts are coordinated and adapted to your context. Each country is at a different stage in the pandemic and has a different set of national or local control measures that have been enacted. Therefore our third principle focuses on aligning your work with the national response.

Below we recommend some practical actions to ensure that your work is consistent with national guidance and responsive to the situation in your country.

  1. Be familiar with the government strategy and current guidelines. Normally these guidelines will be widely available or can be found via the Ministry for Health. Countries are also being encouraged to share their plans more widely, for example, this website provides updates about how each nation is responding (this does not cover all countries yet but is expanding). It is important that staff within your organisations adhere to national guidelines since they will often be involved in role-modelling good behaviours during their work with communities.
  2. Be aware of what stage of the response your country is in. The WHO has defined 4 levels of preparedness, readiness and response based on localised patterns of COVID-19 transmission. Organisations should be encouraged to put together a plan for how their work will be adapted at each one of these stages. There are also several global data trackers so that you can keep up to date with confirmed cases and mortality in your region.
  3. Identify high risk areas. Not all areas of a country are at equal risk during the current COVID-19 pandemic. For example COVID-19 will spread more rapidly in areas with high population density such as informal settlements in urban areas or displacement camps. If these settings exist in your country it makes sense to try to prioritise prevention measures in these settings.

Assess the risk locally and based on your organisational capacity

Our fourth guiding principle is take time to assess risk and err on the side of caution. Make sure that you are not putting your staff or communities at risk through your programming. Here are some practical tips for mitigating risk:

  1. Avoid community gatherings: At this point we would recommend that all COVID-19 response programmes avoid using large community gatherings. If, through assessment, you identify that there are no other ways of reaching a community then you could consider organising events where people are physically distanced (such as in the image below where circles have been marked out with coloured sand).
  2. Make a context-specific decision about household visits: In many countries household level visits may still be safe to conduct but before doing this make sure first follow government advice and guidelines and to assess the risk locally. If your staff are in communities make sure they have the ability to practice hygiene regularly and that they maintain physical distancing. You can find out more about how to do this safely in this brief.
  3. Focus on mass media, social media and handwashing infrastructure: Identify or establish ways of reaching populations if in-person work is not possible. This could include radio, television, social media or text messages. Creating handwashing infrastructure will also be key at this time. You can find out more about how to do this here.

Lessons on hygiene behaviour change from La Mosquitia, Honduras

April 27th 2020 at 19:53

By: David Weatherill, CAWST

This article was originally posted on CAWST. 

To learn about hygiene and handwashing behaviour in the Department of Gracias a Dios, Pure Water for the World Honduras and CAWST partnered with UNICEF to complete a Knowledge, Attitudes, and Practices (KAP) study in 2016. Focused on the communities and schools of Puerto Lempira and Villeda Morales municipalities, the study collected and analyzed qualitative and quantitative data from students, teachers, and parents from 12 selected communities.

David Weatherhill, Global WASH Advisor for CAWST reflected, “The Honduras team have great communication skills and they put these skills to masterful use in completing the KAP study, especially when dealing with some sensitive issues such as menstrual hygiene management.”

This 2016 study informed our interventions and education on water, sanitation, and hygiene (WASH) in schools in the region. It remains relevant as a case study, especially now as we influence and motivate hygiene behaviour change all over the world to combat COVID-19. Findings emphasized the need for maintenance of existing handwashing infrastructure and enhancing community norms around hygiene to motivate consistent hygiene practices, and building on the strong, preexisting knowledge of handwashing practices in the communities.

The team used the RANAS model of behaviour change, which looks at the factors of risk, attitude, norm, ability, and self-regulation [1]. More recently, CAWST has been using the Behaviour Centered Design model, which focuses on changes in the environment, triggering changes in the brain and body of target individuals, which then changes behaviour [2].

Read the full case study here.

References

Mosler, H-J. (2012). A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. International Journal of Environmental Health Research, 22, 431-449.

Aunger, R. & Curtis, V. (2015). A Guide to Behaviour Centred Design. London School of Hygiene & Tropical Medicine.

Working with communities to position handwashing for disease prevention

April 24th 2020 at 20:01

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

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

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

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

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

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

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

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

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

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

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

April 9th 2020 at 20:31

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

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

Changing handwashing behaviours is notoriously difficult

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

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

Community engagement is key

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

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

Logistical challenges of community engagement

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

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

What is working and what is not?

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

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

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

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

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

April 11th 2020 at 15:42

By: Julia Rosenbaum, FHI 360

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

Photo credit: nopphonpattanasri/FreePik

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

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

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

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

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

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

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

Incorporate reflexive cues or “nudges” into messaging

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

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

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

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

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

Target the factors that most influence handwashing behavior change

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

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

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

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