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THE HANDWASHING HANDBOOK THE HANDWASHING HANDBOOK 1 Dedication

We dedicate this handbook to Val Curtis who put on the map and shaped the way we understand human behavior.

Val has spent her whole life championing hygiene. In 2001, she saw the potential of bringing science, business, and policy together to promote hygiene. Through her passion, charisma and evidence-driven approach, she brought these parties together, co-founding the Public-Private Partnership for Handwashing with , which then became the Global Handwashing Partnership. Her creativity and advocacy efforts led to the establishment of and the development of countless practical handwashing tools, including the previous version of this Handwashing Handbook.

Val repeatedly broke the ‘academic mould’. She is a fearless visionary, who used her research to drive real change for the world’s most vulnerable populations. Val’s leadership and impact on the sector has influenced the work of every frontline hygiene promoter, every national policy maker, and every line in this updated handbook – and will continue to do so for years to come. THE HANDWASHING HANDBOOK 2 Contents

Dedication 1 Chapter 3: Designing and Implementing Handwashing Programs 25 Abbreviations 3 The Shift in Behavior Change Approaches 26 Global Handwashing Partnership Partners 4 Using Behavior Change Frameworks 27 Acknowledgements 5 Initial Assessment 31 Foreword 6 Steps of the Design of a Behavior Change Program 32 Chapter 1: Introduction 8 Decision 1: Who is the target audience and what is the desired behavior? 32 Purpose of This Handbook 9 Decision 2: What factors or behavioral determinants most influence the target audience members to perform the desired behavior? 33 About the Global Handwashing Partnership 9 Decision 3: What activities best address these key behavioral COVER PHOTO CREDIT: UNITED PURPOSE UNITED CREDIT: PHOTO COVER What’s in This Handbook? 10 determinants and are feasible for the program context and budget? 40 Chapter 2: Making the Case for Handwashing 11 Monitoring and Evaluation 44 Handwashing with Soap as a Preventive Measure 13 Chapter Takeaways and Resources 48 The Challenge of Handwashing Adoption 15 Chapter 4: Improving Handwashing in Specific Contexts 50 Making the Case Within Government 17 Handwashing in Households 51 Making the Case Within the Private Sector 19 Handwashing in Schools 52 Making the Case to Funders 21 Hand Hygiene in Healthcare Facilities 54 Making the Case for Integrating Handwashing into Other Initiatives 23 Handwashing in Fragile and Conflict-Affected Settings 58 Chapter Takeaways and Resources 23 Handwashing in the Workplace and in Public Places 60 Mainstreaming Handwashing Behavior Change into Other Interventions 61 Chapter Takeaways and Resources 66 Chapter 5: Addressing Handwashing at a Systems Level 68 Building Blocks for Handwashing 69 Tips for Building the System 77 Hand Hygiene for All as a Whole Systems Approach 85 Chapter Takeaways and Resources 88 Conclusion and References 90 Conclusion 91 References 93 THE HANDWASHING HANDBOOK 3 Abbreviations

ACF Action contre la Faim BCT Behavior change technique CDC Centers for Disease Control and Prevention CLA Collaborating, Learning, and Adapting CLTS Community-led total CSO Civil society organization GLAAS Global Analysis and Assessment of Sanitation and Drinking- HCAI Healthcare-associated IPC prevention and control M&E Monitoring and evaluation NGO Nongovernmental organization NTD Neglected P&G Procter & Gamble RCT Randomized controlled trial SNA Social network analysis SDG Sustainable Development Goal SWA Sanitation and Water for All UNICEF United Nations Children’s Fund USAID US Agency for International Development WASH Water, sanitation, and hygiene WASH FIT Water and Sanitation for Facility Improvement Tool WHO World Health Organization WSSCC Water Supply & Sanitation Collaborative Council THE HANDWASHING HANDBOOK 4 Global Handwashing Partnership Partners

STEERING COMMITTEE AND STRATEGIC PARTNERS

MEMBERS

Government of Nigeria Ministry of Water Resources

AFFILIATES

Action Against Hunger Handzies Manila Water Foundation Soapbox United Purpose Banka Bioloo HappyTap Medentech Smixin Vaccine Ambassadors Clean the World Foundation icddr,b MSR Soapen WaterAid DefeatDD International Aid PHAAE SpaTap Wellbeing Foundation Africa Eco-Soap Bank IRC WASH Real Relief Splash World Vision THE HANDWASHING HANDBOOK 5 Acknowledgements

This Handwashing Handbook was prepared Partners across all sectors provided technical Collaborative), Sam Stephens (Clean the World and developed by the Global Handwashing expertise and authored sections of this Foundation), James Stix (Gaia Education), Partnership secretariat. The secretariat would handbook. The partnership would like to Jona Toetzke (German Organization), like to acknowledge the many partners who acknowledge Abby Bucuvalas (Sesame Kristie Urich (World Vision), and Sian White contributed to its development. Workshop), Claire Chase (World Bank), Ron (London School of Hygiene & Tropical Clemmer (Global Handwashing Partnerships Medicine) as authors of this handbook. The Handwashing Handbook has emerged secretariat), Aarti Daryanani (Unilever), Lindsay and developed over time. The partnership Valuable contributions were also made by Denny (Global Water 2020), Robert Dreibelbis would like to acknowledge members of the Benedetta Allegranzi (WHO), Boluwatito Awe (London School of Hygiene & Tropical working group who conceptualized and (United Purpose), Ebuwa Evbuoma (Global Medicine), Louisa Gosling (WaterAid), Astrid reviewed the handbook, including Janita Handwashing Partnerships secretariat), Peter Hasund Thorseth (London School of Hygiene Bartell (UNICEF), Claire Chase (World Hynes (World Vision), Dan Jones (WaterAid), & Tropical Medicine), Tom Heath (Action Bank), Ron Clemmer (Global Handwashing Jean Lapegue (ACF), Karine Le Roch (ACF), contre la Faim [ACF]), Torben Holm Larsen Partnership secretariat / FHI 360), Nga Carolyn Moore (Global Handwashing (Real Relief), Bosun Jang (Sesame Workshop), Nguyen (U.S. Agency for International Partnerships secretariat), Thilo Panzerbieter Alison MacIntyre (WaterAid), Priya Nath Development [USAID]), Aarin Palomares (German Toilet Organization), Hope Randall (WaterAid), David Neal (Catalyst Behavioral (Global Handwashing Partnership secretariat/ (PATH), Geoff Revell (HappyTap), Gretchen Sciences/Duke University), Aarin Palomares FHI 360), Julia Rosenbaum (FHI 360), Thompson (FHI 360), Anthony Twyman (WHO), (Global Handwashing Partnership secretariat), Elizabeth Wamera (Water Supply & Sanitation and Megan Williams (Splash). Om Prasad Gautam (WaterAid), Virginia Collaborative Council [WSSCC]), and Sian Roaf (Sanitation and Water for All), Julia This handbook was edited by Ana Hoepfner White (London School of Hygiene & Tropical Rosenbaum (FHI 360), Elizabeth Salvatore (CAWST) and Kathleen Shears (FHI 360), with Medicine / COVID-19 Hygiene Hub). (Sesame Workshop), David Simnick (Soapbox design by Mike Grant (CAWST). THE HANDWASHING HANDBOOK 6 Foreword

The act of cleaning one’s hands is so powerful, so simple, yet so difficult. With handwashing’s amazing protective nature for health, the impact of handwashing also supports other Sustainable Development Goals such as education and . With all its benefits, you might expect everyone to place a great priority on handwashing. Yet, 40% of households do not have handwashing facilities at their homes and only about one-fifth of the world’s population washes their hands after using the toilet. Even in institutions dedicated to health, one out of six health care facilities do not have hand hygiene stations by points of care or near .

Hand hygiene has been neglected too were also widely ignored. In general, public often, despite the benefits of hand hygiene health advancement of handwashing stood being well known for more than 150 years. still for over a century. It was not until the , a Hungarian doctor 1980s, when a string of foodborne outbreaks working in Vienna, is known as the father and health care-associated infections led to

PHOTO CREDIT: FHI 360 FHI CREDIT: PHOTO of hand hygiene. In 1846, he discovered the United States Centers for Disease Control the connection between hand hygiene and and Prevention (CDC) identifying hand hygiene patient survival. He promoted handwashing as an important way to prevent the spread in in Europe, but to no avail, as of infection, heralding the first nationally handwashing was rejected by scientists and endorsed hand hygiene guideline. doctors at the time. A few years later, the The current COVID-19 pandemic has placed a Crimean War brought a new handwashing spotlight on the often-neglected practice like champion. implemented never before. Hand hygiene, whether through handwashing and other hygiene practices in handwashing with soap or the use of - the war in Italy where she worked, based handrub, is a first line of defense to achieving a reduction in infections. Sadly, the contain the pandemic. The pandemic also hygiene practices promoted by Nightingale THE HANDWASHING HANDBOOK 7 Foreword

catalyzed collective action for the future The global initiative is co-led by UNICEF at home, schools, health care facilities, through the Hand Hygiene for All Global and WHO, and the Global Handwashing workplaces, and throughout our communities. Initiative with a vision for 2030… Partnership is a core partner, using our The Handwashing Handbook contains platform as a global advocate and knowledge learnings of our partners who comprise “…to achieve hand hygiene for all — which hub to support efforts for lasting change. the Global Handwashing Partnership. This ultimately means a new way of working and Together, we can respond, rebuild, and resource offers insights of best and promising living, where hand hygiene is embedded not reimagine to achieve the vision of universal practices to support your work promoting only in health systems to prevent infection, hand hygiene. handwashing—to support your journey as a handwashing hero. but also in our everyday lives. It means all For universal hand hygiene to become a people will have access to the supplies reality, each of us has a role to play. We call All the best for clean hands! they need to clean their hands at critical on everyone—no matter what your work is, moments — in public spaces, schools, health how old you are, or where you live—to join us care facilities, workplaces and homes. It also as we collectively move forward in advancing means a fundamental shift in education, handwashing with soap and all of its benefits for health and wellbeing. We can all be Ron Clemmer attitudes and behaviors, so that hand hygiene handwashing heroes to promote handwashing Global Handwashing Partnership becomes normalized and habitual.” PHOTO CREDIT: WORLD VISION WORLD CREDIT: PHOTO THE HANDWASHING HANDBOOK 8 CHAPTER Introduction 1 PHOTO CREDIT: UNICEF CREDIT: PHOTO THE HANDWASHING HANDBOOK 9 1 Introduction

Purpose of This Handbook This handbook is based on the experience of the Global Handwashing Partnership and presents best practices and new concepts to improve the uptake of handwashing. This handbook updates the approaches shared in the previous Handwashing Handbook, which was published in 2005 by the World Bank with support from the partners of the Global Public-Private Partnership for Handwashing (PPPHW), the original name of the

Global Handwashing Partnership. UNICEF CREDIT: PHOTO

Handwashing has been established as a go beyond communities, moving into network of handwashing champions. The component to achieve proper hand hygiene other settings such as healthcare facilities Global Handwashing Partnership encourages and a range of health and development and workplaces. a collaborative approach to handwashing objectives. Since the publication of the programming and believes that actors from all The Handwashing Handbook aims to equip previous Handwashing Handbook, which sectors have a role to play in the advancement handwashing champions in government, civil focused on national handwashing of hand hygiene uptake. society, private sector, and nongovernmental programs, efforts have shifted to addressing organizations (NGOs) with resources handwashing at all levels. Since then, About the and tools. Equipped with these resources, practitioners have moved from implementing Global Handwashing Partnership handwashing champions can strengthen local freestanding campaigns toward a greater systems to support handwashing, and use The Global Handwashing Partnership was focus on advocacy and more integrated these tools for planning and implementing formed in 2001, as government, private sector, programming. The many key learnings from successful programs to change handwashing multilateral organization, and NGO partners those experiences in scaling up handwashing behavior in a variety of contexts. It is based on saw an opportunity to advance handwashing include the need to create an enabling evidence that reflects the collective expertise with soap through programs and policies. environment, the need to ensure long-lasting of the Global Handwashing Partnership and Global Handwashing Partnership’s work handwashing habits through appropriate aims to share lessons learned with a global is built on the foundation of the Central behavior change approaches, and the need to THE HANDWASHING HANDBOOK 10 1 Introduction

American Handwashing for Diarrheal Disease that are necessary to ensure the success of the context is integration into other types of Prevention Program, which demonstrated that a handwashing program. Topics covered in programs, such as early child development large-scale programs with public and private this chapter range from cost-effectiveness to and nutrition. Each situation has its own sector involvement can be successful in the benefits of integrating hand hygiene into conditions, both enabling or hindering the promoting handwashing and reducing disease. education and other programs, all of which practice of handwashing, and these conditions A significant success of the Partnership provide a solid foundation for inclusion of must be considered to ensure context-specific, has been launching and sustaining Global handwashing in a range of different programs. appropriate approaches. Handwashing Day to spread global awareness Designing and Implementing Addressing Handwashing at a Systems Level around the importance of handwashing Handwashing Programs with soap. Additionally, the Partnership was This chapter describes a systems-level instrumental in advocating for the inclusion of This chapter discusses how to motivate and approach to handwashing. Catalyzing a a handwashing target under the Sustainable sustain handwashing as a habit. Behavior widespread increase in handwashing requires Development Goals. The Global Handwashing change strategies are needed to design and a strong enabling environment to ensure that Partnership also serves as a knowledge hub implement initiatives that trigger and maintain the practice of handwashing and its resulting to share best practices and as an advocate handwashing practice. This means putting benefits can be sustained. Addressing for handwashing on a worldwide scale. Learn the desires and needs of the target audience handwashing at a systems level requires more at globalhandwashing.org. at the center and having their perspectives consideration of the multiple actors and influence the nature and scope of activities. inter-relational elements needed to support What’s in This Handbook? Formative research can help program sustainable handwashing outcomes. planners identify the key factors influencing This handbook is divided into chapters, Throughout the handbook, learnings, case handwashing for the specific audiences. described below: studies, and tools are provided to support Making the Case for Handwashing Improving Handwashing in Specific Contexts planning and implementation of handwashing programs. Users of the handbook are This chapter examines handwashing program This chapter provides the foundation for the encouraged to combine these learnings with activities across a variety of different contexts. prioritization of handwashing programming. their own creativity and knowledge to innovate Different approaches for handwashing To achieve success, handwashing programs and optimize the approaches discussed to interventions are needed for schools, must have the support of key stakeholders. improve at-scale handwashing interventions. Governments, businesses, donors, and other healthcare facilities, workplaces, markets, actors can offer unique skills and resources and other public settings. Another element of THE HANDWASHING HANDBOOK 11 CHAPTER Making the Case 2 for Handwashing PHOTO CREDIT: LSHTM CREDIT: PHOTO THE HANDWASHING HANDBOOK 12 Making the Case 2 for Handwashing

Proper hand hygiene is one of the most effective ways to prevent infection and limit the spread of diseases, such as respiratory infections, diarrheal disease, outbreak-related (such as and ), neglected tropical

diseases, and healthcare-associated infections. Hand hygiene is a primary SDG Target 6.2

measure of health and development, and practices include handwashing with By 2030, achieve access soap and use of alcohol-based handrub. to adequate and equitable sanitation and hygiene for all and end open , DEFINITION paying special attention to the The simple act of handwashing has the needs of women and girls and Hand Hygiene vs. Handwashing potential to avert preventable deaths, those in vulnerable situations The terms hand hygiene and on hands or improve healthcare outcomes, and bolster handwashing have often been kill the microorganisms, thus progress in education, equity, and water, used interchangeably; however, reducing the risk of infection sanitation, and hygiene (WASH) to achieve National averages of access to basic hand hygiene represents the and improving health and the Sustainable Development Goals (SDGs). handwashing facilities in households range broader range of hand cleaning wellbeing outcomes. While handwashing access is measured as or disinfecting actions, while from below 10% to nearly 100% in countries Handwashing with soap is a handwashing is a specific hand part of SDG Target 6.2, the impact of good across the world (World Health Organization specific action of hand hygiene hygiene practice. handwashing behavior cuts across the SDG [WHO] & UNICEF, 2017). Even when facilities that involves the use of soap agenda. For example, handwashing supports Hand hygiene is any action of and water to physically remove and supplies are available, handwashing is hand cleaning and disinfecting, dirt, organic material, and efforts to improve education outcomes by not practiced as consistently or as thoroughly including handwashing with soap microorganisms from hands. reducing the number of school days missed as needed. Globally, it is estimated that only and the use of alcohol-based For this handbook, handwashing and preventing diseases that hinder critical 19% of people their hands after contact hand rub. Proper hand hygiene is the key focus, with the child development (WHO, UNICEF, World Bank with excreta (Freeman et al., 2014). Failure should be the overarching overall goal of ensuring proper Group, 2018; USAID, 2018a). to incorporate handwashing into water and goal. Hand hygiene practices hand hygiene. decrease the presence of sanitation programs could dramatically limit the health impact of such investments, THE HANDWASHING HANDBOOK 13 Making the Case 2 for Handwashing

Figure 1: Distribution of Global Child Deaths by Cause (WHO, 2019a)

Acute Respiratory Infections and failure to include handwashing in other 33% 18% programs limits their achievement of their Birth Asphyxia overall goals. 9.20% Congenital Abnormalities Current investments and efforts to improve Malaria HIV/AIDS hygiene are insufficient to achieve the SDGs. 7% 15% Lack of handwashing infrastructure and soap Injuries 2% are recognized challenges (Mwachiro, 2014; Other Kamm et al., 2014). With the exception of 6% 10% responses to outbreaks of disease, such as Ebola or , few programs focus on hand hygiene as a central issue. Within integrated programs, hand hygiene often receives limited focus. Therefore, the need to Handwashing with Soap as a Cairncross, 2003; Rabie & Curtis, 2006; Ejemot champion hand hygiene at policy, program, et al., 2008; Townsend, Greenland, & Curtis, and community levels continues. Making Preventive Measure 2017; Luby et al., 2005). Handwashing can the case for handwashing requires a clear Handwashing with soap can dramatically also limit disease outbreaks, such as cholera understanding of handwashing benefits and reduce the spread of disease, particularly and Ebola, and reduce healthcare-associated what drives the case for investment. acute respiratory infections and diarrhea, two infections by more than 50% (WHO, 2018a). of the leading causes of child death (see QUICK FACTS Figure 1). Despite significant progress, child Handwashing interrupts the of survival remains a critical issue: more than five disease-causing pathogens. For example, it n Handwashing with soap million children younger than five died in 2018 can provide a barrier in the fecal-oral route of n Only 19% of people worldwide can prevent up to half of from these causes (WHO, 2019a). exposure to pathogens contained in human wash their hands after contact diarrheal episodes and acute , the main source of diarrheal diseases with feces. respiratory infections. Research suggests that handwashing with such as typhoid, cholera, and gastroenteric n One in six healthcare facilities n Handwashing with soap can soap can reduce diarrheal episodes by 28 infections. One gram of human feces can have no hand hygiene have as much as a 92-fold to 47% and can reduce acute respiratory facilities at points of care and contain 10 million and 1 million return on investment. infections, such as , by 20 to near toilets. (Majorin et al., 2014). 50% (Ejemot-Nwadirao et al., 2015; Curtis & THE HANDWASHING HANDBOOK 14 Making the Case 2 for Handwashing

The “F-diagram” (see Figure 2), which with soap makes it possible to limit the merit additional occasions for handwashing. summarizes the routes of fecal transmission of various pathogens. For example, it is important to wash hands transmission, identifies handwashing as one before visiting older adults to prevent the People should wash their hands with soap of the major barriers for interrupting the routes spread of COVID-19. Alcohol-based handrub after using the toilet, after cleaning a child’s of fecal pathogen transmission (Wagner () can be used if soap and bottom (or any other contact with excreta), & Lanoix, 1958; Penakalapati et al., 2017). water are not available; however, handrub and before any contact with food, such as Cutting these routes of transmission is key to is less efficacious than handwashing with , preparing food, and feeding others. preventing diarrheal disease. soap (Blaney et al., 2011; Grayson et al., 2009; Children and adults should also wash their Oughton et al., 2009). Even in areas that are highly contaminated hands after playing or working outside and and have poor sanitation, handwashing after touching animals. Certain pathogens

Figure 2: The F-Diagram: Major Transmission Routes of Fecal-Oral Diseases SAFE WATER BARRIER SANITATION BARRIER Fluids “One gram of human

Fields, feces can contain 10 HYGIENE BARRIER HYGIENE BARRIER Floors million viruses and 1 million bacteria” Flies Food

Fingers

Fomites THE HANDWASHING HANDBOOK 15 Making the Case 2 for Handwashing

The Challenge of So, what has been missing in handwashing It needs flexible funding. Traditional input- Handwashing Adoption programs? Changes at the individual, to-output funding models do not always work household, community, institutional, and well to address human behavior. Handwashing If handwashing with soap is so important, why system levels are required for at-scale interventions need flexible funding that allows doesn’t everyone do it? Organizations and improvement of handwashing. In addition, for failure, learning, and iteration. government agencies have been promoting infrastructure, facilities, and markets must be handwashing for decades, providing soap, It needs to be prioritized. Handwashing readily available. building handwashing infrastructure, and improvement is an important element in conducting handwashing training. Yet, rates of Often, even when people have access to soap WASH, health, nutrition, education, and other handwashing with soap are still extremely low, and water and understand the importance of sectors. While handwashing is an aspect as indicated in Table 1. handwashing with soap, proper handwashing of many programs, it is often not the main is not practiced. The frequency with which focus. Changing handwashing behavior can handwashing should be practiced requires be complex, and appropriate prioritization of habitual behavior change at various times. handwashing interventions is necessary. Table 1: Observed Handwashing Behaviors Around Handwashing programs face the following key It takes dedicated expertise. Often, the World (Freeman et al., 2014) challenges to achieving that change: implementing organizations neglect to Region Prevalence of It takes time. Most community members ensure staff have the proper tools and Handwashing know why, when, and how to wash their hands. capacity in social and behavior change After Contact Something else—habitual behavior—gets in to implement effective behavior change with Feces (%) the way of that ideal. It takes time to explore programs. Time, support, and resources Africa 14 and understand the factors that influence are needed to build staff capacity to apply Americas (High-income) 49 handwashing behavior for a target group, and behavior change principles in program design it takes time to design interventions that will and implementation. The time and financial Americas (Low-income) 16 effectively address those key factors. Many investment required to do so are often not Europe (High-income) 44 handwashing promotion programs lead to budgeted for and are therefore out of a Europe (Low-income) 15 short-term changes in behavior, but after a program’s scope. while, handwashing rates may begin to decline. Southeast Asia 17 It is difficult to measure. Effective This can happen because behavior is dynamic. measurement of community-level changes World 19 Over time, the key factors must be reassessed in handwashing behavior is still difficult. and redesigned accordingly. THE HANDWASHING HANDBOOK 16 Making the Case 2 for Handwashing

Program implementers have typically relied Figure 3: Hygiene Improvement Framework (WASHplus, 2016a) on self-reports of behavior and observation of the presence of handwashing facilities and Promotion soap and water, as well as different proxy Access to Hardware measures, but these mechanisms do not and Services n Communication n Social mobilization provide an accurate picture of actual practice. n Soap n Social marketing Data collected through observation can also n Handwashing stations n Advocacy n Water supply be biased because people may change their n Behavioral nudges behavior if they are aware that they are being observed. Investing time and resources into quality monitoring and evaluation for handwashing is critical. Innovation may also be needed to design low-cost, reliable ways to measure handwashing behavior. Furthermore, Sustainable qualitative and quantitative monitoring of Handwashing the ongoing project can provide learnings Behavior to optimize future programs and support adaptive management to adjust the current handwashing program, though though these project adjustments are not always done.

It takes a multi-faceted approach. It is useful Enabling Environment to use a framework that sets out the need n Policies and strategies n Coordination and for a multi-faceted approach to handwashing institutional arrangements behavior to address the above challenges. n Financing One approach is the Hygiene Improvement n Planning, monitoring, and review Framework (see Figure 3), which can be used to guide planning, implementation, and evaluation of handwashing initiatives. The Hygiene Improvement Framework THE HANDWASHING HANDBOOK 17 Making the Case 2 for Handwashing

suggests that access to hardware and such as developing national hand hygiene they involve the purchase and installation services (handwashing facilities), promotion roadmaps and mobilizing in-country resources, of hardware. This is because people can (communication, marketing, and social should also be pursued if appropriate to physically see the government’s impact mobilization), and an enabling environment facilitate and encourage handwashing. in their communities. However, it can be (financing, policy improvement, capacity difficult to make the case for the funding of To ensure handwashing is included as a building, and partnerships) must all be in a software issue. This is because the impact focus in programs, handwashing advocates place to most effectively improve and sustain is more visible for infrastructure (hardware) must make the case to stakeholders, handwashing practice. versus behavior change (software). While including government, private sector, and handwashing has historically been perceived Implementers should consider the role of funding partners. as a software issue, it is important to note access to supplies such as soap and water that improving handwashing requires both in creating better conditions for proper hand Making the Case Within Government hardware and software, with an important hygiene. Often do-it-yourself or low-cost Key drivers of government interest include role for government to enable access to handwashing facilities can be effective in cost-effectiveness, the scale of health issues, handwashing infrastructure and products increasing access in the short-term, but and links to targets such as the SDGs. The (hardware) in public settings and to coordinate families soon abandon both the facilities and increased burden of communicable diseases handwashing behavior change efforts handwashing practice because the facilities among populations due to poor hygiene (software) nationally. are not convenient or easy to use. For longer- practices remains a major concern on the term impact, it is critically important to work agenda, especially in developing with local partners to address gaps in the countries. Governments must supply chain for aspirational handwashing ensure that clean, accessible, TIP facilities and to promote more desirable “do- and affordable water and it-yourself” facilities (IDS, 2020; UNICEF, 2020). sanitation services are Use relevant information

Likewise, it is important to ensure inspirational available and must prioritize Evaluation Country Profiles Use the latest country-specific communication programming that addresses or through the latest GLAAS handwashing as a component information on deaths caused report. Highlighting how a emotional factors that can influence of good health. by diarrheal disease and country is faring against others handwashing, as well as nudges, which help respiratory infections to build in terms of policy and financing Often, water and sanitation the case for handwashing. create subconscious habits of handwashing. for hand hygiene can be key to programs are attractive Data can be found through the Strengthening the enabling environment, influencing national plans. to governments because Institute for Health Metrics and THE HANDWASHING HANDBOOK 18 Making the Case 2 for Handwashing

RESEARCH FINDINGS

Investigations of the economic and societal effects of handwashing, such as reductions in poverty, medical treatment costs, and lost productivity, can help advocates encourage government decision-makers to support handwashing through programs, strategies, and budgets. The possible return on investment for handwashing through avoided healthcare costs and prevention of

Assessing the Economic Impact of Hand Hygiene Promotion CAWST CREDIT: PHOTO productivity loss can make a convincing case for significant government investment in handwashing programs. Hygiene, sanitation, and health investments focused on hand hygiene are among the most cost- effective investments that can be made with public and private resources. While interventions Though some international organizations to improve hand hygiene across a country or facility may require significant financial and human and governments are starting to increase resources, the return on investment is high considering the anticipated reduction(WHO, in 2009a)costs for. Studies investments in hygiene, handwashing is still healthcare-associated infections (HCAIs) and prevented loss of productivity underrecognized in country-level policies, showing this return on investment include the following examples: plans, and activities. Thus, advocacy efforts n Townsend, Greenland & Curtis (2017) estimated national costs in India and China related to diarrhea for handwashing must be made at every and acute respiratory infections attributed to the lack of handwashing with soap after contact strategic opportunity. with feces. Additionally, they examined the costs and benefits of handwashing behavior change programs using -adjusted life years. Expected net returns of a national behavior change program showed a 35-fold return on investment in China (net annual return of US$2.64 billion) and “To ensure handwashing 92-fold return on investment in India (net annual return of US$5.64 billion).

is included as a focus in n Thu et al. (2015) completed a study before and after a hand hygiene promotion program in intensive programs, handwashing care and critical care units of large tertiary hospitals in Vietnam that determined hand hygiene advocates must make compliance, incidence of HCAIs, and associated costs. The program cost was US$6.50 per patient and saved US$1,074 for every HCAI prevented. Even for scenarios with a lower rate of HCAIs the case to stakeholders, than the actual observed rate, the handwashing intervention was projected to have a positive return including government, on investment. private sector, and funding n An evaluation of the cost-effectiveness of the Australian National Hand Hygiene Initiative in 38 of partners.” the country’s largest hospitals found varying levels of return on investment across the different states and territories. Overall, this hand hygiene program proved cost-effective, with a cost of (Graves et al., 2016). AU$29,700 per year of life gained due to HCAI prevention THE HANDWASHING HANDBOOK 19 Making the Case 2 for Handwashing TIP

Speak their language

Whenever possible, use or highlighting the positive examples, research, or stories impact on their workforce from the context most familiar productivity can be key to to a company. For example, private sector engagement. Making the Case Within the aligning handwashing goals Avoid technical jargon, so the with a company’s overall goals Private Sector message is clear. As the private sector moves to focus on stakeholders rather than just shareholders, businesses should play even more of a key time, expertise, and resources in handwashing the company. A healthy workforce and clean role in promoting handwashing. Companies programs, providing an indirect route to a working environment can save the company can affect meaningful change in multiple potential increase in profits. both time and money. During a disease ways: by focusing on their immediate sphere outbreak, such as the COVID-19 pandemic, of influence among their staff and areas of Multinational corporations may see a wider support for hand hygiene among a company’s work, through broader activities linked to benefit of participating in a public-private workforce is more important than ever to corporate social responsibility, and through partnership (PPP) to support handwashing. maintain productivity. their business supply chain if they are involved Involving the international headquarters in handwashing facilities or products. That of a company can help drive country-level Examples of several of the Global is, companies can benefit communities investment. It is possible to unlock financial Handwashing Partnership private sector through corporate social responsibility resources through co-branding opportunities partners’ efforts to support handwashing handwashing programs and companies can by splitting off specific activities of a national is included in the case studies on the improve their workforce productivity through handwashing program for co-branding with a following page. handwashing programs that target their specific company. For example, one company staff and their families. Finding the value- may support a school handwashing program add of handwashing improvement activities in a country, while another company may and aligning the issue with a company’s support handwashing programs for maternity overall social responsibility goals is critical hospitals, all as part of a coordinated to ensuring the support of a company for nationwide handwashing program.

handwashing programs on a larger scale. UNILEVER CREDIT: PHOTO Companies also have an opportunity to When companies have a handwashing promote handwashing within their workforces, product business line, handwashing with the possibility to reduce the spread of promotion programs offer the opportunity of germs, reduce absenteeism and medical extra synergies through investment of their costs, and boost the overall productivity of Handwashing at school helps to create life-long habits THE HANDWASHING HANDBOOK 20 Making the Case 2 for Handwashing

CASE STUDIES Private sector handwashing activities

The private sector engages in global handwashing scale-up, often leveraging country handwashing initiatives and handwashing messages to expand the visibility of soap and hygiene brands. Examples of the private sector’s commitment to handwashing activities include the following:

Colgate-Palmolive Essity Proctor & Gamble Unilever In the context of COVID-19, the Colgate- Essity, a leading global hygiene and health P&G has a long history of promoting Through its Lifebuoy brand, Unilever is Palmolive Company identified the need company, is working with children in handwashing across countries and working to scale up more integrated to empower people to take their health primary schools across the United States within their own workforce. Through handwashing programs with partners. into their own hands, by teaching proper through its Handwashing Works! program. its Safeguard brand, P&G developed an Thus far, Lifebuoy has reached 17 million handwashing techniques and providing The program provides handwashing tools educational, health-focused program people in rural Pakistan and Bangladesh soap to millions in need. Colgate quickly to educators, including lesson plans and in China aimed at reducing the number through its flagship program, School of mobilized five of its manufacturing in-class activities, to promote handwashing of children who suffer from disease. 5, increasing handwashing knowledge by plants to produce 25 million bars of among students. The program’s pilot, The program teaches children healthy 33% and handwashing practice by 43%. specifically made soap. The packaging which was launched in 2018, observed a handwashing habits through a series Lifebuoy also launched an innovative of this soap functions as an educational nearly 45% increase in students’ quality of of interactive games and activities. partnership with the Global Vaccine device, featuring proper handwashing handwashing based upon a scoring system Since the program’s inception in 2007, Alliance (GAVI) in 2017 to protect children instructions and easy-to-follow visuals of steps and length of handwashing. it has reached over 72 million children under 5 from illnesses and premature to overcome language barriers. The Through its Tork brand, Essity has also with handwashing messages that aim death by promoting handwashing soap bars were distributed by Colgate’s developed toolkits to promote hand hygiene to establish good handwashing habits with soap and immunization together. network of partners to communities in 28 in kindergartens and schools with a free at a young age (P&G, n.d.). During the This GAVI–Unilever collaboration is an countries. Colgate-Palmolive also donated handwashing app (Ella’s Handwashing COVID-19 pandemic, P&G has also example of a partnership that used the an additional $20 million in health and Adventure, available for free on iOS and provided monetary and product donations combined expertise of both organizations hygiene products. Colgate repurposed Android devices) and Max’s Handwashing to affected areas such as Wuhan, to help prevent millions of unnecessary its nine US-based Bright Smiles, Bright School, a hand hygiene educational Huanggang, Shiyan, and Huangshi. As child deaths through integrated Futures mobile dental vans to distribute package. With the Tork Clean Care program, part of its COVID-19 response, P&G has programming (Unilever, 2019). To respond health and hygiene products. The vans Essity offers various handwashing and also committed US$10 million for hygiene to the COVID-19 pandemic, Unilever distributed 1.4 million bars of soap, as hygiene tools for work environments, education and product donation to partnered with the United Kingdom’s well as other hygiene products, to school including health care, food services, promote handwashing habits among kids Department for International Development districts and food banks. government, groceries/pharmacies, in underserved communities in the United (DFID) to target 1 billion people through manufacturing facilities, educational States. This new initiative will help reach Hygiene Behavior Change Coalition institutions, and office buildings. For an estimated 48 million kids under the age handwashing programs. example, the Tork VR Hand Hygiene app of 12. P&G also takes pride in promoting is a free educational tool for hand hygiene handwashing within its own workforce, among health care workers. providing handwashing guidance and instructions to all employees. THE HANDWASHING HANDBOOK 21 Making the Case 2 for Handwashing

Making the Case to Funders agreements, or contracts), and the timeline and process for doing so. Increasingly, funds Making the case for handwashing to funders, are distributed at country level, but advocating such as charities, private foundations, and for handwashing may require efforts in both bilateral and multilateral agencies, is similar to the host country and the donor’s country. advocating for government support. Funders Donors are increasingly attracted to programs are interested in maximizing the return on that can leverage various sources of financing, their investment of scarce resources, and whether from public, private, or other sources,

PHOTO CREDIT: GLOBAL WATER 2020 WATER GLOBAL CREDIT: PHOTO will want to know the latest evidence on for interventions and programs. the costs and related effects that can be expected from handwashing approaches (see Multilateral agencies, such as UNICEF, that Research Findings under Making the Case mainly provide grant funding, have programs Within Government). Funders will also want that can support handwashing at country to understand where the greatest needs are level. Development banks such as The World in a country, and the overall gap for meeting Bank have lending programs for water and defined handwashing impact targets. sanitation, early child development, and nutrition that may specify expenditure on To obtain donor support, it is important to hygiene promotion and infrastructure. determine donors’ priorities. Consider where decision-making lies, the mechanisms for obtaining funding (grants, loans, cooperative

“Donors are increasingly attracted to programs that can leverage various sources of financing, whether from public, private, or other Handwashing in healthcare facilities requires commitment and funding sources, for interventions and programs.” THE HANDWASHING HANDBOOK 22 Making the Case 2 for Handwashing

TIP Proposal Writing Include a theory of change. Be iterative and flexible. When developing a proposal for a Program design is not a funder, consider the following tips: one-person job. Theories of change show how While program design should be planned activities will lead to systematic, it is not a linear process. Identify the proposal requirements Pull together a small team to develop predicted outputs, contributing to It is likely that the initial plan may of the donor. the proposal. This could include need to be adjusted to fit within the people at different levels within the desired objectives and goal of Most donors have standardized permissible budget, to be feasible an organization. For example, it is the program. Setting this out for the formats or criteria for receiving within the given time period, or useful to have individuals who are donor is another way of justifying the proposals. Before starting the to allow for unforeseen risks and familiar with the realities of working inputs and program components that process, ensure these requirements security challenges. in the setting where the program are being requested. are understood. will be delivered. Likewise, it may

Understand donor priorities. be useful to include staff based ISTOCK CREDIT: PHOTO within headquarters who may have a Take time to read the donor’s website broader understanding of successful to understand the types of programs approaches for handwashing they have funded previously, as well behavior change. It can also be as their priority funding themes, useful to involve staff who are priority countries, and their overall familiar with developing budgets and aim or mission. If submitting a monitoring and evaluation plans. proposal to a competitive funding call, be sure to understand the aims Follow a systematic process for and constraints of that particular program design and document this in funding call. If the donor has not the proposal. previously funded hygiene programs, Use the proposal writing process a stronger case for the public health to explain how the program will be impact and cost-effectiveness of developed and highlight some key the program may be needed. In all insights to justify design choices. hygiene behavior change proposals, Include an options appraisal which make sure to define the behavioral lists potential courses of action challenge within a given context. against a set of criteria (e.g. evidence of effectiveness, cost, feasibility, political will) to demonstrate why the proposed approach is likely to be best suited to the setting. THE HANDWASHING HANDBOOK 23 Making the Case 2 for Handwashing

Making the Case for Integrating such integration can be found in education. impact has often been a missed opportunity. Handwashing Into Other Initiatives Handwashing facilities as a part of WASH- The benefits of integrating handwashing friendly schools, with WASH education into education, health, early childhood Handwashing interventions are often a part and behavior change along with water and development, nutrition, and equity and of water, sanitation and hygiene (WASH) sanitation facilities, have been shown to inclusion programs, as well as examples of programming, with hygiene being an integral result in a marked improvement in school approaches of integration into these programs, part of WASH programming. Even in WASH attendance and teacher-pupil interaction can be found in Chapter 4: Improving programs, the case must be made for time (WASHplus, 2016b). Another example Handwashing in Specific Contexts. adequate priority being given to handwashing, for integration comes from a professional as water has typically received the greatest procedure context, where handwashing is Chapter Takeaways and Resources focus, followed by a focus on sanitation, at the nexus of infection prevention and Handwashing is a simple, cost-efficient with these two interventions receiving the control measures and better health outcomes practice that can greatly improve public health vast majority of the budget, time—and in healthcare facilities. Yet, recent global and support a range of development goals. consequently—the priority. Catalyzing the estimates suggest that one in six health In fact, handwashing is vital to implementing habit of handwashing, rather than short- care facilities lack hand hygiene facilities at comprehensive, integrated programs to term adoption of handwashing facilities, both points of care and near toilets (WHO & address many health and development issues. requires considerable time and effort, as well UNICEF, 2019). Interventions that promote as expertise to implement best practices. sustainable changes in handwashing behavior Key Takeaways Handwashing cannot be sold short and expect in health care facilities can prevent health n  Handwashing is a simple yet neglected the maximum impact of WASH programming. care-associated infections and other diseases practice. Although handwashing is an Moving beyond WASH and integrating (Brearley, Eggers, Steinglass, & Vandelaer, 2013; easy, effective way to avert preventable handwashing interventions with other related Rabie & Curtis, 2006; Darmstadt et al., 2005; deaths and ensure good health, initiatives should be a high priority. Because Gautam et al., 2017). handwashing rates around the world are handwashing has cross-cutting effects and Many projects and programs integrate far below where they should be. To be is a behavior that is emphasized for infection handwashing into other programming to most successful, health and development and prevention control, safe preparation of leverage the programming for maximum efforts must include strategies to promote food and feeding of children, child health, and impact. However, while integrating and facilitate handwashing. prevention of disease outbreaks, it merits handwashing into related programs can greater emphasis in programs than what it maximize the benefits, this leveraged often receives. One of the many examples for THE HANDWASHING HANDBOOK 24 Making the Case 2 for Handwashing

n Different groups will have different Additional Resources for Making the Case n Centers for Disease Control and motivations to promote handwashing. It for Handwashing Prevention. Life is Better with Clean Hands is important to understand the perceived Promotion Toolkit. This toolkit provides n Global Handwashing Partnership. benefits of investing in handwashing for promotion and outreach suggestions, as Clean Hands for All: A Toolkit for Hygiene different stakeholders. Determine the value well as sample social media messages Advocacy. This advocacy toolkit equips added by handwashing investments and and other online campaign materials hand hygiene champions with tools and incorporate it into advocacy messages to that can be used to make the case for resources for integrating handwashing governments, private sector, funders, and handwashing to specific audiences. messaging into new or existing campaigns other relevant actors. or programs. n Essity. Clean Hands at the Heart of Your n Addressing handwashing practice Business. This infographic explains why n Global Handwashing Partnership. Global requires multiple stakeholders. hand hygiene should be at the heart of Handwashing Partnership Resource Governments play an important role businesses. Hub. This resource hub offers a range of in prioritizing handwashing in national handwashing resources and materials for n Unilever/Lifebuoy. Healthy Handwashing policies, while the private sector, NGOs, handwashing advocacy. Habits for Life. This page has a range of and civil society can provide insights on case studies, materials, and approaches to how to incorporate handwashing into n Global Handwashing Partnership. Hand promote handwashing through advocacy specific activities and contexts. Hygiene in Health Care: Advocacy Pack. and partnerships. This advocacy pack equips champions n Handwashing benefits are cross-cutting. with templates and messages to advocate It is feasible, acceptable, and appropriate for hand hygiene in healthcare settings. to integrate handwashing initiatives into programs focused on goals beyond n Global Handwashing Partnership. proper hand hygiene. Policy makers and Handwashing – Vital for Sustainable implementers alike must look Development. This brief provides toward investing in more integrated key statistics and discusses the handwashing programming to ensure investment case for handwashing with better health, nutrition, education, and soap as it relates to the Sustainable economic outcomes. Development Goals.

 THE HANDWASHING HANDBOOK 25 CHAPTER Designing and Implementing 3 Handwashing Programs PHOTO CREDIT: WATER AID WATER CREDIT: PHOTO THE HANDWASHING HANDBOOK 26 Designing and Implementing 3 Handwashing Programs

Catalyzing handwashing behavior change requires designing and implementing interventions to motivate and sustain handwashing as a habit. This chapter SPATAP CREDIT: PHOTO draws on decades of research and program experience in social and behavior change, recognizing the need to understand the target audience and key factors influencing handwashing behavior, often called behavioral determinants. Despite the act’s simplicity, efforts to improve handwashing can be complex.

Improving handwashing is not a one-time The Shift in Behavior soap (Clayton et al., 2003; Biran et al., 2009; activity, rather it is a practice that must be Change Approaches Scott & Herbold, 2010; Contzen et al., 2015). supported, reinforced, and mainstreamed as Early handwashing promotion typically Such realizations caused handwashing a critical behavior that should be practiced involved teaching populations about disease researchers and practitioners to engage multiple times every day. Proper design of transmission under the assumption that if the skills of social marketing agencies and handwashing programs takes time, resources, people were better informed, they would take health psychologists. They shifted the focus effort, and commitment. Programs must protective action based on their increased away from what those in the WASH sector address the various key determinants for knowledge. However, such approaches had thought would change behavior to focusing handwashing among different audiences minimal success (Clayton et al. 2003; Biran on the opinions, priorities, and needs of the and contexts, and new research is often, et al. 2009; Scott & Herbold, 2010; Contzen et target audiences. Increasingly, programs but not always, needed to identify the al., 2015). Reasons suggested for this lack of incorporated a learning phase prior to key determinants for the target audience. success include that knowledge about hand program design (often described as formative Behavioral nudges are also powerful tools hygiene and disease transmission was already research) to gain a better understanding of to increase the habit of handwashing, if high in most contexts (Curtis et al., 2009; Rabbi the barriers to and enablers of behavior within effectively targeted. Designing a handwashing & Dey, 2013) and awareness of biomedical a specific context (Biran et al., 2005; Scott et program is not quick and easy, but facts appears to be a weak determinant for al., 2007; Curtis et al., 2009; Greenland et al., design efforts will pay off in improved impact routine behaviors such as handwashing with 2013; Xuan et al., 2013; Rahman et al., 2017). during implementation. This shift has led to handwashing program THE HANDWASHING HANDBOOK 27 Designing and Implementing 3 Handwashing Programs

designs that address a range of behavioral widened the lens to identify the most design programs to change handwashing determinants through multiple interactions important behavioral determinants influencing behavior. These frameworks or approaches with communities and a variety of delivery handwashing. Attention then turned to the offer systematic ways to address an channels to change behavior (Greenland et al., role of access to necessary supplies, such otherwise complex design challenge. 2017; White, Hasund Thorseth, Dreibelbis, as water and soap. Because running water is Although the terminology and methods used & Curtis, 2020) often not available or easily accessed in many vary, the process for designing behavior resource-poor countries, innovators developed With growing evidence that hand hygiene change interventions is relatively similar do-it-yourself, low-cost handwashing facilities. knowledge is necessary but not sufficient across these frameworks. Most approaches The limited data available on the effectiveness to trigger handwashing, program planners recommend an initial assessment that PHOTO CREDIT: WELLBEING FOUNDATION AFRICA FOUNDATION WELLBEING CREDIT: PHOTO of such technologies indicate that they may typically involves program designers gathering improve handwashing behavior initially existing knowledge about the target behaviors, (Zhang et al. 2013; Biran, 2011; Husain et audience, and context. Deeper insights are al., 2015). However, when WASH promotion then gathered by carrying out small-scale programs end, communities often end up with research or learning among the target a “graveyard” of dysfunctional do-it-yourself population to assess what the key behavioral handwashing stations (Mbakaya, Kalembo, & determinants are for that target audience and Zgambo, 2020). This happens because the context (or validate the existing evidence). products lack many of the features considered As a reminder, behavioral determinants desirable in a handwashing station, and are defined as factors that influence the because of a lack of focus on providing performance or non-performance of a inspirational programming for real behavior behavior, in this case handwashing. Some change (Devine, 2010). frameworks use the term “factors” while other Using Behavior Change Frameworks frameworks refer to “behavioral determinants.” The next stage involves iteratively creating Navigating the broad range of behavior and pretesting an intervention package to change approaches and understanding the address the key determinants. Then, the full- similarities and differences among them scale intervention is completed, followed by can be a challenge for practitioners. Table 2 evaluation, while monitoring ideally happens summarizes characteristics of some behavior during the program and feeds into improving Leaders can be important influencers for handwashing change approaches that have been used to the intervention. THE HANDWASHING HANDBOOK 28 Designing and Implementing 3 Handwashing Programs

Table 2: Summary of Behavior Change Frameworks and Approaches Often Used to Change Handwashing Behavior

Behavior change Focus Determinants included Tools for Behavior change process How activities or behavior change framework assessing defined techniques are chosen or approach determinants

Behavior General n Brain: knowledge, risk, motives, Formative Five-step process with No specific guidance provided Centered reactions, and psychological research toolkit clear guidance on how to Design trade-offs undertake each: (Aunger & Curtis, n Body: characteristic traits, skills, n Assess (A) 2015) and sensations n Build (B) n Setting: infrastructure, props, roles, n Create (C) routines, and norms n Deliver (D) n Broader Environment: the biological, n  physical and social environment, and Evaluate (E) the wider context COM-B General n Capability: psychological No guidance No guidance provided Choose from the following list of (Michie, van and physical provided behavior change techniques and types Stralen, & West, n Opportunity: social and physical of activities: 2011) n Motivation: automatic and reflective n Knowledge (e.g., feedback on behavior) n Skills (e.g., instruction on how to perform behavior) n Memory, attention, and decision processes (e.g., cues) n Behavioral regulation (e.g., adding objects to environment) Designing General n Self-efficacy/skills Barrier analysis Clear way of analyzing Framework for users to identify bridges for Behavior n Perceived positive and negative with clear findings to recommend to activities Change consequences guidance courses of action for training (Food Security n Social norms and Nutrition n  Network Social Access and Behavioral n Cues for action Change Task n Perceived susceptibility Force, 2013) n Perceived severity n Perceived action efficacy n Divine will n Policy n Culture THE HANDWASHING HANDBOOK 29 Designing and Implementing 3 Handwashing Programs

Behavior change Focus Determinants included Tools for Behavior change process How activities or behavior change framework assessing defined techniques are chosen or approach determinants

FOAM Hand- n Opportunity: access to infrastructure, Guidance on Guidance on operationalizing No specific guidance provided (Coombes & product attributes, social norms how to do programs Devine, 2010) specific n Ability: knowledge, social support formative research, n  Motivation: beliefs, outcome including doer/ expectations, threats, and intention non-doer studies

IBM WASH WASH n Determinants across a range of No guidance No guidance provided No specific guidance provided (Dreibelbis et al., behaviors levels: societal/structural, community, provided 2013) individual, habitual n Determinants across a range of domains: psychological, technological, contextual

Levers of General n Understanding: awareness and No guidance n Make it understood No specific guidance provided Change acceptance provided n Make it easy for children (Unilever, n.d.b ) n Ease: convenience and confidence n Make it desirable n Desirability: self and society n Make it rewarding n Make it a habit

RANAS General n Risk: knowledge, vulnerability, Doer/non- Four-step process: List of behavior change techniques: (Mosler, 2012) and susceptibility doer survey 1 Identify behavioral and n Risk factors (e.g., present facts) complemented n Attitude: beliefs, costs, benefits, contextual factors n Attitude factors (e.g., prompt to talk and feelings with qualitative methods 2 Measure and determine to others) n Norms: others’ behavior, behavioral factors n Norm factors (e.g., prompt others’ disapproval, and 3 Select behavior change public commitment) personal importance techniques and define n Behavioral factors (e.g., prompt n Ability: knowledge, confidence behavioral strategies identification as a role model) in performance, continuation, 4 Implement and evaluate n  and recovery Ability factors (e.g., provide instruction and infrastructure) n Self-regulation: action planning, n  action control, barrier planning, Self-regulation factors (e.g., provide remembering commitment feedback on performance) n Social, physical, and personal context THE HANDWASHING HANDBOOK 30 Designing and Implementing 3 Handwashing Programs

Behavior change Focus Determinants included Tools for Behavior change process How activities or behavior change framework assessing defined techniques are chosen or approach determinants

Social General Includes determinants across a range No guidance No guidance provided No specific guidance provided Ecological of levels: provided Model n Intrapersonal (CDC, n.d.) n Interpersonal n Institutional n Community and policy

Social General No standardized list, but commonly Guidance on Uses a six-step process: Organization around the four Ps Marketing explores: how to assess 1 Getting started of marketing: product, price, place, (NSMC, n.d.) n Knowledge behavioral and promotion determinants 2 Scope n  Current practice qualitatively 3 Develop n External factors affecting the through 4 Implement intervention: socio-cultural, participatory 5 Evaluate technological, economic, ecological, workshops political, legal, and ethical 6 Follow up n Motivation Definestask areas for each n Costs and benefits step

Wash’Em Hand- Focuses on determinants likely to vary Rapid Involves four steps: Decision-making software to (Wash’Em, n.d.a) washing- most substantially in crises, including: assessment 1 Learning about the rapid generate specific handwashing specific n Behavioral setting tools and an assessment tools promotion activities associated n  Disease perception training pack 2 Using the rapid n Context and identity assessment tools n Motives and touchpoints 3 Analyzing the data and entering it into the software 4 Generating recommendations Guidance also provided on monitoring and evaluation THE HANDWASHING HANDBOOK 31 Designing and Implementing 3 Handwashing Programs

Initial Assessment

As the design of a handwashing behavior change program begins, it is important to take advantage of the existing information about the target population and the context-specific conditions. Table 3 provides an outline of

some topics that are useful to understand VISION WORLD CREDIT: PHOTO before designing a program.

Table 3: Topics to Learn About Before Designing a Handwashing Behavior Change Program

Level of information Relevant Topics to Understand Sources

Global n Association between handwashing and public health outcomes Academic journals and (e.g., reduction of diarrheal diseases) NGO reports n Behavioral determinants of handwashing behavior in various settings n Approaches that have been applied to change behavior in other countries and their results

National n Availability of services/facilities (e.g., water, sanitation) National NGO reports, n Local health priorities large surveys, and government data and n  National goals/indicators associated with the target behavior policies. Country level estimates of service coverage are available at the WHO/UNICEF Joint Monitoring Programme dashboard

Local n Availability of services/facilities (e.g. water, sanitation) Small-scale research, n Local health priorities NGO reports, and local government data n  Local efforts and gaps in existing programming and policies n National goals/indicators associated with the target behavior n Behavioral determinants in the specific context Mirrors can be a powerful nudge for handwashing THE HANDWASHING HANDBOOK 32 Designing and Implementing 3 Handwashing Programs

Steps of the Design of a Behavior Decision 1: Who is the impact (e.g., midwives or food-handlers). In Change Program target audience and what is the other cases, a particular audience segment might be targeted because a unique set of Designing effective strategies to change desired behavior? factors or behavioral determinants influence handwashing behavior requires attending to A wide range of audiences may be targeted their practice (or failure to practice) of three key decisions (see Figure 4): as part of handwashing promotion, including handwashing and they cannot be reached with households, schoolchildren, health workers, n Who is the target audience and what is more general approaches. the desired behavior? market vendors, and other types of workers. Identifying which target group to focus on is Primary of children are an n What factors or behavioral determinants key, because the barriers to and enablers of important target audience of handwashing most influence target audience members handwashing behavior may be different for programs because they are responsible for to perform the desired behavior? each group. Putting the needs of the target the children’s hygiene environment. In most audience at the center of the program will help settings, the primary is a child’s n What activities best address these key mother; however, this is not always the behavioral determinants and are feasible enable their handwashing behavior. case. It is important to identify the primary for the program context and budget? Sometimes the target population has already caregiver for a household and document been identified by a donor, funding stream, Figure 4: Key Decisions for the Design of a Behavior Change Program who else participates in caring for the child, or program context, but it may need further such as grandmothers, siblings, and fathers. 3 segmentation or prioritization if the audience School-age children may be a target audience 1 is large or varied. If not defined, target because they are the community leaders and audiences are best selected by consulting caregivers of the future. Furthermore, forming existing data (both epidemiological and good handwashing habits at a young age What Who is the behavioral). This process of further defining an activities best makes one more likely to continue the practice target audience address these audience may be an iterative process, as data and what is in the future. determinants? the desired gathering and planning move forward. behavior? What What is the behavioral objective of a factors or Handwashing programs often target audience determinants handwashing program? For example, the influence that groups whose handwashing behavior can behavioral objective could target children to behavior? have the largest impact. In some instances, consistently and correctly wash their hands smaller segments of the audience may be with soap or other handwashing agents. In identified as priorities because of their direct some instances, it will be vital to define the links to risk behaviors with population-level 2 handwashing behavior in terms of context THE HANDWASHING HANDBOOK 33 Designing and Implementing 3 Handwashing Programs

SYSTEM 2: GOAL-DIRECTED

n Responsible for new and infrequent behaviors and time (frequency and duration), such as Figure 5: Brain Systems (e.g., IUD insertion, indoor residual spraying for malaria) handwashing at home and before preparing n Features of process: food. Also, the desired behavior could be for n Guided by attitudes/goals/values primary caregivers to always wash hands for n Conscious, deliberative at least 20 seconds before picking up or caring n Knowledge of steps can be verbalized for an infant (context) during the first 30 days n Performance is relatively slow, via thought and attention of the child’s life (frequency and duration). Decision 2: What factors or behavioral determinants most SYSTEM 1: HABIT

influence the target audience n Responsible for established, frequent behaviors members to perform the desired (e.g., oral contraceptives, bed net use) behavior? n Features of process: n Guided by “cues” or “triggers” Taking time to understand and assess n Less conscious, more automatic behavioral determinants or the factors that n Performance of steps is not conscious, and they are most influence a behavior is critical so therefore harder to verbalize that a handwashing program can focus on n Performance is quick, using past behavior as a guide, the key determinants. and does not require thought or attention Understanding How Brains Guide Behavior

In recent years, academics and practitioners additional, non-psychological System 2 factors (e.g., program designers have increasingly recognized that behavioral determinants such as hardware availability have assumed that increasing people’s determinants of handwashing can be (Kahneman, 2011). knowledge about germ theory will change their categorized into “System 1” factors (more behavior) and have underestimated System 1 The System 1 and System 2 framework reflexive, habitual determinants) and “System factors (e.g., have neglected ingrained habits provides a powerful reminder that 2” factors (more reflective, conscious decision- and physical cues that can nudge increased handwashing is partly a planned, rational making determinants). Successful behavior handwashing) (see Figure 5). decision but is also heavily influenced by habit, change must address both emotional culture, and “nudges” from the environment. Handwashing habit formation requires motivators (System 2) and physical cues Historically, handwashing interventions converting handwashing from a behavior that to support habits (System 1), along with have often overestimated the importance of people decide to undertake (intention) into THE HANDWASHING HANDBOOK 34 Designing and Implementing 3 Handwashing Programs

an action that is an automatic response and unhealthy habits and replace them with automation. Initially, however, behavior change does not involve the decision-making parts of healthy habits, Neal et al. (2015) recommend a programming must rely on motivational the brain (habit) (Neal et al., 2015). A habit is six-pronged approach (see Table 4). factors, such as social norms, emotional a learned, reflexive behavior that is triggered drivers, and access to enabling infrastructure These principles of habit can help program unconsciously by familiar cues in a person’s and supplies, to drive change. designers reshape behavior change efforts life (Wood & Neal, 2007). Once formed, habits to spark lasting habitual behaviors and Behavioral Determinants and their Influence are easily triggered and prompt a person to handwashing sustainability (Marteau, Hollands, on Handwashing Behavior act as they did in the past, even if that person’s & Fletcher, 2012). Once handwashing becomes conscious mind wants to do something The different behavior change frameworks a habit, key determinants that involve decision- else (Wood & Neal, 2016). Changing habitual incorporate, weigh, and group the behavioral making, such as social norms and emotional behavior typically involves both disrupting determinants in varying ways. For example, drivers, take a back seat as the process existing (unhealthy) habits and promoting the the RANAS framework refers to Attitudes and in the brain evolves from motivation to formation of new (healthy) ones. To break Beliefs as behavioral determinants, while the Table 4: Principles of Habit

Principles Example

Ensure Supportive Environment Environmental cues, such as soap and water, must be immediately and consistently available, to facilitate automatic handwashing behavior. “Handwashing habit formation requires Leverage Context Changes to the physical or action environment, such as motherhood or starting school, can prompt new habits. Handwashing can also piggyback off pre- converting handwashing existing habits. from a behavior that Eliminate Friction Reducing choice, simplifying actions, and diminishing perceived effort can people decide to support habit formation. Making handwashing easy and accessible will help undertake (intention) build habit. into an action that is Provide Ownable Cues Cues trigger handwashing behavior. Posters, colored footsteps, or other local cues can nudge people to wash their hands an automatic response and does not involve the Encourage Practice Having people actively washing their hands through a handwashing demonstration can help them remember the proper technique. decision-making parts of the brain (habit)” Promote Meaning and Motivation Habits are stronger when they have a meaningful purpose, such as when a mother washes her hands to keep her children healthy. THE HANDWASHING HANDBOOK 35 Designing and Implementing 3 Handwashing Programs

Designing for Behavior Change framework captures the same behavioral determinants under the categories of Culture, Social Norm, Perceived Susceptibility, and others. Either of the frameworks could be used to design a successful behavior change program. The PHOTO CREDIT: HAPPY TAP HAPPY CREDIT: PHOTO key to program planning is using evidence to identify the few key determinants most influential in the performance or non- performance of handwashing in the context of the target audience.

Knowledge. Knowledge about handwashing can be defined as knowing the benefits of handwashing, knowing how to effectively wash hands, and knowing when to wash Enabling products facilitate handwashing practice hands. Handwashing knowledge is necessary but not sufficient for motivating people to its importance after defecation and did not practice, and the prominent placement of practice handwashing. Knowledge seems extend to recognition of other key times for those supplies may serve as a reminder to to be context dependent, and increasing handwashing, such as before eating, before wash hands (Contzen & Mosler, 2015; Rabbi & knowledge of a problem without improving serving food, or before handling infants Dey, 2013). The more readily accessed water self-efficacy often leads to psychological (Rabbi & Dey, 2013). Enhancing knowledge is, the more likely individuals are to wash their defense mechanisms, avoidance, or reactance about germs without linking it to something hands with soap and water. rather than changes in behavior (Cho & Witte, of plausible, immediate value, such as lower 2005). A 2017 systematic review showed that Recent studies also suggest that the healthcare costs, is unlikely to lead to higher sanitation- and hygiene-based messaging placement of handwashing supplies at levels of handwashing (Curtis et al., 2009; aimed at increasing knowledge and improving handwashing stations can successfully White et al., 2020). skills resulted in only temporary improvements nudge handwashing practice (Dreibelbis, in handwashing behavior (De Buck et al., 2017). Enabling infrastructure and products. Easy 2016). The selection and placement of In Bangladesh, knowledge of handwashing access to necessary enabling infrastructure enabling technologies can critically influence was mostly restricted to acknowledging and products can facilitate handwashing handwashing frequency and practice. For THE HANDWASHING HANDBOOK 36 Designing and Implementing 3 Handwashing Programs

“Providing soap or another handwashing agent close to the flowing example, commercial and do-it-yourself washing hands is positively associated with water in a convenient handwashing stations can provide flowing handwashing behavior in Haiti, Zimbabwe, and arrangement water, enabling people to practice a key Ethiopia, but not in rural Burundi or in Ghana, element of proper handwashing technique, where perceptions of risk were low (Contzen & increases the rather than having to dip their hands Mosler, 2013; Friedrich et al., 2018; Contzen et likelihood that they into a bowl. Providing soap or another al., 2015; Seimetz et al., 2017; Scott et al., 2007). are used for proper handwashing agent close to the flowing Fear is primarily a driver for handwashing in handwashing.” water in a convenient arrangement increases the case of , such as cholera, but the likelihood that they are used for proper old habits return after the is gone handwashing. In settings such as schools (Contzen & Mosler, 2013; Curtis et al., 2009). or other institutions, placement of several Beliefs and attitudes. Beliefs and attitudes handwashing stations in locations associated can affect handwashing practice. Unlike with a key time for handwashing—particularly other determinants, these two determinants near latrines and or eating areas— consistent handwashing behavior in Haiti are considered umbrella determinants, as can improve the frequency and quality of and India (Contzen & Mosler, 2013; Biran et al., they are broad categories that reflect social handwashing (Dreibelbis, 2016). 2014). Conversely, greater perceived severity norms and perception of risk. Beliefs and of illness is correlated with a lower likelihood Emotional drivers. Emotional drivers can attitudes regarding handwashing are highly of having a handwashing station in Senegal motivate a particular behavior and often culturally dependent, with little consistency (World Bank, 2012)—although in this case, come in the form of emotions, such as status, across studies. In Kenya, women who believe mothers may have perceived more of a risk disgust, and fear. These emotions can play handwashing increases attraction are more because they lacked a handwashing station. a substantial role in handwashing behavior. diligent about handwashing; however, some Other determinants closely related to beliefs On the positive side, individuals desire to be people believe that women who focus on and attitudes that are known to influence admired and respected; this is a driver in areas handwashing are trying to position themselves handwashing behavior are intention where handwashing with soap is a mark of above their neighbors. (Aunger et al., 2010; (Seimetz, Kumar, et al., 2016), commitment status. Likewise, people want to avoid being Curtis et al., 2009). (Contzen et al., 2015), and planning (Contzen & labeled “dirty;” this fear may be intensified Depending on context, beliefs about the Mosler, 2013). following a Community-Led Total Sanitation severity of illness and how handwashing triggering event or similar campaigns (Biran Social norms. Social norms are informal might prevent illness operate in different et al., 2014; Curtis, Danquah, & Aunger, 2009; beliefs or understandings among a group that ways. Perceptions of the severity of illness, Aunger & Curtis, 2016). Disgust about not drives the group’s behavior (Mackie, Moneti, for example, are associated with more THE HANDWASHING HANDBOOK 37 Designing and Implementing 3 Handwashing Programs

Shakya & Denny, 2015). Social pressure to negative norms will require addressing gaps because what people say they do is often practice handwashing operates in complex in provider motivation – which may be best different from what they actually do. That ways. Numerous handwashing interventions addressed through changes in social norms. is, people tend to report their handwashing have found that being affiliated with a group behavior as they perceive it should be done It is important to note that a program may and joining in with what others are doing is a rather than what they actually do. For this not need to address all of these determinants key motivator of handwashing behavior (Biran reason, simply asking questions about to successfully impact handwashing et al., 2014; Hoekstra et al., 2009; Leontsini behavior may not provide a realistic picture of practice. Rather, key determinants should be & Winch, 2014). Failure to establish new actual practices. identified based on the target audience and norms that would support handwashing is behavioral objective. For some behavior change frameworks, sometimes cited as a cause for the failure the primary formative research method is of interventions. Descriptive norms (the How to Collect Information about linked with the framework. If a framework number of people in a community or family Behavioral Determinants is being used which does not have a set who regularly wash hands) are consistently Formative research is often used to support primary formative research approach, the associated with better handwashing behavior the design of handwashing behavior change choice of methods for formative research in various contexts, including in Ethiopia, Haiti, programs. Understanding handwashing could be based on which determinants of and Senegal (Contzen et al., 2015; Contzen & behavior can be complex and challenging behavior need to be studied because they Mosler, 2013; World Bank, 2012). Injunctive norms (when people close to an individual approve or disapprove of a behavior) are DEFINITION similarly significant (Leontsini & Winch, 2014). Social norms also influence behavior in What is formative research? healthcare facilities. One study that observed n Aims to understand what people think, feel, and handwashing behavior in two states in Nigeria do in relation to a behavior found that despite adequate handwashing n Seeks to learn about broader contextual factors facilities and sufficient knowledge, health that may influence behavior care providers did not follow the WHO- n Focuses on generating sufficient information to recommended hand hygiene protocol (Buxton inform program implementation et al., 2019). Non-compliance varied by time  of day but not by type of health care provider. n Involves qualitative and quantitative methods This variation suggests that disruption of n Is often completed rapidly THE HANDWASHING HANDBOOK 38 Designing and Implementing 3 Handwashing Programs

It is also important to remember that no data collection can still yield valuable insights formative research methods are perfect; all through methods such as interviews, focus have biases or weaknesses. For example, group discussions, and observation. Just one quantitative methods have a high degree day of immersion in the lives of the target of generalizability and can be helpful in audience is far better than none, but a week to

PHOTO CREDIT: FHI 360 FHI CREDIT: PHOTO answering the who, what, and when questions two weeks of learning from a population can for program design, but often fail to establish provide a more in-depth understanding. the why and how. Also, quantitative research Many behavioral theories recommend using can be more time consuming due to specific methods to understand different preparation and statistical analysis. Qualitative determinants. For example, Behavior Centered research can complement quantitative Design (see Table 2) has a particularly methods by providing deep insights into the comprehensive list of participatory tools that target audience or contexts, and answering can be used for understanding handwashing some of the why and how questions. or other behaviors. Table 5 summarizes Qualitative research can also be used as some common formative research methods Good formative research requires good planning an exploratory method when not enough along with their strengths and limitations. information is known to construct valid and For examples of techniques to measure are the least known or understood of likely reliable survey instruments for quantitative handwashing, see Table 6. key determinants affecting handwashing research. Through triangulation—using behavior. Formative research builds on different research methods and drawing existing knowledge, and programs can together the findings—researchers can often use previously conducted surveys construct a more complete picture and evaluations to inform their design. For of the current practice of a behavior and example, if data from a previous survey about its determinants. the target audience’s handwashing knowledge is available, formative research efforts should Formative research studies should be focus on understanding other behavioral tailored to program needs and resources. It determinants which seem important but were is optimal to allow sufficient time in the field not explored adequately or clarifying lingering to effectively understand the drivers of target questions from the previous survey about key behavior change, but when this is not possible determinants of handwashing. due to resource constraints, briefer periods of THE HANDWASHING HANDBOOK 39 Designing and Implementing 3 Handwashing Programs

Table 5: Common Formative Research Methods

Method Explanation Strengths Limitations

Focus Group Involves asking a small number of people n Allows consensus to form on specific n Data may not be as in-depth as that Discussions to discuss a range of topics related to their issues related to handwashing gathered with other methods. It can handwashing behaviors n Can be more efficient than other methods be difficult to get honest answers from of data collection participants on sensitive topics, especially within a group discussion

In-depth Interviews Is a qualitative research technique that n Essential to determine ultimate cause n Requires a trained interviewer. Can be explores an individual’s perspective about a of behavior. time-consuming, so this is normally done particular behavior n Can reveal motives and barriers if on a small scale done thoroughly

Observation Involves staff spending an extended n Provides a realistic understanding n Participants should be informed that period of time (e.g., 3 hours each) within of behavior and the context in which “daily routines” are being observed households, observing daily routines it occurs (rather than handwashing behavior) to and behavior n Can identify barriers to ideal behavior minimize bias n Can be time-consuming, so is normally done on a small scale n Households may be hesitant to act in their normal ways in front of a stranger

Surveys Standardized questionnaires that are n Easy to train staff to do n Self-reported handwashing behavior tends administered to a large number of people to n Can be used as baseline data, and then to to be over- estimated, and there may be generate rates of reported behaviors support program evaluation biases in reporting of beliefs or beliefs n Data can be generated only on what is asked, and it is easy to miss information n Collection and analysis can be time-consuming THE HANDWASHING HANDBOOK 40 Designing and Implementing 3 Handwashing Programs

“Behavior change techniques (BCTs) ... serve as a bridge to an Data collected through formative research

can help program designers identify the key activity” UNICEF CREDIT: PHOTO determinants of a behavior for the selected target audience. Those key determinants should be addressed through the selection of program activities, so that barriers are mitigated and enabling factors are built upon, and that leads us to the next decision in the design process. Decision 3: What activities best address these key behavioral determinants and are feasible for The habit of handwashing should start young the program context and budget? change describes how a program proposes behavior. It is important to note that BCTs are Using the information gathered from to bring about a change in behavior or health not synonymous with activities, rather they formative research, program designers select, outcomes, outlining a step-by-step series serve as a bridge to an activity. Examples of refine, and implement a set of activities of causal events. When developing a theory BCTs include providing cues and infrastructure best suited to address the key determinants of change, it is useful to use a “backwards (ability), informing the target audience of of the target behaviors among the target mapping” approach, which starts with the facts from credible sources (information), and audience. Much like matching the right desired impact and outcomes and works prompting feedback on the behavior (self- tool for a job, this involves matching each backwards to identify the short- and medium- regulation) (Michie et al., 2013). A specific behavioral determinant to a proposed activity term actions and objectives required to example of a BCT includes incentives. While to change behavior. The process requires achieve the outcomes (Brown, 2016). incentives are a category of activities, there planners to think about how they will actually are multiple ways incentives could be applied Behavior Change Techniques Make the bring about behavioral change (by identifying in practice through specific activities. Activities Connection to Activities behavior change techniques) and how the should be more specific about the incentive target audience will be reached (by identifying Behavior change techniques (BCTs) are a type type and who, when, and how it is used for appropriate delivery channels). These are or category of activities that are theoretically the program. often combined to create a theory of change informed and correspond with the key Formative research findings must be linked for a behavior change program. A theory of determinants for the target audience and with BCTs and then developed into detailed THE HANDWASHING HANDBOOK 41 Designing and Implementing 3 Handwashing Programs

activity descriptions that can be implemented reach them through different delivery channels. media and the internet, determine which in the program setting. The following Community perspectives can be ascertained websites and social media platforms are frameworks provide additional guidance on during formative research, through either trusted and how they are used within how to make this transition: RANAS process, market research on the target audience or the culture. Wash’Em, and Designing for Behavior Change even simple brainstorming exercises. Accessibility: While overall reach is important, (described in Table 2). When deciding which delivery channels to use, it is also necessary to consider which delivery Figure 6 shows an example of the consider the following: channels are most appropriate for different process of translating formative research segments of the population. Women and Reach: Which delivery channels are available into BCTs, which are then used to develop girls, older people, people with , to the majority of people in the target project activities. people with pre-existing medical conditions, population? If considering mass media, pay people living in rural areas, and other Delivery Channels Bring Communications attention to which stations people tune in to vulnerable groups are all likely to be harder to Life and at what times. Different members of the to reach through most delivery channels. It family may tune into a different station or Community members and/or key informants may be necessary to actively engage these listen at different times of the day. If working should also be consulted when program populations to identify their preferences and in an area where people have access to social planners are mapping out all of the ways to tailor materials to their needs.

Figure 6: Process to Translate Formative Research Findings to Project Activities

Behavior: Behavior change Context-relevant Formative research findings handwashing with soap techniques activity

Context: Students struggle to Use environmental cues Add bright yellow footprints School setting remember to wash to trigger the right to the pathway that leads

in a low-income country their hands with soap behavior in the right from the toilet to the CHILDREN THE SAVE CREDIT: PHOTO with soap at key times situation handwashing facility THE HANDWASHING HANDBOOK 42 Designing and Implementing 3 Handwashing Programs

Credibility and trustworthiness: Which of information often depends on its design, & Curtis, 2017). Additionally, experienced communication channels or individuals do content, and format (e.g., photos and videos hygiene and behavior change professionals people trust or respect? Exploring these may be more persuasive than text alone can provide expertise and assist with the questions with communities may challenge [Joffe, 2008]), whether messages resonate design of activities, including selecting common assumptions about what constitutes with a person’s beliefs and values, and on the most effective communication channels reliable public health information. For example, who shares the information in a person’s for reaching particular audiences and a study among Rohingya refugees living in social network. addressing certain key determinants for the Bangladesh found that during outbreaks target audiences. Interventions that use a range of delivery they preferred receiving information from channels to engage and remind populations Activities of the handwashing program trained community leaders, such as imams of their messages are typically more may include supporting a sustainable and women’s group leaders, over health successful in changing behavior. Selection of increase in access to key handwashing and aid workers who are not always seen the appropriate mix of delivery channels and supplies, such as soap, or supporting the as trustworthy and who are sometimes activities is key to increasing and improving establishment of policies with sanctions to misunderstood (ACAPS, IOM, 2020). Refugees handwashing practice. Planners must promote handwashing by food vendors. As also trusted public health information from carefully design and manage the activities to discussed earlier in this chapter, the presence members of the Rohingya diaspora rather ensure they address the needs and priorities of a handwashing facility can make people than from local news services, because identified through audience research. more likely to wash their hands, so having Bangladeshi and Burmese news services adequate facilities for handwashing is often are seen as stigmatizing refugees, and even Activities for Handwashing Uptake an important issue for programs to address legitimizing violence against them. Translating formative research into BCTs in the contexts being targeted, whether Influence and persuasion: Even though and contextualizing activities is often in homes or in public places. The design certain delivery channels or sources of the most challenging part of designing a and placement of a handwashing facility information may not be seen as credible or behavior change program. To overcome can also help drive behavior. For example, trustworthy, they may still be persuasive or these challenges, it is useful to work with a nudges, such as mirrors at the handwashing influential. For example, many people know to diverse group of actors to develop creative station or footsteps leading from the latrine question the credibility of information they see handwashing activities. This may include to the handwashing station, can encourage on social media. However, people might find creative or marketing agencies, public health handwashing behavior on a subconscious social media posts influential and persuasive practitioners, and representatives from the level, which facilitates habit formation. for a range of reasons. The persuasiveness target population (Aunger, White, Greenland, THE HANDWASHING HANDBOOK 43 Designing and Implementing 3 Handwashing Programs

RESEARCH FINDINGS

Specific activities of a handwashing improvement strategy may also include Using a “Nudge” to Increase the Habit of Handwashing communication activities, such as radio dramas and interpersonal communication, as The term “nudge” was popularized by Thaler and Sunstein’s book of that name, published in 2008. WITHOUT appealing to their rational well as engagement of influential community Nudges involve directing people’s behavior in a particular way leaders to strengthen social norms regarding thinking; providing traditional incentives; or forbidding any options. In other words, nudges use design handwashing at critical times. Placing elements to encourage handwashing behavior on a subconscious, emotional level. handwashing messages at key locations can The use of “surprise ,” transparent soap bars with a toy embedded in the middle, could be . These modified soap bars entice children to wash their hands act as a cue to trigger handwashing behavior. considered a “nudge” (Watson et al., 2019a) Likewise, showcasing the power of soap so they will be able to play with the toy in the middle, making handwashing fun. Another example of a nudge is painting colorful footsteps on the ground leading from school latrines to handwashing stations, through simple and fun activities, such as which was found to be an effective way to nudge children to wash their hands after using the toilet washing hands covered with glitter, can be (Grover, Hossain, Uddin, Venkatesh, Ram & Dreibelbis, 2018). an important visual to increase knowledge In both cases, these interventions were effective at increasing handwashing behavior but did not involve among children. Creating lasting handwashing changing rational thinking (e.g., teaching people about germ theory), offering traditional rewards (e.g., habits requires the whole community to work money), or prohibiting any behavior (e.g., changing rules). Many behavioral determinants could potentially together and adopt handwashing with soap be influenced by “nudges.” However, a concern is whether the impact of a nudge would wear off over time. regularly. Rewarding people or institutions Whether nudges create lasting change or only short-term change warrants further research. as they continue to practice and prioritize a new behavior can be important to move them toward habit formation. Small tokens, such as stickers, or simple praise can provide incentives to sustain handwashing behavior. 2016). Utilizing prominent and respected the target audience and how they interpret For example, USAID’s Clean Clinic Approach figures to encourage handwashing can also the messages or activities. Likewise, listen to focuses on facilitating incremental, low-cost be a way to catalyze long-lasting handwashing the target audience about whether anything is WASH improvements to improve maternal behavior among the target audience. unclear, whether the messages and activities and newborn health outcomes. Clinics that are relevant to them, and how the project After developing an initial draft version of commit to taking the steps outlined in the materials and approach makes them feel. It is a project plan, it is critical to pretest the approach are rewarded with a certificate critical to adjust materials and activities based communications approaches, so that any honoring their commitment to WASH on this feedback, so that the behavior change needed adaptations can be made before (Maternal and Child Health Survival Program, program can be optimized. implementing at scale. Take time to learn from THE HANDWASHING HANDBOOK 44 Designing and Implementing 3 Handwashing Programs

Monitoring and Evaluation supporting continuous learning through to measure progress through both monitoring organizational culture, process, and resources and evaluation activities. Monitoring is an Monitoring and evaluation (M&E) processes (USAID, 2018b). The frequency of monitoring ongoing process and should primarily focus can assess the performance of a project or must match the planned uses of the results of on indicators related to activities and outputs, program, ensuring the program can effectively the monitoring effort. but may also include routine assessment of monitor change. M&E should be thought of intermediate and long-term outcomes of a as a single process, utilizing data collected Evaluation refers to the systematic project. Impact evaluation focuses primarily on an ongoing basis and at different time assessment determining whether a program on the higher-level goals of the theory of points. M&E data support learning and is achieving or has achieved its stated goals change, assessing the achievement of accountability for all stakeholders, including and objectives. There are different types of outcomes and impacts (USAID, n.d.). funders, beneficiaries, implementers, and evaluations and the evaluation design will Figure 7 provides a worked example of policy makers. It is critical to plan monitoring depend on the questions which need to be indicators for a project that plans to change and evaluation processes at the proposal answered. Process evaluations are completed handwashing behavior with the aim of writing stage to ensure M&E processes are to inform the degree of fidelity to the project reducing COVID-19 transmission. sufficiently resourced. design which implementers have had when conducting the project. Impact evaluations Monitoring is a continuous process of PHOTO CREDIT: CAWST determine the effect of the program for the collecting data throughout the lifecycle of a overall long-term outcomes. To support program. It involves the collection, analysis, impact evaluations, baseline studies are often communication, and use of information completed before the project begins to provide about the program’s progress. Monitoring a baseline to measure progress against. Then data should highlight the strengths and at the midterm or end of the project period, a weaknesses in implementation. Adaptive study is completed to determine the overall management allows decisions and results of the project. adjustments to be made in response to changes in the environment. Collaborating, Indicators for Monitoring and Evaluation Learning, and Adapting (CLA) is a framework As part of developing the theory of change and set of practices that promote intentional discussed in the Decision 3 section of this learning and flexible program design by chapter, indicators are developed and defined Handwashing practice can be difficult to monitor THE HANDWASHING HANDBOOK 45 Designing and Implementing 3 Handwashing Programs

The figure uses the following definitions: n Outputs: The direct results of the project n Impact: The long-term, large-scale activities. All outputs are things that can challenge that the program will contribute n Inputs: The raw materials that the be achieved during the period of the to addressing. project requires (e.g., money, materials, project and are linked to the objectives technical expertise, training, relationships, and goals. and personnel) to deliver activities, and achieve the outputs and objectives. n Outcomes: Specific statements of the benefits that a project or intervention is n Activities: The process or actions taken designed to deliver. These should support that will transform inputs and resources the goal and be measurable, time-bound, into the desired outputs. and project-specific. Many projects have more than one objective.

Figure 7: Examples of Indicators for a Handwashing Program

Inputs Activities Outputs Outcomes Impact

Populations have sufficient Program funding Distribution of hygiene kits access to soap Handwashing with soap practiced at key times Reduced incidence of for interrupting COVID-19 COVID-19 Trained staff Repairs to water points Populations have sufficient transmission access to water

Partnerships with Handwashing stations Populations are able to government and other are constructed in public wash their hands organizations in the area places conveniently

Populations find it easy to Nudges are added to remember to wash their handwashing facilities hands at key times

Populations are motivated Radio drama to wash hands at key times THE HANDWASHING HANDBOOK 46 Designing and Implementing 3 Handwashing Programs

Measuring Handwashing There are a range of ways that handwashing is programming can have, and strive toward Behavioral Outcomes commonly measured (see Table 6). optimization of the programming through Collaborating, Learning, and Adapting (CLA) Handwashing behavior is notoriously hard “What gets measured gets done” is a common or another adaptive management approach. to measure (Ram, 2013). This is because it saying that emphasizes the importance of Handwashing is too important to “go through is a routine behavior that typically happens monitoring and evaluation and the careful the motions” of doing a good job on a project, multiple times a day, making it difficult to selection of indicators included in the M&E or for staff to work really hard on a program, accurately recall. It is also a socially desirable plan. The saying can also be interpreted as: only to discover that the design had somehow behavior, meaning people know it is the right “What gets measured gets valued.” All staff missed the mark on effectiveness. The M&E thing to do and will often say that they practice working on handwashing programming should process serves as a tool to optimize the proper hand hygiene even if they do not. value the goals and impacts that handwashing outcomes of the program.

Table 6: Handwashing Measurement Techniques

Description Strengths Limitations

Self-reported behavior This is normally measured via a survey or n Self-reported information is normally Does not provide a reliable understanding interview. There are a range of ways people quick and easy to obtain of behavior due to social desirability bias can self-report aspects of handwashing n Useful to understand knowledge (people are likely to say they wash their behavior. Questions can measure about behavior hands more than they actually do) and frequency, handwashing at critical times, recall bias (people find it hard to remember n  knowledge, product use, and intention Can be used to complement other handwashing frequency accurately) behavioral outcome measures

Proxy measures Proxy measures include assessing an n Quick to collect data (much quicker than Does not reflect actual behavior (including indirect measure of handwashing, such a survey) frequency and timing of handwashing) as availability and use or depletion n Provides a realistic estimate of behavior but it gives an indication of what behavior of handwashing materials. The Joint (much better than self-reported surveys) is likely to be. To do this, it uses an Monitoring Programme hygiene indicator, assumption: if soap and water and a n  which uses a spot-check assessment to Compares program to other handwashing facility are not present see whether there is a handwashing facility handwashing programs around outside the toilet, then hands are not being with soap and water present, is an example. the globe and is used by most washed, as it would be too difficult and national governments inconvenient to do on a regular basis. Even when these things are present, they do not guarantee handwashing, but their presence does create the right enabling conditions, indicating that the family members could easily practice handwashing if they wanted THE HANDWASHING HANDBOOK 47 Designing and Implementing 3 Handwashing Programs

Description Strengths Limitations

Handwashing Ask people to demonstrate how they would n Useful for understanding the factors in This is subject to social desirability demonstration normally wash their hands if at a particular the environment that could enable or bias. When someone demonstrates critical occasion (e.g., after toilet use). prevent handwashing their “normal” handwashing behavior, n Can help to understand behavior within a they will likely show their version of particular context “ideal handwashing” n Can help to inform programmatic changes and improvements to infrastructure

Diary-keeping Participants are given a diary and some n More reliable than asking about self- n Hard to do reliably at scale stickers representing common daily reported handwashing behavior, as the n Needs support and training to be actions. Handwashing is one of many daily participants are not aware of which provided to participants actions. Each day participants are asked to behavior is of interest to the researchers n  record which actions they did. Handwashing may be over-reported due to social desirability bias

Structured observation Data collectors spend an extended period n Measures actual behavior rather than n Time consuming and hard to do at scale of time, e.g. 3 hours or more in each reported or proxy measures n Requires staff to be well trained household, school, or workplace observing n Can be useful to learn about behavior in n Behavior may be affected by the behavior and noting down whether or not context and within daily routines hands are washed at critical occasions. To presence of observers n  minimize bias, participants are not told that Considered the most reliable way of n In some settings, observation may handwashing is being observed, but rather measuring handwashing behavior be unacceptable that the data collectors are learning about daily routines.

Handwashing monitors Handwashing monitors are electronic n Measures actual behavior rather than n Can only measure behavior in the setting devices that are installed in soap reported or proxy measures where they are installed dispensers or taps, to track handwashing n Monitors are normally not visible and n Generates a lot of data, which can be behavior in a particular setting. have no effect on people’s behavior challenging to analyze n Needs specialized expertise to set up n Not normally possible to track who is performing the behavior if multiple people wash their hands in the settings where the monitors are positioned THE HANDWASHING HANDBOOK 48 Designing and Implementing 3 Handwashing Programs

Chapter Takeaways and Resources n Follow a systematic process. n Build on what is known. This chapter Behavior change programs are more provides practical examples of and When designing programs for handwashing likely to succeed when they employ resources from successful (and behavior change, planners must translate an evidence-based, theory-driven and unsuccessful) approaches to behavior theories and frameworks into activities in the systematic process. Clear articulation change. There is no need to start from field. Behavior change frameworks provide of the target audience, desired behavior scratch. Rather, consult and confirm an overarching strategy for interventions and the identification of the key available data and apply best practices. designed to trigger and maintain handwashing behavioral determinants will help practice. Key takeaways include: n Assess and adjust. Monitoring and practitioners to identify the most evaluation are an important part of appropriate behavior change techniques, program design and implementation. activities and channels for an effective Practice adaptive management to allow “Handwashing is too handwashing program. important to ‘go through for adjustments in response to changes the motions’ of doing a n Know the audience. Handwashing in the target audience and environment, behavior change is context dependent. or in areas of programming that could good job, on a project or Different determinants affect the be improved. Share key insights learned for staff to work really handwashing behavior of different throughout the process. hard on a program, audiences. It is critical to understand only to discover that the the target audience and determine what design had somehow would motivate and support handwashing.

missed the mark n Identify determinants that influence on effectiveness.” handwashing practice. It is important to consider the two systems of the brain —“System 1” (more irrational, habitual determinants) versus “System 2” (more rational, conscious decision-making determinants) —when designing behavior change activities. Consider emotional drivers as well as environmental cues. THE HANDWASHING HANDBOOK 49 Designing and Implementing 3 Handwashing Programs

Additional Resources for Designing and background information on the technique n USAID, SCALE & PRO-WASH. Make Me Implementing Handwashing Programs as well as some basic information on a Change Agent. This updated “trainer behavior change theory. of trainers” manual builds the skills of n Global Handwashing Partnership. Using community workers to promote WASH- Nudges to Encourage Handwashing with n Food Security and Nutrition Network integrated and context-specific behavior Soap. This brief describes the role of Social and Behavioral Change Task change in their communities. nudges and provides guidance on their Force. Designing for Behavior Change use as interventions. for Agriculture, Natural Resource n Wash’Em. Wash’Em Tools and Software. Management, Health, and Nutrition. The Wash’Em process is used to design n Global Handwashing Partnership. This curriculum, originally adapted rapid, evidence-based, and context- Communicating Hand Hygiene During from the Academy of Educational specific hygiene programs, with a focus COVID-19. This guidance brief provides Development’s BEHAVE tool, trains on crisis-affected populations. suggestions and tips for accelerating participants to apply the Designing for planning for behavior change initiatives, n WASHplus. Behavior-Centered Behavior Change Framework to improve with a focus on COVID-19. Approaches to Improve Health Outcomes. development programming. This technical brief presents the n Eawag: Swiss Federal Institute of Aquatic n Institute of Development Studies. WASHplus approach to behavior change Science and Technology. Systematic Handwashing Compendium for Low applied in various country settings. Behavior Change in Water, Sanitation Resource Settings: A Living Document. Elements of the brief include the WASH and Hygiene: A Practical Guide Using the This compendium provides guidance Improvement Framework, the BEHAVE RANAS Approach. This manual gives and examples of low-cost handwashing Framework, small doable actions, stages practitioners a tool to use in designing an facilities that can be implemented in low- of change, and the science of habit. effective behavior change campaign. and middle-income countries. The methodology is explained step n World Bank Water and Sanitation by step, all necessary skills and other n UNICEF. Handwashing Stations and Program. Practical Guidance for requirements are described, and possible Supplies for the COVID-19 Response. Measuring Handwashing Behavior. pitfalls are noted. This document explains handwashing This working paper discusses a station designs for policy makers and set of handwashing indicators and n Food for the Hungry. Barrier Analysis implementers, with an emphasis on recommendations for their use in Facilitator’s Guide. This resource guides local manufacturing and procurement country programs. trainers through a step-by-step process for that complement existing technical and conducting barrier analysis and provides programmatic guidance. THE HANDWASHING HANDBOOK 50 CHAPTER Improving Handwashing 4 in Specific Contexts PHOTO CREDIT: WORLD VISION WORLD CREDIT: PHOTO THE HANDWASHING HANDBOOK 51 Improving Handwashing 4 in Specific Contexts

Chapter 3: Designing and Implementing Handwashing Programs provides insights for the scale-up of handwashing that can be applied in a range of contexts. For optimal prevention of the spread of diseases, handwashing must be practiced at home, as well as in schools, healthcare facilities, workplaces, marketplaces, and emergency contexts. Handwashing contributes to achieving the objectives of many different sectors, and thus should also be considered as PHOTO CREDIT: UNITED PURPOSE UNITED CREDIT: PHOTO a part of integrated programming that addresses education, health, nutrition, early child development, and equity and inclusion. Improving handwashing in specific contexts and through integrated programming is discussed in this chapter.

Handwashing in Households different sets of determinants likely influence do with how water and soap are prioritized whether caregivers practice handwashing in households with limited supplies of both. Despite the evidence that hand hygiene is after cleaning a baby’s bottom versus whether Certain members of the household, such inextricably linked to limiting the spread of men wash their hands before eating or after as husbands and mothers-in-law may have communicable diseases, the practice of handling livestock. Therefore, there is no single more influence over when these valuable handwashing in the home is still suboptimal. best practice approach to motivating the resources are bought and used. Therefore, all Limiting disease transmission requires improvement of handwashing in households. family members must be included in efforts to handwashing at several junctures, including increase handwashing within the home. before food preparation and eating, after Chapter 3 reviews the various determinants defecation or cleaning a baby’s bottom, as and their roles in influencing handwashing Successful handwashing improvement in well as after other potential exposures to behavior. Handwashing knowledge is shown the home is often motivated by links to child pathogens, such as contact with animals, to be necessary but not sufficient. Access health and growth; specifically, keeping fecal money, and cell phones. to key enabling products such as water and contamination from being spread from hands soap are fundamental determinants; however, to food and water. Because of this motivating As discussed in the previous chapter, a even when people have access to soap and linkage, handwashing in households is range of behavioral determinants influences water and understand the importance of often an integral part of child and nutrition the practice of handwashing, and these handwashing with soap, they often do not programming. More recently, handwashing determinants likely vary by target audience practice proper handwashing. Though it is has been added to the standard triggering and by juncture for handwashing. For example, difficult to ascertain why not, often it has to event for Community-Led Total Sanitation THE HANDWASHING HANDBOOK 52 Improving Handwashing 4 in Specific Contexts

(CLTS) to complement the objective of CLTS Handwashing in Schools Lack of WASH facilities and hygiene education to move a community away from open in schools is detrimental to the health and According to the WHO/UNICEF Joint defecation. This addition includes a Shit education outcomes of schoolchildren. Monitoring Programme, 31% of schools and Shake exercise that demonstrates the Widespread health impacts, such as diarrhea, worldwide—serving nearly 570 million link between handwashing and preventing intestinal worms, and respiratory infections, children—lack access to basic drinking feces . In Malawi, use of this tool contribute to school absenteeism and water. In sub-Saharan Africa, potable water rather than the standard CLTS triggering increased drop-out rates, whereas having is not available in almost half of the schools. approach led to a 55% increase in households handwashing as well as water and sanitation Globally, more than 620 million children do not installing a new handwashing facility and services in schools has been shown to have access to basic sanitation at school, and a 15% increase in soap being found at the result in a marked improvement in school 900 million lack basic handwashing facilities handwashing facility (Maulit, 2015). On the attendance and teacher-pupil interaction time at school (WHO & UNICEF, 2018). other hand, a study in Nigeria found that (WASHplus, 2016b; Willmott et al., 2015). CLTS with the addition of the Shit and Shake exercise along with a significant additional Schools can create the routine of handwashing for students behavior change approach did not result in substantial changes in handwashing practice. While this intervention did produce slightly better results than implementing CLTS alone, the effects were likely not sufficient to produce an improvement in public health (Biran et al., 2020). This study indicates the need to identify more effective approaches for integrating handwashing into CLTS programming, such as a focus on both handwashing stations and social and behavior change communications while the enabling environment for handwashing is also strengthened. PHOTO CREDIT: SPLASH CREDIT: PHOTO THE HANDWASHING HANDBOOK 53 Improving Handwashing 4 in Specific Contexts

Different interventions have been found to Identify WASH priorities for the context Include the larger community. Handwashing successfully increase handwashing in schools. and audience. Consult with sector experts, programs should understand the power UNICEF’s Three Star Approach encourages advisors, government officials, partners in the of children as change agents, focusing on schools to take simple, inexpensive steps field, community members, and those who will empowering children to share what they that are designed to ensure all students wash directly engage in implementation, such as learn with others. For children’s learning to their hands with soap, have access to drinking teachers and administrators, to help identify have the maximum impact at home, parents water, and are provided with clean toilets priorities and clear learning objectives for and community members should also be (UNICEF, 2013). Likewise, WASH-Friendly the audience. It is important to remember intentionally engaged. Getting buy-in from Schools provide a supportive environment for that these objectives need to be achievable parents will not only make them more reliable water, sanitation, and hygiene services by children. receptive to handwashing messages but in schools, which improves learning outcomes can also lead to stronger community support Develop content that is engaging and fun (FHI 360, 2014). Interventions that are simple, for school infrastructure improvements for the target audience. Define simple key scalable, and sustainable ensure that schools and maintenance. messages and design curricula and content can meet the needs of children. that will convey those messages in a fun, easy- Handwashing infrastructure and the Even where schools have WASH facilities, to-understand way. Ensure that the content availability of soap and running water are physical and social barriers may prevent and materials can be easily implemented by essential for behavior change. Access to some students, such as girls and children the facilitators (teachers, community workers, handwashing facilities and supplies are with disabilities, from accessing these and health practitioners). critical to promoting the day-to-day practice of services. Inclusion requires shifts in not only handwashing with soap at critical times and Create a routine to encourage handwashing the physical environment (infrastructure reinforcing good handwashing habits. throughout the school day. Schools improvements to allow physical access to Schools need to secure the recurrent funding provide a unique environment to encourage facilities) but also in attitudes (reduction required for soap so they can sustain handwashing at key times in the day. in stigma or misinformation) (Staniford & handwashing practices. Because teachers can shape a child’s routine Schmidtke, 2020; Watson et al., 2017). throughout the day, it is possible to build in a Logistics matter. Programming must be For organizations that are developing and routine time for handwashing, such as before intentionally aligned with what is going on at implementing WASH in Schools programs lunch, to encourage the habit of handwashing the school. Consider school term schedules, and content, the following considerations can at key times. Getting children into the habit of holidays and festivals, exam periods, student help ensure a successful, inclusive outcome washing their hands as part of a daily school matriculation cycles, and other items on the including improved handwashing: routine can help ensure this practice becomes school calendar. part of a child’s lifelong habits. THE HANDWASHING HANDBOOK 54 Improving Handwashing 4 in Specific Contexts

CASE STUDY School Program Creating Handwashing Heroes through the WASH UP!

WASH UP!, a school-based WASH In 2015, World Vision and Sesame Workshop launched program that targets children ages six to nine in remote, low-resource communities. The initiative aims to improve children’s WASH knowledge and behavior by using engaging, WASH UP! endeavors to create an play-based materials, such as storybooks and games.

ecosystem for children where they are interacting with key hand hygiene messages in school, PHOTO CREDIT: WORLD VISION WORLD CREDIT: PHOTO learning from their teachers, and accessing infrastructure to support behavior change. Working in 15 countries, WASH UP! has directly reached over 200,000 children, showing significant changes in handwashing knowledge for participating students. Research conducted in Zambia with grade one students showed a 61% increase in knowledge of germs. The program also worked to sustain social impact by catalyzing a disruption in social norms around hand hygiene behaviors and through the power of educating children. For example, in Ghana, children took it upon themselves to build handwashing stations using local materials. In Zambia, children demanded soap from school management to practice handwashing. These incremental moments lead to communities where hygiene is a sustained part of the conversation, and where health behaviors are constantly reinforced at school, at home, and in communities.

Hand Hygiene in Health Care hygiene practices, including handwashing Facilities with soap, is critical to prevent the spread of infection in health care facilities and ensure Health care facilities are intended to be centers the safety of health care workers, patients, of healing, yet millions of people are affected and their visitors (Centers for Disease Control by health care-associated infections each and Prevention [CDC], 2019). On average, year. Recent estimates suggest that globally approximately 15% of patients in lower- and one in six health care facilities —and up to middle-income countries and 7% of patients in 40% of health care facilities in Sub-Saharan higher-income countries are affected by health Africa —lack basic provisions for hand hygiene care-associated infections (Allegranzi, et al., at points of care and near toilets (WHO & 2011; WHO, 2018b; Watson et al., 2019b). UNICEF, 2019). Adherence to proper hand THE HANDWASHING HANDBOOK 55 Improving Handwashing 4 in Specific Contexts

Research shows that simple, cost-effective infection prevention and control (IPC) measures, such as appropriate hand hygiene practices, can reduce health care-associated infections by more than 50% (WHO, 2018a).

In health care settings, hand hygiene through 2020 WATER GLOBAL CREDIT: PHOTO using an alcohol-based handrub or through handwashing with soap and water should be practiced at five critical moments identified by the WHO:

1 Before touching a patient 2 Before clean/aseptic procedures Capacity building should happen in institutions and across the system 3 After body fluid exposure/risk 4 After touching a patient water, sanitation, and hygiene are neglected in are described in the context of the UNICEF/ 5 After touching patient surroundings health care facilities (WaterAid, n.d.). WHO Hand Hygiene for All Initiative (See the (WHO, 2009a). section on Hand Hygiene for All in Chapter 5: WHO identifies eight core components that Addressing Handwashing at a Systems Level). Health care providers must know and make IPC programs impactful and effective understand proper protocols explaining why, at the national and facility level and provides The WHO multimodal hand hygiene when, and how to perform hand hygiene minimum requirements for achieving these improvement strategy, a core component of (WHO, 2009b). They must also have the core components at the country level (WHO, WHO’s guidelines for effective IPC programs, means to follow those protocols. Promoting 2019b). Evidence on hand hygiene supports highlights five elements to improve hand hand hygiene in health care settings requires all the core components with two strong hygiene in health care facilities (WHO, 2009c). working with and through the to recommendations on hand hygiene included This includes addressing infrastructure and drive and sustain behavior change, and move in Components 6 and 8, which detail the resources, training and education, monitoring beyond individual determinants to address need for materials and equipment to perform and feedback, communications and systems and the enabling environment hand hygiene and the need for hand hygiene reminders, and the institutional culture around (WHO, 2009c). Often, health systems are well monitoring and feedback, respectively (WHO, hand hygiene. Programs must also target established in countries, but basics such as 2020). WHO strategies on hand hygiene multiple parts of the health system, including in the context of IPC and WASH programs governance, financing, research, and service THE HANDWASHING HANDBOOK 56 Improving Handwashing 4 in Specific Contexts

effective hand hygiene action during critical behaviors instead of penalizing poor ones. In moments of care. Using WASH FIT’s “essential addition, IPC committees must be active and indicators” can help to quickly identify key hand hygiene should be routinely monitored at gaps and guide the implementation of facility the facility level to ensure sustained adherence improvement plans (WHO, 2018b). Proper to good hand hygiene. WHO core component training on hand hygiene protocols to build 6 emphasizes monitoring and feedback, and PHOTO CREDIT: WATERAID CREDIT: PHOTO capability is also critical for all members includes an auditing process as part of a of the health care workforce (WHO, 2019b). quality improvement process that seeks to Effective training goes beyond simple improve patient care and outcomes. As part didactic classroom messaging, and includes of this IPC core component, hand hygiene innovative approaches with activities informed monitoring and feedback in health care by adult learning theory, such as team- and facilities is strongly recommended by WHO as task-based strategies and bedside mentorship. a national performance indicator. Training models widely used in many resource- Performing hand hygiene at the point of Handwashing is critical for infection prevention and control limited settings —such as step-down training care, preferably using alcohol-based handrub —may not reach all members of the health products if available, or with soap and water care staff and do not address the need for if hands are visibly soiled (and using gloves, delivery, to ensure WASH infrastructure is follow-up or refresher training over time. when recommended) is the basis of IPC. in place and that recurrent budgets provide Pre-service training in hand hygiene should Proper hand hygiene, including handwashing ongoing operations and maintenance to be institutionalized for all clinical staff, in with soap, must be practiced by all in health support handwashing. particular doctors, nurses, midwives, and allied care facilities, including health care workers, health professionals, and hand hygiene should Systems and procedures to procure, deliver, staff, patients, and visitors. WHO strongly be a core part of routine in-service training and manage resources are critical to ensure recommends that hand hygiene materials for all, including cleaners and auxiliary staff. the necessary hand hygiene infrastructure is in and equipment should be readily available Iterative and innovative models for training place. This includes funding for a continuous at all points of care and toilets (WHO, 2019b). are needed. supply of hand hygiene products and Overcrowding in facilities increases the infrastructure, such as hand hygiene stations The effective use of audit and timely feedback risk of infection transmission, which further at all points of entry, points of care, and has been associated with improvements in highlights the need for all visitors and health near toilets. Access to appropriate facilities clinical practice as supportive supervision care workers to protect themselves and others and supplies can support frequent and models that encourage good hygiene through proper hand hygiene. THE HANDWASHING HANDBOOK 57 Improving Handwashing 4 in Specific Contexts

CASE STUDY

Improving Hand Hygiene in a Health Care System

Nkwan Jacob Gobte is a nurse and infection prevention supervisor in Cameroon. When he was originally appointed as an infection and prevention control (IPC) nurse in 2002, his hospital was experiencing frequent outbreaks of neonatal sepsis, which is caused by bacteria and is a consequence of poor hand hygiene and disinfection practices.

Nkwan and his colleagues changed IPC behavior by conducting trainings (teach it), providing appropriate supplies (build it), and empowering facility leaders to take ownership (live it). As a first step, Nkwan facilitated training and education sessions and held one-on-one discussions with hospital staff on the importance of IPC to keep patients safe. Despite some initial resistance,

80% of staff members improved their knowledge of basic IPC principles, PHOTO CREDIT: GLOBAL HANDWASHING PARTNERSHIP HANDWASHING GLOBAL CREDIT: PHOTO including hand hygiene. At the time, no alcohol-based handrub was available at the hospital, which made it difficult to practice hand hygiene during WHO’s five moments. To address this lack of supply, Nkwan and his colleagues decided to produce handrub with locally available ingredients, using the formula recommended by WHO and following specific safety procedures. Within a few months, the hospital staff was making enough handrub to place containers at all workstations and points of care. With the supplies and knowledge in place, Nkwan looked to the piece that would allow the improvements to be sustained: ownership. He convinced the top leadership of the system to prioritize IPC in their facilities. This buy-in resulted in two major policy changes: an IPC nurse was appointed at each facility, and every clinical staff member was required to carry handrub in a pocket for use at here. points of care. Read Nkwan’s full hand hygiene profile THE HANDWASHING HANDBOOK 58 Improving Handwashing 4 in Specific Contexts

Handwashing in Fragile and Conflict-Affected Settings

In settings where there has been an infectious

disease outbreak, natural disaster, armed WASH’EM CREDIT: PHOTO conflict, or forced displacement, the social and physical environments of the affected population are disrupted. Water and sanitation systems are often damaged, and health systems become overburdened or dysfunctional. Such situations create the ideal environment for the spread of pathogens.

It is estimated that 40% of all mortality in the Fragile and conflict-affected settings provide a myriad of contexts and challenges acute phase of a crisis is due to diarrheal diseases (Connelly et al., 2004). Children are particularly vulnerable. For example, during to be condensed and simplified to rapidly The disruptive effects of conflict and conflicts, children younger than five are 20 respond to needs during an infectious disease fragility influence people’s behavior. The times more likely to die from diarrhea than outbreak or humanitarian crisis. determinants of behavior in such settings may be distinct from those in stable settings from violence itself (UNICEF, 2019b). Governments or NGOs are often (White et al., 2020). Handwashing interventions in fragile and responsible for providing handwashing conflict situations should follow the same facilities, soap, and water, in contrast with In fragile and conflict settings, providing principles as handwashing programs in stable settings, where populations are usually access to conveniently located, desirable any other settings. However, the following partially or fully responsible for purchasing handwashing facilities with soap and water is circumstances make humanitarian contexts handwashing products. likely to be the most effective way of changing behavior. Table 7 provides a list of products unique in terms of both programmatic Time, resources, and capacity may be limited that have been demonstrated to be effective constraints and the circumstances that may during a crisis. Hygiene promotion is likely in promoting hand hygiene in emergencies, influence handwashing behavior: to be one of many interventions designed whether through handwashing with soap or to respond to the needs of the affected Program cycles may be shorter. The multiple alternative practices. stages of hygiene program design often need population and improve wellbeing, resulting in many competing uses for scarce resources. THE HANDWASHING HANDBOOK 59 Improving Handwashing 4 in Specific Contexts

Table 7: Products in Emergency Settings The following approaches for designing and delivering handwashing programs have Product Description Source been tested in fragile and conflict settings Jengu Handwashing Facility Jengu is an open-access Jengu, n.d. and deemed feasible and appropriate by handwashing facility that can be built various organizations: locally or procured. It was designed n  through reviewing the literature Wash’Em: The Wash’Em process is and consulting with crisis-affected specifically designed for emergency populations and humanitarians. contexts. This program design process is guided by a set of five easy-to-use rapid Promotion and Practice This kit contains a water container and Elrha, n.d. Handwashing Kit dispenser for making a handwashing assessment tools, which are linked to station that is affordable, durable, a software that translates assessment desirable, and easy to construct. insights into program activities. Wash’Em This kit also contains soap and handwashing reminders. has been used by various humanitarian actors as well as national WASH clusters SuperTowel This product is designed to be an Torondel, Khan, Holm Larsen, & and typically allows for program design alternative to handwashing with White, 2019; White, Petz, Desta, within one week (see Table 2). soap. It is a microfiber towel with an Holm, & Larsen, 2019 treatment. Users dip it n Barrier Analysis: Barrier Analysis is a in a minimal amount of water and rub commonly used survey-based approach it on their hands. The SuperTowel is for identifying the key determinants of particularly useful for settings where water and soap are scarce and for behavior. It has been used by multiple populations on the move. health and development actors in a range of settings, including fragile and conflict Surprise Soap This soap has a toy embedded inside. Watson et al., 2018 settings (See Table 2). Children using this product were n  found to be four times more likely to Mum’s Magic Hands: Mum’s Magic wash their hands with soap. Hands has been developed by Oxfam and Unilever. It provides a set of interactive behavior change activities that are based on storytelling and emotional drivers. The package can be easily adapted to different contexts and has been tested in several emergency settings (see Case Study on following page). THE HANDWASHING HANDBOOK 60 Improving Handwashing 4 in Specific Contexts

CASE STUDY

The program was piloted among mothers across earthquake- Improving Lives in Refugee communities and people affected by floods, affected areas in Nepal and was successful in improving Emergency Settings earthquakes, or other natural or man-made disasters are among knowledge and practice of handwashing with soap during critical through Handwashing the most vulnerable to disease. Lifebuoy teamed up with Oxfam moments throughout the day, such as before eating and after to create a customized program that goes beyond simple product with Soap going to the toilet. Since then, the program has been expanded to donation, seeking to influence behaviors in settings where more than 10 countries. crowding and diarrheal disease are high. The Nepal program showed significant increases in the practice Every situation is different, so the team spoke to women who of handwashing with soap before eating and preparing food (18% were affected by different emergencies—in Nepal, Pakistan, and and 17%, respectively). the Philippines—to better understand the challenges faced in The program also proved to significantly increase the practice of day-to-day life. Unilever and Oxfam also identified the barriers handwashing with soap after going to the toilet; post-intervention, and motivators to behavior change in each of these settings. In 45% more mothers were observed washing their hands with soap. PHOTO CREDIT: UNILEVER CREDIT: PHOTO response, they developed Mum’s Magic Hands, a program that reaches mothers, based on universal insights that can work even in extremely difficult settings.

Personal hygiene, including handwashing humanitarians should try to provide soap and a public place, the risk of spreading disease behavior, suffers when people experience handwashing facilities that are nice to use. is often high because people are in close psychological distress, as is often the case proximity and share eating areas, workstations, Collaboration is an important consideration in fragile and conflict-affected settings. It toilets, and other areas that harbor germs. in the design and delivery of handwashing is important to ensure that the approach programs in fragile and conflict settings. While Workplaces, whether formal (office) or to handwashing improvement in these collaboration between different NGOs and informal (roadside stand), can be breeding settings is sensitive to the broader needs of branches of government is important in all grounds for viruses and bacteria that can the population. For example, the program settings, it is especially critical in emergencies, survive for an extended period of time manager or director may want to explore how where programming can easily become on shared surfaces and spread between a hand hygiene program can be integrated into chaotic or duplicative. individuals via direct or indirect contact and livelihoods programming. (University of Iowa, 2013; Reynolds et al., 2015). During crises, people are also often stripped Handwashing in the Workplace Office surfaces host high bacterial counts, of their agency (forced to rely on what and in Public Places with the highest germ content found in shared organizations provide) and dignity (forced to Handwashing with soap is one of the most spaces such as break rooms, kitchens, and live in circumstances that are much worse effective ways to avoid getting sick and (DeNoon, 2012). Likewise, informal than what they are used to). Hand hygiene spreading illness in public spaces, such as workspaces, such as food stands, are also programs can be designed to help people a workplace or marketplace (CDC, 2016). In a key place for disease transmission (Soon, deal with these circumstances. For example, Baines, & Seaman, 2012). THE HANDWASHING HANDBOOK 61 Improving Handwashing 4 in Specific Contexts

Studies suggest that implementing hand a good alternative if soap and water are hygiene programs at work and in other not available. public settings can increase hand hygiene n Use signage and posters. Signs and compliance (Arbogast et al., 2016; Hubner et al., posters in key areas, such as toilets and 2013; Savolainen-Kopra et al., 2012). kitchens, can remind people to wash their PHOTO CREDIT: CAWST CREDIT: PHOTO The following are important considerations hands at critical times. Remember to for encouraging handwashing at work, in change messages frequently, because marketplaces, and in other public spaces: the same sign or poster is often ignored after being seen routinely. Social pressure n Provide access to handwashing to wash hands around the workplace stations with running water and soap. can also improve handwashing practice Handwashing stations with running among workers, and management water are the basic facilities needed should provide leadership and also for the practice of proper handwashing. encourage employees to step forward as Soap dispensers must be kept full and handwashing advocates in the workplace. functioning. If a workplace does not have a maintenance team, creating a Mainstreaming Handwashing Hand hygiene can be a particular challenge in public places schedule for workers to monitor supplies Behavior Change Into of handwashing materials can create Other Interventions accountability for full access to the means of handwashing. A wealth of evidence supports integrating Proper hand hygiene, including handwashing handwashing into related interventions. with soap, has shown a significant reduction n Offer alcohol-based handrub (hand Handwashing has broad-reaching benefits in employee sick days and self-reported acute sanitizer). Placing handrub dispensers and can have a positive impact on a range respiratory infections and (Hubner et throughout a workplace can also of development sectors. Handwashing al., 2010; Stedman-Smith et al., 2015). encourage regular hand hygiene practices therefore can, and should, be integrated into Despite the evidence, many people when soap and water are not available. related development programs, policies, and often ignore this health-saving practice Washing hands with soap and water is initiatives. Integration of handwashing can be in workplaces and other public settings. the best way to completely remove germs effective in sectors such as education, health, Unplanned absences from work and sick from hands, but alcohol-based handrub nutrition, early child development, and equity employees can cause a loss of productivity. can kill harmful bacteria and is considered and inclusion programming. THE HANDWASHING HANDBOOK 62 Improving Handwashing 4 in Specific Contexts

PHOTO CREDIT: ESSITY Education practice is a critical step in reducing illness and deaths. For example, schoolchildren who Handwashing as part of a full package of wash their hands are up to 50% less likely to WASH services for schools is an important contract pneumonia and experience diarrheal complementary element to education episodes— two of the leading global killers for programming and can improve school children (Luby et al., 2005; Luby et al., 2006). attendance and teacher-pupil interaction Likewise, children receiving handwashing time. Schools also provide a key venue for interventions were 68% less likely to have promoting handwashing with soap during intestinal helminth infections in Ethiopia the formative years of students, when many (Mahmud et al., 2015). habits are being developed. Please refer to the WASH in Schools section in this Handwashing integration is also critical for chapter for a discussion on implementing this other vulnerable groups, such as those living synergistic programming. with HIV/AIDS or those with other pre-existing conditions. Programs should include behavior Health change programming on washing hands Adoption of appropriate handwashing is at critical times and with proper technique needed at scale to achieve numerous health across programs. It is important to integrate goals. The need for handwashing in health WASH policies and guidance into overall care facilities was discussed earlier in HIV programs and policies, as handwashing this chapter, but the potential synergies of impacts are closely linked with the health integrating hand hygiene and health go far outcomes of this group (WHO & USAID, 2010). beyond health care settings. Hand hygiene Integrating handwashing into other health can contribute to better health outcomes for programs, including outbreak prevention, mothers, children, people living with HIV/AIDS, maternal and child health, and neglected and others. In addition, it is an essential part of tropical diseases (NTDs), can help these responses to outbreaks of diseases, such as programs achieve their overall goals. For cholera or COVID-19. example, handwashing with soap can reduce Children are often at particular risk for the transmission of soil-transmitted helminths diseases related to poor water, sanitation, and and other NTDs. Integrating handwashing can Handwashing has cross-cutting impact across hygiene. Proper handwashing access and help increase public trust for NTD treatment different programming THE HANDWASHING HANDBOOK 63 Improving Handwashing 4 in Specific Contexts

CASE STUDY programs, such as mass drug administration, Integrating Handwashing with Programs in Nepal and reduce the likelihood of reinfection among treated populations (WHO, 2015a). Integrating hand hygiene promotion alongside vaccines In 2014, WaterAid partnered with the Family Welfare Division of Nepal’s Ministry of Health can also maximize the impact on a child’s (formerly the Child Health Division) to launch a novel pilot project at scale. This initiative explored whether integrating hygiene into routine immunization could strengthen the health. A caregiver may come to a vaccination vaccination program, improve behaviors, build capacity among health workers, and offer a clinic more than five times over the first two sustained mechanism for integration. A behavior change intervention was designed through years of a child’s life. Leveraging these routine a creative process informed by formative research. The hygiene promotion program was visits to improve the handwashing practices implemented in four districts targeted to caregivers or guardians of children younger than one of the child’s caregiver can ensure an even year of age. Approximately 35,000 caregivers were exposed at least five times to creatively greater impact on child health. designed hygiene intervention activities within a year. A central motivator promoted in these activities was to be an “ideal family.” Nutrition Because handwashing and To create a social desire for key behaviors among caregivers, the program used engaging hygiene activities, such as games, stories, competitions, songs, public commitments, and essential nutrition activities The “first 1,000 days” from all rely on mothers and other rewards. During a 45-minute educational session conducted before each vaccination, five key conception to a child’s second behaviors were reinforced: exclusive breastfeeding, food hygiene, handwashing with soap, caregivers, the integration of birthday plays a key role in handwashing and nutrition household water and milk treatment, and hygienic use of the toilet, including the disposal of the lifelong wellbeing of the programming can occur children’s feces. Visual props and cues, such as branded mirrors, baby bibs, fans printed with seamlessly. After all, families individual. Undernutrition of key behaviors, and messages printed on a vaccination schedule, were used to reinforce these do not divide their day into the mother or child during this nutrition and hygiene behaviors. different sectors; all these time can lead to stunting and Third party evaluators measured project outcomes after one year of activities are part of the life its life-long consequences, implementation. The outcome evaluation showed that the integrated project was effective in changing behaviors, achieving a 51% increase of a family. affecting cognitive function, in the number of caregivers who reported practicing the five nutrition earnings, and even next- and hygiene behaviors. The intervention strengthened routine generation birth outcomes (Crane, Jones, & immunization coverage, reduced drop-out rates, and built confidence

Berkley, 2015; Sharp & Estes, 2010). Without among health workers to implement such novel approaches. good hygiene practices and a safe, clean After the successful pilot, the government of Nepal retained the program in the four districts environment, children suffer from repeated and made a policy decision to expand it nationwide (77 districts total), with a target population diarrhea, intestinal worm infections, and fecal- of 650,000 annually. oral contamination (WHO, 2008; WHO, UNICEF, World Bank Group, 2018). Hand and food hygiene for children when complementary THE HANDWASHING HANDBOOK 64 Improving Handwashing 4 in Specific Contexts

foods are introduced at six months and common WASH programming achieves To address this gap, several stakeholders have continued through 24 months is especially that level of impact (Null et al., 2018; Luby et developed guidance and support documents critical, given the precipitous rise in diarrhea al., 2018; Humphrey et al., 2019; Cumming et for WASH integration into nutrition and when foods and water are first introduced al., 2019). UNICEF & WHO (2019) concluded food security programming. Handwashing to infants. Though there is much left to that the three RCTs highlight the need for and other WASH interventions can be understand about the condition, there is implementation of WASH programming on integrated with nutrition and food security mounting evidence that environmental enteric a systems level, with greater investment in programming in various ways to meet the dysfunction (EED), a chronic inflammation of governance for leadership, policy, planning, conditions, opportunities, and restraints the small intestine, can weaken the body and financing, capacity building, and monitoring of the situation. Case studies from Africa, prevent optimal absorption and utilization as discussed in Chapter 5: Addressing Asia, and Latin America have examined of nutrients, and impair linear growth in Handwashing at a Systems Level. Also, different methods of integration, including infants and young children (Lauer, 2020). other studies suggest the need to focus on national nutrition programs with a WASH Poor WASH conditions can expose the gut multisectoral approaches in the early years to component, large-scale projects aimed at to large quantities of harmful microbes and ensure a hygienic, stimulating, and nurturing reducing malnutrition through a cross-sectoral this has strong biological plausibility to be a environment that enables children to reach approach, WASH interventions integrated into cause of environmental enteric dysfunction. their full potential (Britto et al., 2017). nutrition programming during humanitarian Having both an inadequate diet and poor emergencies, and the co-siting of WASH and Despite multiple commitments to integrate WASH conditions can predispose infants and nutrition activities in nutritionally vulnerable WASH, including handwashing, into nutrition young children to a debilitating life, restricting geographic areas (WHO, UNICEF, U.S. Agency programs, additional progress is needed to cognitive and physical development to an for International Development [USAID], 2015). optimize this synergistic programming extent that cannot be made up in the course of (WHO, UNICEF and USAID, 2015). A more Not only should the designers of nutrition a lifetime (USAID, 2018a). concerted effort to make handwashing programs consider how to include However, findings from three large-scale a priority is needed to prevent the loss of handwashing and other WASH elements, but randomized controlled trials (RCTs) have nutrients and break the vicious cycle of WASH program implementers should consider brought into question the impact of WASH undernutrition resulting from diarrhea and how they can address nutrition as part of an programming on child growth and diarrhea in other infectious disease. integrated approach to expand their impact on poor communities, including how clean the broader outcomes, especially for children. child’s environment needs to be to achieve a significant impact on child health and whether THE HANDWASHING HANDBOOK 65 Improving Handwashing 4 in Specific Contexts

PHOTO CREDIT: ESSITY

Early Childhood Development years, through actions tailored for each age cohort to maximize children’s developmental Early childhood development (ECD) includes outcomes, with handwashing playing a physical, socio-emotional, cognitive, and role for each of those cohorts. The focus motor development during a child’s first of integrated programming and policies eight years of life (WHO, n.d.). These are the should be on children and mothers, as well years when the brain develops most rapidly, as other influential caregivers such as fathers, especially during the first 1000 days. Early grandmothers, and siblings (Dodos, 2017). childhood development forms the foundation Actions to support a child’s handwashing can of the life of each individual. Thus, early begin before a child is even born by installing childhood development ultimately contributes a handwashing station, which sets the stage to all development goals, and several for early handwashing for the child. During other areas contribute to early childhood the neonate period (the first 28 days of life), development. One study found that promotion integrating handwashing by caregivers as a of handwashing for young children resulted step before picking up an infant can have a in those children scoring better on a detailed tremendous impact on neonatal survival and test of their development when they were subsequent development (Rhee, Mullany, & between five and seven years old (CDC, 2012). Khatry, 2008). In addition, washing a child’s Synergies between WASH, nutrition, and early hands provides another opportunity for a childhood development for the wellbeing of caregiver’s nurturing actions to positively young children inspired the formation of the influence a child’s early development. During Clean, Fed and Nurtured Initiative the early years, children are at a time with high (cleanfednurtured.org). capacity for change, and thus creating the UNICEF, WHO, and other development habit of handwashing lays the foundation for and educational agencies address this health and wellbeing throughout one’s entire window of opportunity of the first eight life (Cusick and Georgieff, n.d.).

Handwashing can be an important tool in early childhood development THE HANDWASHING HANDBOOK 66 Improving Handwashing 4 in Specific Contexts

Equity and Inclusion Programs must focus on equity, including Chapter Takeaways and Resources designing and locating handwashing Hand hygiene interventions can contribute Handwashing has cross-cutting effects facilities to be accessible and user-friendly for to equality and empowerment by providing in many different contexts. It is important everyone. Hand hygiene messages should be opportunities for women, girls, people with to understand how handwashing can be communicated in a way that reaches everyone, disabilities, older adults, and other groups optimized for contexts such as schools, including those who have difficulties with to take on new leadership roles rather than health care facilities, and other public places. seeing, hearing, understanding, or moving, and being passive beneficiaries of predesigned Likewise, handwashing should be integrated handwashing illustrations should represent the interventions. This is critical and directly into other health and development initiatives true diversity of communities (Wilbur, 2020). impacts many; e.g., children and adults to leverage impact. Key takeaways from this with disabilities make up an estimated 15% Responsible hand hygiene interventions chapter include: of the world’s population (UNICEF, 2020). must avoid perpetuating gender stereotypes n Identify handwashing priorities based However, making handwashing programs or contributing to harmful norms. Instead, on the context and audience. Developing and policies inclusive and respectful of all they can play a role in encouraging inclusion content that is specific and engaging people does not just happen automatically. It and empowerment by promoting equal to a target audience is critical to ensure requires deliberate focus and the intentional gender roles. For example, communication handwashing behavior change among involvement of specific groups. messages could emphasize a woman’s role as different populations. a professional or leader, in addition to those of n Connect handwashing with other related PHOTO CREDIT: WATERAID a wife and mother. Handwashing messaging should represent people with disabilities development issues to optimize health with dignity and as active agents of change and development outcomes. in society. The integrated nature of the Sustainable Development Goals challenges practitioners and policy makers to adopt strategies that will lead to benefits across multiple areas. Integrating handwashing into related health and development initiatives can drive progress across the SDG agenda. THE HANDWASHING HANDBOOK 67 Improving Handwashing 4 in Specific Contexts

Additional Resources for Improving n Global Water 2020. Ten Immediate n WHO & Neglected Tropical Disease NGO Handwashing in Specific Contexts WASH Actions in Healthcare Facilities Network. WASH and Health Working for COVID-19 Response. This brief Together: A ‘How-To’ Guide for Neglected n Global Handwashing Partnership. describes ten immediate WASH actions Tropical Disease Programmes. This Hand Hygiene Profile Series. that low-resource health care facilities toolkit provides step-by-step guidance on This series provides case studies can undertake with a limited budget and how the WASH and NTD communities highlighting handwashing heroes in health compiles resources for action in health can engage with one another and work care settings. care facilities. collaboratively to improve delivery of n ACF. WASH’Nutrition. This practical water, sanitation and hygiene services n International Labor Organization. Hand guidebook provides recommendations to underserved populations affected by Hygiene in the Workplace: Policy Brief. for increasing nutritional impact through many neglected tropical diseases. This policy brief emphasizes that safe integration of WASH and nutrition and healthy working conditions are n WHO, UNICEF, & USAID. Improving programs. fundamental for decent work conditions Nutrition Outcomes with Better Water, n Essity/Tork. Tork “Safe at Work” Toolkits. and highlights the need for hand hygiene Sanitation, and Hygiene: Practical These toolkits can support businesses to prevent the spread of diseases in a Solutions for Policies and Programmes. in creating a safer work environment work setting. This document summarizes the evidence through hand hygiene. Current toolkits on the benefits of WASH for improving n UNICEF. Field Guide: The Three Star are available to support governments, nutrition outcomes and describes how Approach for WASH in Schools. This field health care facilities, food services, WASH interventions can be integrated into guide provides an overview of the Three manufacturers, groceries and nutrition programs. Star Approach and how it can be applied pharmacies, educational institutions, and to improve WASH in schools. office buildings. n WaterAid Australia. Towards Inclusive n GIZ and UNICEF. Scaling Up Group WASH: Sharing evidence and experience Handwashing in Schools: Compendium of from the field. This publication provides Group Washing Facilities Across the Globe. a practical guide to achieve equity and This publication introduces the concept inclusion in WASH programming around of group handwashing and discusses the world. the principles and basic requirements for handwashing facilities. THE HANDWASHING HANDBOOK 68 CHAPTER Addressing Handwashing 5 at a Systems Level PHOTO CREDIT: FHI CREDIT: PHOTO THE HANDWASHING HANDBOOK 69 Addressing Handwashing 5 at a Systems Level

Despite its simplicity, handwashing is a complex issue. If handwashing is to be practiced universally and sustainably across a country, focusing on the handwashing behavior of individuals is not enough. Creating an enabling environment to support the scale-up of handwashing requires a focus on the whole system, including the many actors and PURPOSE UNITED CREDIT: PHOTO their interrelationships, which can enable handwashing to be practiced at homes, schools, workplaces, health care facilities, and other public settings. The focus on local systems for handwashing at the national, regional and community levels is based upon the understanding that “achieving and sustaining any development outcome depends on the contributions of multiple and interconnected actors” (USAID, 2014).

DEFINITION Building Blocks for Handwashing effectively. An indication of how effective these building blocks are functioning can be System “building blocks” are one way to found in the reports of the WHO/UN-Water What is a Local System? understand and tackle the complexities of the Global Analysis and Assessment of Sanitation system to support handwashing. Sanitation A local system is the interconnected and Drinking-Water (GLAAS) initiative, and Water for All (SWA) defines the building set of actors that jointly produce a particularly the 2020 report on hygiene (WHO societal outcome. “Local” refers to blocks for systems as: coordination and & UN Water, 2020). The report examines actors in a country and can be at institutional arrangements; policies and national policies, plans, targets, and finance. the national, provincial, district, and strategies; financing; planning, monitoring, It shows that countries often have national community level. and review; and capacity development (see policies and plans for hygiene; however, they Figure 8). The interactions and collective lack the financial and human resources to performance of these fundamental elements fully implement the policies and plans to of the larger system are what allows the improve hygiene, such as handwashing with system to function and strengthening these soap. By assessing these building blocks and building blocks will strengthen the system. the linkages between them in more detail, For handwashing practice to be optimally practitioners can identify specific scaled up and maintained, every actor and gaps to target in interventions, to achieve every element of the system must function larger impact. THE HANDWASHING HANDBOOK 70 Addressing Handwashing 5 at a Systems Level

Figure 8: SWA Handwashing Building Blocks

Strengthen the enabling environment for hand hygiene (SWA Building Blocks)

Coordination Planning, Policies and Capacity and institutional Financing monitoring, and strategies development arrangements review

Coordination and Institutional Arrangements essential to achieving their objectives, with organizations. Coordination mechanisms government agencies providing appropriate should be inclusive, allowing for participation The aim of systems thinking is to identify, leadership (IRC WASH, 2018a; WaterAid, 2017; of a broad range of stakeholders in dialogue understand, and amplify approaches that USAID, 2014). These actors include the private and identification of mutual interests in service build on complex synergies and relationships sector, civil society organizations, faith-based delivery and hand hygiene learning. among a myriad of stakeholders and actors. organizations, funders, and government At a systems level, achieving and sustaining Mapping the system can provide a better entities across different ministries, from the handwashing outcomes depends on all the understanding of the actors, resources, community to the national level. actors in a system doing their part to promote and coordination mechanisms that affect handwashing and viewing handwashing as The ministries responsible for health and water handwashing in a country (See the Tips resources are usually charged with ensuring for Building the System section of this a hand hygiene directive and more generally chapter for more detail on mapping the assure the quality of water, sanitation, system). Leveraging the whole local system DEFINITION and hygiene services. While institutional can ensure there are no major gaps in the arrangements vary, these ministries play a enabling environment, and leads to greater Institutional arrangements leadership or coordination role, integrating sustainability, adaptability, and accountability. refer to formal relationships and WASH into long-term initiatives. It is critical It is critical that actors understand their roles mechanisms for communication, that the leaders of the system understand the and their needed interactions with others; collaboration, and coordination among capacity and resources that each organization policies and strategies can help to provide the key actors in a country. has available to perform its role in the clarity for these roles and coordination, as system to support handwashing as well as shown in the next section. the coordination mechanisms among these THE HANDWASHING HANDBOOK 71 Addressing Handwashing 5 at a Systems Level

Policies and Strategies agencies can provide an understanding of Examples of such policies for institutions how handwashing policies and strategies include requiring handwashing prior to food Policies and strategies are mechanisms are prioritized. Some agencies have stand- preparation at a school or handwashing by which a government sets out its vision alone handwashing policies and guidelines, for birth attendants at a health care (policy) and determines its plan of action but it is more common for handwashing to facility. Another example of a strategic (strategy). This process includes establishing be incorporated into national policies and policy to support handwashing is one that objectives and setting national standards frameworks for sanitation, health, or other requires budgeting for the construction for hand hygiene, which have cross-cutting related topics. For example, in Mali, both and maintenance of water supply and effects across multiple sectors. National handwashing stations and latrines are handwashing infrastructure, for any building policies should identify targets to improve requirements for communities pursuing Open project at an academic institution. handwashing infrastructure and provide Defecation Free certification (WHO, 2015b). guidance on strategies and institutional Policy frameworks for countries and arrangements for achieving those targets. Policies should also be utilized at institutions, institutions can provide clarity on roles and Policies that include timebound targets to such as schools or health care facilities, yet responsibilities for management, from funding benchmark advances in scaling up hand the development and use of policies for to daily maintenance. hygiene can help catalyze and motivate institutional settings are often overlooked. continued progress on increasing the uptake of hand hygiene, especially through handwashing with soap (WHO and UNICEF, 2020).

Policies and strategies should provide guidance for investment to support hand PHOTO CREDIT: UNICEF CREDIT: PHOTO hygiene. Clear policies and strategies can help define the institutional arrangements, responsibilities, and interactions of different actors. They can also help clarify ownership, management, and accountability mechanisms for WASH services within institutions. Comprehensive mapping of policies that address handwashing across THE HANDWASHING HANDBOOK 72 Addressing Handwashing 5 at a Systems Level

CASE STUDY Nigeria’s National Hygiene Promotion Strategy

The Nigeria Federal Ministry of Water Resources, with the support of Hygiene promotion interventions are cross-cutting, and this strategy UNICEF, DFID, and the European Union, developed the National Hygiene contributes to child health, education, and overall development in the Promotion Strategy, along with guidelines for hygiene promotion in country. Thus, partnerships are needed among various stakeholders communities and schools. The strategy serves to support people from all levels of the system (national, state, community, and schools). across the country in sustaining hygienic behaviors and brings high The table below highlights some of the partners in this strategy and visibility to hygiene promotion activities. Find the full strategy here. their roles and responsibilities.

Roles and Responsibilities Partner National State Community School Timeline

Federal Ministry Policy development, Implementation of CLTS triggering by local Providing water and Until 2025 of Water engagement with partners community-led total government area team, sanitation facilities Resources and donors, monitoring, sanitation, including training of volunteers coordination training for CLTS and and health professionals, hygiene promotion monitoring activities

Federal Ministry Policy development Identify and focus on Train and sensitize Support daily Until 2025 of Health with childhood-related malnutrition-sensitive relevant groups at handwashing activity diseases, link hygiene areas, diarrheal infection, community level for in each school and the promotion with nutrition cholera, and related areas hygiene promotion and adoption of hygiene and other related issues CLTS activities habits by pupils

Donors Increase financial aid to - - - Until 2030 support every Nigerian adopting good hygiene practices

Civil Society, Build an environment Help states to build a Support communities Support schools to build Until NGOs that supports hygiene supportive environment to build a supportive a supportive environment 100% of promotion for hygiene promotion environment for hygiene for hygiene promotion objectives promotion are achieved THE HANDWASHING HANDBOOK 73 Addressing Handwashing 5 at a Systems Level

There are several pitfalls related to policies Financing and strategies that should be guarded Systems level support for sustained against in scaling up handwashing. One handwashing uptake requires enough funding issue that can arise from handwashing being to cover current and future costs. Realistic, included in broader policies or strategies,

transparent budgets with funding streams 360 FHI CREDIT: PHOTO rather than as a stand-alone hand hygiene identifiable for handwashing are needed. focus, is that handwashing does not receive Countries with established national hygiene appropriate priority in the documents or in the policies and plans should make sure the plans programming being completed in accordance are costed and that financial and human with the documents. Another common issue is resource needs will be met for implementation that much of the handwashing programming of the plans. Scaling up handwashing will is completed by NGOs and CSOs, which may require substantial investments in upgrading not follow the requirements and guidelines or maintaining facilities and infrastructure, of the handwashing policies and strategies. completing formative research to design The work of NGOs and CSOs is critical in their effective behavior change programming, support of handwashing, as can be seen in promoting hand hygiene practices, and the example of the Nigeria strategy. Even integrating hygiene in government processes while these organizations are trying to support such as planning, monitoring, and review. handwashing, when they do not follow the Budgets at different administrative levels must “Countries with government vision for handwashing, they address handwashing needs if the targets for can cause negative effects upon the country established national hand hygiene are to be achieved. system that is supporting handwashing. hygiene policies Another issue is that often there are good However, current levels of funding to support and plans should policies and strategies, but there is a lack of handwashing are largely inadequate for make sure the plans funding for implementation, which leads us to support of the scale-up of handwashing. are costed and the next system building block of financing. Strengthening finance means improving that financial and existing financing mechanisms and increasing human resource the overall flows into WASH and related sectors (IRC WASH, 2018b). Hand hygiene needs will be met for actors can advocate for allocation of implementation of the plans.” THE HANDWASHING HANDBOOK 74 Addressing Handwashing 5 at a Systems Level

budget lines for handwashing programs where return on investment for support of Scaling up and sustaining handwashing is they do not currently exist or are inadequate. handwashing programming, tracking the best supported by a government-led, multi- While many of these advocates are cost and impact of handwashing programs stakeholder cycle of planning, monitoring, outside of government, there is a need for within more national programs will further and learning. Where such sector planning handwashing advocates within governments build the case for handwashing, especially processes are weak or not in place, partners to make a strong case for funding to for the country of the study, as well as for should jointly support efforts to build and support handwashing. neighboring countries. strengthen them. Just like there is often a need for advocates for greater budgets The benefits of handwashing are compelling Planning, Monitoring, and Review to support handwashing, handwashing for a government or agency’s related interests, Government leadership is essential for advocates are needed to advocate for especially when the perceived threats to allocating, directing, and coordinating internal adequate planning, monitoring, and review for national health are considered more drastic, and external resources in accordance with handwashing. Sometimes the best advocacy such as during a cholera or coronavirus national priorities, strategies, and plans. is to offer to help government colleagues to outbreak. Even in normal health situations, the return on investment for handwashing, Representatives from across the system are needed for planning, monitoring and review with the cost savings of productivity losses and health care costs avoided, provides a compelling case for officials responsible for public finance. Refer to the research findings in the Making the Case Within Government section in Chapter 2 for results from studies regarding return on investment.

Setting budgets based on hand hygiene targets and tracking hygiene expenditures can help develop a culture where hand hygiene investment is prioritized. In Uganda, for instance, providing a budgeting tool for hand hygiene and other WASH expenditures facilitated district-level allocations without the need for extensive advocacy (WASHplus,

2014). While there is evidence for a good 360 FHI CREDIT: PHOTO THE HANDWASHING HANDBOOK 75 Addressing Handwashing 5 at a Systems Level

plan and facilitate the process for planning, in reference to national policies, plans, and of actors can be held accountable (IRC monitoring, and review. In this way, the targets, along with robust methods for WASH, n.d.; UNICEF, 2019a). Accountability process is catalyzed, and steps need to be gathering and using data. These methods mechanisms should facilitate critical built into the process to ensure its long-term should include monitoring systems to reflection on progress toward the uptake sustainability. And sometimes the advocacy track the progress toward strengthening of handwashing, and support planning starts with making the case that inclusive and the enabling environment for hand hygiene for adjustments in programs to optimize systematic planning, monitoring, and review as well as the progress in the practice of scale-up. For example, organizations can are needed to achieve systems-level goals to handwashing. Hand hygiene data collection share achievements through a newsletter to support hand hygiene. should be mainstreamed into routine stimulate sustained involvement. Monitoring administrative data collection systems (e.g., and review should cover not only the When national handwashing plans and management information systems) as well implementation efforts of the system actors, targets are set, systems for monitoring, as surveys or spot checks (e.g., household but also cover the progress and health of the evaluation, and review must be established. surveys, regulatory checks) (WHO and UNICEF, system itself. Acts of sharing information, Key performance indicators should be defined 2020). Existing monitoring and indicator loaning equipment, or formally agreeing

PHOTO CREDIT: WELLBEING FOUNDATION AFRICA FOUNDATION WELLBEING CREDIT: PHOTO systems include the WHO/UNICEF Joint to support an effort are indicators that the Monitoring Programme indicators for hygiene system is healthy and growing (FHI 360, 2020). in households, schools, and health care Capacity Development facilities, as well as the WHO/UNICEF Water and Sanitation for Health Facility Improvement The enabling environment for hand hygiene Tool (WASH FIT) (WHO & UNICEF, n.d.; requires skills, knowledge, and leadership to WHO, 2018b). Progress towards systems support the uptake of handwashing. Capacity improvement goals could be tracked in the building and development plans address GLAAS reports data. Reviews of performance the capabilities of institutions to fulfill roles through multi-stakeholder platforms and and responsibilities at scale, including the dialogue mechanisms are needed to optimize availability of necessary structures, tools, the learning for programming. training, and incentives (Sanitation and Water for All, 2020). Individuals in different sectors These planning, monitoring, and review and at various levels should have the capacity processes should be accompanied by clear to effectively engage in the system to support mechanisms for mutual accountability, in handwashing through their roles as policy which decision makers and each group Capacity development must be done across the system makers, researchers, implementers, funders, THE HANDWASHING HANDBOOK 76 Addressing Handwashing 5 at a Systems Level

and advocates. People working in hygiene All stakeholders need to have the capacity have diverse training and backgrounds, with to adapt their actions based on changing some being health staff while others will be contexts, to support an enabling environment engineers, social scientists, and behavior for handwashing. Throughout the system, change practitioners. One of the challenges for capacity building needs to optimize the handwashing is that each of these professions support for handwashing, and adequate may use different terminology about hygiene. budget and time need to be invested to ensure Therefore, part of the capacity building needs adequate capacity building is completed. to be learning the terminology of others in the system, so that good communication can be facilitated. “part of the capacity building Mapping existing capacities can help planners needs to be identify gaps and opportunities for capacity learning the development. workers and other staff members will likely need terminology training in the implementation of hand hygiene of others in improvement activities. Investing in leadership the system, development is also key at institutional and so that good community levels. Building the understanding communication of return on investment for handwashing can be facilitated.” is important among finance ministry staff, as well as health and WASH professionals. Training personnel in providing supportive supervision is key to ensuring the various multi-sectoral responsibilities to support handwashing are carried out. Facilitating PHOTO CREDIT: WSSCC knowledge exchange can provide best practices and lessons learned for capacity building and development. THE HANDWASHING HANDBOOK 77 Addressing Handwashing 5 at a Systems Level

Tips for Building the System them, to form national or subnational level the flow of information among stakeholders handwashing partnerships. This helps to representing diverse interests and agendas. With the building blocks from earlier in the enhance the collaboration of partners to Likewise, this team should maintain close chapter to provide a guide for systems a higher level. Accountability is also an contact with all stakeholders and support strengthening interventions, the tips for important element to ensure the system is them in organizing events, sharing information, activities discussed in this section have functioning to support handwashing and maintaining focus on their commitments proven to be valuable approaches to build as desired. to collaborative action. In this way, the reliable, sustainable, and resilient systems. members of the systems strengthening Without leadership, no change to a system Leadership for Systems Strengthening team stimulate momentum and promote can be accomplished, so establishing the Effective systems strengthening requires a accountability for meeting the targets that initial leadership for system strengthening leadership team with strong communications groups pledge to meet. Sharing—and even is the first step in the journey toward a capabilities, as well as a good understanding publicizing—the fulfillment of these stronger system to support handwashing. of systems strengthening and how to promises helps build collective enthusiasm Throughout the process, advocacy can be support improved networking within a and momentum. necessary to motivate actors to take the system (FHI 360, 2020). Individuals from action that is needed to accomplish the entities that have specific responsibilities for change. Collaboration catalyzes strengthening DEFINITIONS handwashing are natural candidates for a of relationships between the organizations systems strengthening team for handwashing, within the system, building up to the point of Systems strengthening since improving the system falls within their fostering collective impact. Another crucial team work responsibilities. However, if the team early step in strengthening the system is A team that is formed to lead the members do not have expertise in systems to know it well and understand its current improvement of networking and strengthening, expert technical assistance to condition. This is accomplished through capacity building within a system support their efforts is recommended, and mapping the system. While establishing could possibly be provided by an NGO with leadership for change and mapping the Cross-sector advisory systems strengthening expertise. system are two of the first steps for system committee change, these steps are revisited throughout The systems strengthening team handles A group formed to make recommendations for the system the system strengthening process. As many of the tasks related to partnership strengthening process. It includes key the groups of the system come together coordination and relationship building. The groups across the network, as well as for collective action, it may be desirable team should remain neutral, while facilitating thought leaders who are experts in for a subset of the organizations, or all of the development problem THE HANDWASHING HANDBOOK 78 Addressing Handwashing 5 at a Systems Level DEFINITION

Social capital

is the strength of bonds within each group, as well as of the bridges to other groups within the system. It The initial system mapping (see the is developed through the growth of Mapping the System section later in this interpersonal relationships, shared chapter) becomes the basis for identifying goals, cooperation, and trust. and inviting core stakeholders into the systems strengthening process. A cross- sector advisory committee can be valuable Catalyze Collaboration and Build action. It is essential that these populations in ensuring that viewpoints and expertise Social Capital have a voice in planning for handwashing from the many relevant sectors are taken into behavior change. account. This committee can further expand A focus on building social capital among the system mapping process, ensuring a system stakeholders from the outset can An example of a collaboration that could be wider scope of related issues and facilitate better system strengthening leveraged to greatly improve handwashing stakeholders is included. Their knowledge outcomes (FHI 360, 2020). Social capital is practices is for handwashing behavior from different experiences, viewpoints, and essential for stimulating collective action change programs to be closely linked and networks allows the understanding of the within a system, and for sustaining that implemented in conjunction with water supply system to expand in multiple directions, progress over time. Strengthening bonds programs. This collaboration is catalytic for shedding light on the complexity of within sectors and building bridges across handwashing because the ease of obtaining relationships and underlying challenges. sectors creates more social capital and water makes handwashing much less of a catalyzes more momentum for change. family burden, and this reduction of burden A systems strengthening team and the Improvements in the level of communication is especially true when families have piped cross-sector advisory committee should among stakeholders and in the connection of water to their houses. These times of change consider not only stakeholders who are their relationships is a condition for sustained of rapid development of a benefit for the actively engaged in handwashing and collective action and impact. household and community offer a unique related issues, but also new partners (such opportunity to promote handwashing. as media, influential personalities, and The system that supports handwashing is religious leaders) who are important to any “owned” by multiple sectors. Different sectors To support this collaboration, bonds need to social change process. This growing list of often speak “different languages,” so learning be strong across two very different sectors: individuals identified in the network can serve how to listen and understand each other is water supply professionals, who have an as an invitation list to the first formal system an important foundational step. Also, the engineering and technical background; and strengthening event (see Foster Collective system may include marginalized populations behavior change specialists who have a very Impact section later in this chapter). who have far less power than other actors, different background, focused on “soft” skills. but have important roles to play in collective Agreeing on collaboration for common goals THE HANDWASHING HANDBOOK 79 Addressing Handwashing 5 at a Systems Level

group thinks that the handwashing behavior Advocacy change group is holding up the pace of the Advocacy is critical at multiple junctures of the intervention. However, recognizing potential systems change process. From rallying behind conflicts ahead of time, and then planning an initial vision to scaling up handwashing for how issues will be addressed, also builds efforts, advocacy is needed to motivate PHOTO CREDIT: FHI 360 FHI CREDIT: PHOTO social capital between the groups—not just in and inspire actors in the system to achieve the planning phase, but also when problems improvements in policy, investment, planning, are addressed satisfactorily during the and monitoring to support overall system implementation phase. change. For effective advocacy, it is important Building professional relationships across the to develop targeted messages based upon two groups is an important step in building specific “asks” and audiences. For example, social capital. One of the steps for building an “ask” could target a country’s government these relationships is to allocate time for officials to develop finance strategies and interpersonal discussions and facilitating budgets that allocate resources for design of Building social capital across the system these discussions to explore personal or a nationwide handwashing behavior change professional commonalities. Two people program and support for all of the actors of is a significant step towards establishing might think the other’s profession is a the system to implement the program. social capital, but working through a detailed mystery to them, but they also might find planning process of how to coordinate these There are several mechanisms for great commonality in their management different activities builds even more social handwashing advocacy. One of the most style to motivate optimal performance capital between the groups. Learning to effective ways to advocate for an issue is to through supportive supervision. Exercises speak each other’s technical language is an speak directly with decision makers, either to help groups within the system to find important step for these two groups, since through various communication channels those commonalities will support growth of their professional terminology is so different, or in person. National-level decision makers, professional relationships and development and any questions about terminology should such as those within ministries of planning, of social capital within the system. be addressed in the planning process. It is finance, WASH, public health, and education Ultimately, that social capital will help to not just language, but also approaches which are important audiences, as are their regional-, catalyze collaboration between the groups, differ, as water supply programming can have provincial- or district-level counterparts. Direct strengthening of the systems, a much different schedule from behavior outreach to these decision makers can help and an enhanced enabling environment change programming. This can create conflict drive investments toward handwashing and for handwashing. between the two groups, as the water supply mobilize participation from other actors, THE HANDWASHING HANDBOOK 80 Addressing Handwashing 5 at a Systems Level

including communities, the private sector, civil the focus and pressure on decision makers an opportunity to draw attention to hand society organizations, and other stakeholders, to take action in adequately supporting hygiene on a worldwide scale. It is important to develop and support sustainable handwashing programs. Likewise, community that these days are used to drive action. For handwashing solutions. events can draw attention to handwashing example, a global advocacy day could be as an important issue that impacts the used as a platform for governments and other Media, whether traditional or social media, can community. The use of commitments has system leaders to pledge their commitments also be a powerful tool to convey advocacy also been used to improve the strengthening to prioritize handwashing through their messages. Media can help others learn of handwashing systems. Advocacy days, respective agencies or organizations. about the need for hand hygiene, and can put such as Global Handwashing Day, provide

CASE STUDY

Global Handwashing Day Global Handwashing Day provides a platform n Budget lines dedicated to handwashing Is More Than Just a Day for advocates to raise awareness of the behavior change importance of handwashing on a global scale. Global Handwashing Day has served as a catalyst However, awareness alone will not achieve for high-profile events where government success. Appropriate financing and government leaders have announced new handwashing- commitment are required to drive progress related initiatives or policies. In the Philippines, in handwashing. for example, local and national government Since the inception of Global Handwashing Day departments used Global Handwashing Day 2010 PHOTO CREDIT: WSSCC CREDIT: PHOTO in 2008, an increasing number of national and to collectively pledge to promote handwashing with local governments have committed resources, soap as part of a healthy school environment for established policies, and implemented programs to all children nationwide. The departments of health, support handwashing with soap. In previous years, education, social welfare, and development signed government commitments have included: an intra-governmental agreement and worked to enforce handwashing practices within schools. In n Commitments to integrate handwashing into another example, as part of Nigeria’s “Clean Nigeria school curricula and teacher training programs Campaign”, Global Handwashing Day 2019 served n Policies to ensure handwashing stations are as an important reminder of the need to incorporate built alongside new latrines handwashing targets. THE HANDWASHING HANDBOOK 81 Addressing Handwashing 5 at a Systems Level

DEFINITION focus on elements of the system that they can n What are current alliances Mapping the System build on, and gaps they need to address. and partnerships?

A contextual analysis designed to To consider different elements of a system for n What political, legal, and regulatory forces identify critical gaps and significant mapping, the USAID local systems approach affect handwashing scale-up efforts? opportunities in a system focuses on the Five Rs – resources, roles, n What are the current handwashing relationships, rules, and results (USAID, 2014): activities? n Resources include budget allocations or n What are the sources of funding and specific handwashing infrastructure. levels of funding for those activities? Mapping the System n Roles involve the number of actors n Is there support for handwashing that take on defined roles to address One of the first steps in visualizing a system is integration in other programs handwashing. thinking broadly about the core issues —and and initiatives? the related social, economic, governmental n Relationships focuses further on n Has adequate formative research been and environmental forces. Doing this the interactions among the actors in a completed to identify the behavioral contextual analysis is called mapping local system. determinants for handwashing with the system. Relationships among key n Rules are important and set the different groups in the target areas? stakeholders within the system are outlined, governance. noting where and how they are working, n What is the experience and expertise what issues concern them, and with whom n Results are the outputs and outcomes. of different actors? What are the gaps they are already collaborating. This network in capabilities that inhibit the system In mapping the system for handwashing, information should be shared to optimize the support for handwashing scale-up some of the questions that should be function of the system, and for monitoring and sustainability? answered include: changes in the system. n Where are the greatest needs and n What is the status of handwashing among A crucial mapping task is to identify critical opportunities for scaling up handwashing? different populations? gaps and significant opportunities in a system, based upon research and consultations n What groups support handwashing? How with the networks of key leaders and do different actors support handwashing? actors. Identifying a system’s strengths and weaknesses in this way will help stakeholders THE HANDWASHING HANDBOOK 82 Addressing Handwashing 5 at a Systems Level

DEFINITION

Whole-System-in-the-Room

A participatory event to stimulate shared understanding and catalyze formation of coalitions for collective action One of the analytic tools that can be used for systems mapping is social network analysis (SNA), a tool for studying social systems that focuses on the complex relationships n Identifies targets, allies, opponents, handwashing, their common goals, and between individuals and organizations (Harper, and constituents for the system the major barriers to achieving those 2020). SNA can increase understanding of the strengthening goals goals. Barriers may lie in governance, structure, economic, and social factors. structural characteristics of a network, such Mapping the system is not a one-time activity Governance barriers can include lack of a as who the central actors in a network are, for system strengthening. After initial system policy or strategy to guide handwashing how tightly interconnected or fragmented the mapping has been completed, the map is filled programming throughout health, education, network is, and what subgroups or clusters in more intricacy through planning and system and other sectors. An example of a barrier in exist. Strengths and weaknesses of important strengthening activities, as relationships and structure could be an absence of personnel aspects of the system can be determined, understanding grow within the network. including topics such as communication or equipment needed to ensure access to within the system, flow of resources, Foster Collective Impact handwashing facilities in an institutional setting. An example of a barrier involving both power structures, and the overall functioning Following initial mapping of the system of economic and social factors would be a lack of the network. relationships, a major event can be held to of options among low-income communities begin the process of catalyzing collaboration Another tool that can be used to map the for handwashing facilities. system is power analysis. It is used to identify and building partnerships to strengthen the the key decision-makers and others who have system. In the SCALE+ approach, this event is The stakeholders develop goals for how to power over specific issues, as well as people called Whole-System-in-the-Room and brings affect selected critical gaps and significant and organizations who can influence those together 50 to 100 participants from every opportunities in order to catalyze system- people (Tiberghien, 2012). Power analysis: relevant sector and viewpoint of the system wide change, ensuring that interventions are (FHI 360, 2020; Weisbord & Janoff, 2010). designed according to the system’s context n Helps to reveal power relations, map Its first task is a large-scale, participatory and demands. Applying a systems lens means stakeholder relationships, and identify mapping of the specific issue or problem, priorities may emerge in different parts of a channels of influence, as well as risks which adds significant depth to the preliminary system. Depending on the barriers identified, of conflict. mapping work. technical interventions may include policy reform, social marketing campaigns, technical n Reveals hidden mechanisms of During a Whole-System-in-the-Room event, training, organizational capacity building, power that affect participation by stakeholders work together to identify the or advocacy. marginalized groups most pressing issues faced in improving THE HANDWASHING HANDBOOK 83 Addressing Handwashing 5 at a Systems Level

During the event, participants agree on Even if holistic handwashing system collaborative actions to reach the consensus strengthening is not being completed in goals. Commitments made by stakeholders to a country, it can be valuable to form a act and contribute resources to achieve those handwashing partnership as a coordination goals become the basis for a preliminary mechanism to support handwashing. The PHOTO CREDIT: CAWST CREDIT: PHOTO system strengthening action plan. Task forces partnership could include various private are assigned to oversee and implement sector, government, and civil society actors. different elements of the overall action One example of this kind of coordinating body plan. Establishing common goals allows is the Kenyan National Business Compact, stakeholders to invest more fully which brings together all manufacturers of in actions that complement the actions of soap for collective impact in Kenya (Global other participants. Handwashing Partnership, 2020). National and subnational level handwashing partnerships National and Subnational Level can be formed quickly, especially during Handwashing Partnerships times of an outbreak such as COVID-19, and With the leadership, collaboration, social can ensure a specific focus on handwashing capital, and agreed collective impact created among a group of private sector, government, through the system strengthening process, and other partners. An example of this type it could be desirable for partners to form of partnership includes the hygiene working a handwashing partnership to take the group within a National WASH Cluster. coordination relationship to a higher level Steps for rapid formation of a handwashing than the collaboration established thus partnership mirror the normal steps of far. Formation of a national or subnational partnership formation but are accelerated level handwashing partnership may be one to reflect the urgency of the crisis. The first of the goals of the system strengthening step is to establish the need and role for a process from the beginning, or it may be handwashing partnership, including synergies identified as desirable through the collective of pooling resources to address opportunities impact process. The creation of subnational and gaps to accomplish immediate, shared handwashing partnerships can also help to goals (Global Handwashing Partnership, 2020). localize the fight for handwashing and enable Steps for forming a handwashing partnership a scale response across the country. include identifying stakeholders, such as THE HANDWASHING HANDBOOK 84 Addressing Handwashing 5 at a Systems Level

CASE STUDY private sector partners with expertise and SWA’s Mutual Accountability Mechanism resources in marketing and supply chain, establishing focal person(s) for leadership, The Sanitation and Water for All (SWA) Mutual Accountability Mechanism is a process for planning activities that are appropriate for the governments and other stakeholders to make commitments on specific actions they will take context of the outbreak with limited time and to achieve the targets set by the SDGs and then to report back on their actions to achieve difficulties in completing formative research, their commitments (Sanitation and Water for All, 2019). Representative commitments include: and reflecting on lessons learned through

collaborative action to optimize the next Country Group Making Commitment Target Year activities. To sustain the partnership in the Commitment long term, there must be added value for each individual organization. Good communication Bhutan Government Develop an inclusive national road map for 2020 sanitation and hygiene can ensure more aligned efforts, limited overlap in activities, and facilitate each partner in understanding the added value of Gambia Government To increase the proportion of households with 2021 a place for handwashing with soap and water the partnership. from 30.3% to 60% (urban) and from 26% to 50% (rural) by December 2021 Accountability

Systems strengthening emphasizes mutual Lesotho Government End population practicing 2023 accountability among stakeholders—to and improve hygiene practices in schools, health facilities, and selected each other and to their publicly shared rural communities commitments. Accountability can take several forms, from direct feedback to formal political processes. Sanitation and Water for All has Rwanda Government Technically and financially support the 2020 development and implementation of the developed a mutual accountability mechanism Ministry of Health-led National Handwashing and the commitments provide examples of Sub-strategy in FY2019-20 commitments of national governments and civil society to support handwashing. Tanzania Civil Society Identify approaches that will improve 2020 sanitation and hygiene in poorly served and remote areas by 2020 THE HANDWASHING HANDBOOK 85 Addressing Handwashing 5 at a Systems Level

Under a system strengthening plan, some of Hand Hygiene for All as a Whole Table 8 provides specific actions outlined the central goals may be stronger stakeholder Systems Approach by the Hand Hygiene for All Global Initiative relationships, better communication among through system building blocks (described in WHO, UNICEF, and a set of core partners, stakeholders, and improved cohesion the Building Blocks for Handwashing section). including the Global Handwashing Partnership, of the system. Therefore, monitoring for launched the Hand Hygiene for All Global accountability in a systems approach may Initiative in 2020, with the goal of universal have considerably different indicators, hand hygiene and a vision to achieve it — compared to a program that is not focused on which ultimately means a new way of working systems. Accountability mechanisms provide and living, where hand hygiene is embedded information on whether the system is working not only in health systems to prevent infection, well or if adjustments are needed to adapt to but also in everyday lives. To truly reimagine changes in the environment (USAID, 2014; IRC a world where no one is left without access WASH, n.d.; Sanitation and Water for All, 2019). to hand hygiene, all of society must play Strong accountability relationships are crucial a role in collaboration with international to a durable and adaptive local system. These partners, national governments, public and “Systems relationships provide the feedback channels private sectors, and civil society. Working strengthening that keep the system dynamic and sustainable. across sectors is essential and requires emphasizes mutual Transparency of data and public access the kind of systems approach described in accountability to information are important elements to this chapter. The initiative will work towards support accountability. Participatory forms building political leadership, a strong enabling among of monitoring and evaluation can ensure environment, and robust supply and demand stakeholders—to that products and interventions are locally for hand hygiene in every country. each other and to useful, empower all systems stakeholders, The initiative is designed around three stages: their publicly shared and encourage collaborative problem solving. commitments.” Ensuring flexible feedback mechanisms gives 1 Responding to the COVID-19 pandemic the system dynamism. Such adaptability to 2 Rebuilding infrastructure and services respond to changes based on new learning deepens overall accountability for successful 3 Reimagining hand hygiene in society improvements (USAID, 2014). THE HANDWASHING HANDBOOK 86 Addressing Handwashing 5 at a Systems Level

Table 8: Hand Hygiene for All Actions by Building Block

Respond (short-term) Rebuild (medium-term) Reimagine (long-term)

Coordination and institutional arrangements

n Convene a national coordination group with n Give schools and businesses the appropriate n Implement legal and regulatory frameworks for representation from different government guidance and support to implement improved hand hand hygiene in public spaces, including standard authorities (health, WASH, education), the private hygiene measures for re-opening operating procedures in schools and hospitals sector, and civil society n Develop mechanisms for working with the private n Implement WHO hand hygiene multimodal sector, identifying new win-win partnerships to fill improvement strategies across all levels of the gaps and build on opportunities health system

Policies and strategies

n Review policies and standards/ requirements about n Issue inter-ministerial/ inter-agency policy n Convene all stakeholders to review existing gaps hand hygiene in health care facilities, schools, and roadmaps with steps for accelerating the scale-up and agree on strategies for addressing them other settings of hand hygiene n Set timebound targets to benchmark advances in n Map hand hygiene policies across agencies, with scaling up hand hygiene suggestions for alignment and operationalization at n Develop and approve new hand hygiene provision local and facility levels and education policies in different settings to address bottlenecks n Advocate for a hand hygiene curriculum for all schools

Financing

n Set and budget for targets in terms of coverage of n Support schools with adequate planning n Ensure that targets are costed and that financed hand hygiene facilities in public spaces and health and financing of hand hygiene measures as plans for hand hygiene in different settings are care facilities they re-open featured in national plans, loans, and grants n Activate contingency funds and supplementary n Reprogram activities and budgets n Increase budget allocations for the implementation budgets n Mobilize resources to meet immediate needs with and monitoring of hand hygiene programs n Direct emergency funding to reach the most a longer-term vision n Include a budget for hand hygiene in preparedness vulnerable people and those with disabilities plans for public health emergencies THE HANDWASHING HANDBOOK 87 Addressing Handwashing 5 at a Systems Level

Respond (short-term) Rebuild (medium-term) Reimagine (long-term)

Planning, monitoring, and review

n Set up systems for rapid data collection about the n Fill gaps in data on hand hygiene in health care n Conduct comprehensive baseline and follow- use of hand hygiene stations in schools, health facilities, schools, and other public settings up assessments of hand hygiene facilities and care facilities, and public settings n Identify and prioritize vulnerable populations who behaviors across multiple settings n Identify vulnerable populations who are most still lack hand hygiene at home n Mainstream hand hygiene data collection into at risk and least likely to be able to practice hand n Prioritize schools that lack hand hygiene facilities routine administrative data collection systems hygiene measures for upgrading prior to reopening (e.g., management information systems), as well as surveys or spot checks (e.g., household surveys, n  Build on the momentum to get hand hygiene regulatory checks) included in upcoming surveys of households, schools, and health care facilities n Ensure that hand hygiene features in regular sector reviews

Capacity development

n Rapidly train community health workers, n Map existing capacities and identify gaps n Invest in leadership development of key staff hygiene promoters, health care staff, and other and opportunities for development, including responsible for hand hygiene activities at essential workers in hand hygiene promotion and strengthening the enabling environment, promoting institutional and community levels best practices hand hygiene practices, and shaping the market for n Incentivize investments in handwashing by n Facilitate knowledge exchange of lessons learned handwashing supplies institutions and individuals, including recognition and examples of best practices at international, of contributions national, and subnational levels n Develop or update context-specific programming n Support local suppliers and manufacturers to scale guidance and tools for rolling out hand hygiene up production and distribution of hand hygiene programs at scale facilities and supplies n Invest in the professionalization of the hand hygiene workforce n Integrate hand hygiene into national training programs and curricula THE HANDWASHING HANDBOOK 88 Addressing Handwashing 5 at a Systems Level

Chapter Takeaways and Resources n Adopt systems thinking. A holistic n Develop methods for accountability. approach is needed to address Accountability mechanisms should Achieving and sustaining handwashing handwashing with soap in a sustainable facilitate critical reflection on whether the outcomes depends upon the support and way. Understanding the connections system is working well or if adjustments contributions of the many actors —from among multiple actors and their are needed. government, business, funders, NGOs, civil interrelated motivations and challenges society, academia, and communities —that can stimulate collective action toward comprise systems at the national, regional, a common goal. Building bridges and community levels. Key takeaways for across networks and increasing bonds addressing handwashing at the systems within organizations can lead to better level include: development outcomes.

n Map the system. A contextual analysis of the system to support handwashing can help stakeholders identify any challenges or significant opportunities, as well as key relationships. When mapping the system, stakeholders should consider focusing attention on the Five Rs – resources, roles, relationships, rules, and results.

n Conditions and systems are dynamic. Stakeholders should consider changes from the perspectives of the many actors in the system, building toward universal recognition of the need to promote and practice handwashing. Reflection and learning allow stakeholders to refine the systems approach and to consider changes in conditions for handwashing behavior or changes in the system itself. THE HANDWASHING HANDBOOK 89 Addressing Handwashing 5 at a Systems Level

Additional Resources for Addressing n IRC WASH. WASH Systems Academy. and practical steps for progress, and Handwashing at a Systems Level The IRC WASH Systems Academy is a serves as a basis for deeper collaboration series of free online courses aimed at with all partners to support sustainability n Global Handwashing Partnership. “How assisting WASH sector professionals though local systems. to” Brief: National and Subnational in applying systems strengthening Handwashing Partnerships. This guidance n WHO & UNICEF. Hand Hygiene for All approaches to their work. brief discusses the importance of national Global Initiative. This document highlights or subnational partnerships, outlines steps n LSP Consortium. Local Systems Practice the WHO and UNICEF Hand Hygiene to move forward with a handwashing User’s Guide. This guide provides for All Global Initiative, which calls for a partnership, and provides examples from insights on several methodologies systems approach to building a culture of successful national partnerships. that can assist local missions and hand hygiene. organizations in applying a systems lens n Agenda for Change. Agenda for Change n World Bank Water and Sanitation to drive development. Systems Library. This library provides Program. Guidelines for Assessing the different resources for WASH systems n Sanitation and Water for All. SWA Enabling Environment Conditions for strengthening including principles, Building Blocks and Collaborative Large Scale, Effective and Sustainable concepts, examples, and experiences. Behaviors. Building blocks and Handwashing with Soap Projects. This collaborative behaviors provide a common document guides programmatic staff n International Rescue Committee. Social framework for addressing handwashing at on how to carry out a programmatic Network Analysis Handbook. This a systems level, describe the key elements, assessment of the enabling environment handbook provides a step-by-step guide and outline ways partners can work for handwashing, and shares lessons to social network analysis. together to strengthen a WASH system. learned about relevant approaches and n IRC WASH. Understanding the WASH conceptual frameworks. n Sustainable Services Initiative. system and Its Building Blocks. This Strengthening WASH Systems: Tools working paper explains different systems for Practitioners. This toolbox provides approaches for WASH, defines the information on systems strengthening for building blocks of the WASH system, country or field-based practitioners. identifies critical links to other building blocks, and describes implementation at n USAID. USAID Local Systems Framework. different administrative levels. This framework defines the principles of engaging local systems, provides clear THE HANDWASHING HANDBOOK 90 Conclusion and References PHOTO CREDIT: FHI 360 FHI CREDIT: PHOTO THE HANDWASHING HANDBOOK 91 Conclusion

This handbook outlines approaches to promoting handwashing with soap through context-adapted behavior change and systems-level programming. For handwashing to be widely accepted and sustained, initiatives should consider both the physical (hardware) and psychosocial (software) aspects of handwashing behavior change. Government agencies, the private sector, nongovernmental organizations, and academia PHOTO CREDIT: CAWST CREDIT: PHOTO all have important roles to play in accomplishing universal, appropriate handwashing practices.

Key takeaways drivers and barriers are most important in and inclusion programs. Prioritizing a given context. Behavioral determinants, handwashing within these activities will Practice handwashing at all key times such as nurture or disgust, are examples of ensure a greater impact. and places. The habit of handwashing drivers that can have a powerful influence on needs to be well established in the home, Consider the system. Handwashing behavior handwashing habits. Targeting key but life extends far beyond the home and is influenced by influences beyond an behavioral determinants in the program so should good hand hygiene. Appropriate individual. For example, policies and leadership design is critical to change behavior. Going handwashing is also needed in schools, health can be powerful drivers of handwashing deeper into habit formation, the use of nudges, care facilities, workplaces, marketplaces, and uptake, with a supportive enabling such as mirrors for handwashing stations, emergency contexts. environment motivating handwashing at a can encourage handwashing behavior on a systems level. For handwashing practice to Use best practices for behavior change. subconscious level. be scaled up and maintained, every actor and Education alone is not enough to catalyze Mainstream handwashing behavior change. every element of the system must function handwashing practice. Handwashing behavior Handwashing with soap has important effectively. Systems building blocks include: change programs must leverage locally cross-cutting benefits, so it is important to coordination and institutional arrangements; relevant behavioral determinants, enabling integrate handwashing promotion activities policies and strategies; financing; planning, factors and barriers of handwashing behavior into interventions beyond WASH, including monitoring, and review; and capacity for the specific target audience. Formative nutrition, early child development, health, development. By assessing these building research is critical to understand which THE HANDWASHING HANDBOOK 92 Conclusion and References

blocks and the linkages between them, practitioners can identify specific gaps to target in their interventions for larger impact.

Evaluate results and share findings. Evaluating programs and sharing lessons learned is critical to improve handwashing programs at scale. Additional evidence on the importance of handwashing and related issues will help improve the integration of handwashing into other programs. It is critical to share examples and learnings from evidence-based programs and strategies that showcase the synergies between handwashing and nutrition, infectious diseases, and other related areas. In addition, further research on the cost-effectiveness of approaches to changing handwashing behavior will help optimize implementation and ensure sustainability.

Handwashing with soap remains one of the key challenges of the SDG agenda. With greater recognition of its benefits, more support for an integrated systems approach, and a more comprehensive approach to behavior change, handwashing with soap can be universally recognized, promoted, and practiced. THE HANDWASHING HANDBOOK 93 References

Assessment Capacities Project & International Organization for Migration. (2020). Biran, A. (2011). Enabling technologies for handwashing with soap : a case study COVID-19 explained: Overview of Rohingya perceptions (ed 1). https://reliefweb.int/ on the tippy-tap in Uganda (English). Water and sanitation program working A – B report/bangladesh/covid-19-explained-overview-rohingya-perceptions-edition-1- paper. Washington, DC: World Bank. https://documents.worldbank.org/en/ 26th-march-2020 publication/documents-reports/documentdetail/805931468117886154/enabling- Adane, M., Mengistie, B., Mulat, W., Medhin, G., & Kloos, H. (2018). The most technologies-for-handwashing-with-soap-a-case-study-on-the-tippy-tap-in-uganda important recommended times of hand washing with soap and water in Biran, A., Schmidt, W-P., Varadharajan, K. S., Rajaraman, D., Kumar, R., Greenland, preventing the occurrence of acute diarrhea among children under five years of K., Gopalan, B., Aunger, R., & Curtis, V. (2014). Effect of a behaviour-change age in slums of Addis Ababa, Ethiopia. Journal of Community Health, 43(2), 400- intervention on handwashing with soap in India (SuperAmma): A cluster- 405. randomised trial. The Lancet , 2(3), e145–e154. https://doi. Agenda for Change. (n.d.) Agenda for Change systems library. Retrieved August 5, org/10.1016/S2214-109X(13)70160-8 2020, from https://washagendaforchange.org/#library Biran, A., Schmidt, W-P., Wright, R., Jones, T., Seshadri, M., Isaac, P., Nathan, N. A., Allegranzi, B., Bagheri Nejad, S., Combescure, C., Graafmans, W., Attar, H., Hall, P., McKenna, J., Granger, S., Bidinger, P., & Curtis., V. (2009). The effect of a Donaldson. L., Pittet, D. Burden of endemic health-care-associated infection in soap promotion and hygiene education campaign on handwashing behaviour developing countries: Systematic review and metaanalaysis. The Lancet 377(9760), in rural India: a cluster randomised trial. Tropical Medicine & International Health, 228-241. https://doi.org/10.1016/S0140-6736(10)61458-4 14(10), 1303-1314. https://doi.org/10.1111/j.1365-3156.2009.02373.x American Society for Microbiology, American Cleaning Institute. (2010). A survey Biran A., Tabyshalieva, A., & Salmorbekova, Z. (2005). Formative research for of handwashing behavior. Rochester, NY: Harris Interactive. hygiene promotion in Kyrgyzstan. and Planning, 20(4), 213-21. Arbogast, J. W., Moore-Schiltz, L., Jarvis, W. R., Harpster-Hagen, A., Hughes, J., & Biran, A., White, S., Awe, B., Greenland, K., Akabike, K., Chuktu, N., Aunger, R., Curtis, Parker, A. (2016). Impact of a comprehensive workplace hand hygiene program V., Schmidt, W. & Van der Voorden, C. (2020). A cluster-randomised trial to evaluate on employer health care insurance claims and costs, absenteeism, and employee an intervention to promote handwashing in rural Nigeria. International Journal of perceptions and practices. Journal of Occupational and Environmental Medicine, Research. https://doi.org/10.1080/09603123.2020.1788712 58(6), e231–e240. https://doi:10.1097/JOM.0000000000000738 Blaney D. D., Daly E. R., Kirkland K. B., Tongren J. E., Kelso P. T., & Talbot E. A. (2011). Aunger, R. & Curtis, V. (2015). A guide to behaviour centred design. London, Use of alcohol-based hand sanitizers as a risk factor for outbreaks in England: London School of Hygiene & Tropical Medicine. long-term care facilities in northern New England: December 2006 to March 2007. American Journal of Infection Control, 39(4), 296-301. Aunger, R. & Curtis, V. (2016). Behaviour Centred Design: Towards an applied science of behaviour change. Review, 10(4), 425-446.Aunger, Brearley, L., Eggers R., Steinglass R., & Vandelaer J. (2013). Applying an equity R., Schmidt, W.-P., Ranpura, A., Coombes, Y., Maina, P. M., Matiko, C. N., & Curtis, V. lens in the decade of vaccines. Vaccine, 31 (Suppl 2), B103-B107. http://dx.doi. (2010). Three kinds of psychological determinants for hand-washing behaviour org/10.1016/j.vaccine.2012.11.088 in Kenya. Social Science & Medicine, 70(3), 383–391. https://doi.org/10.1016/j. Britto, P. R., Lye, S. J., Proulx, K. Yousafzai, A. K., Matthews, S. J., Vaivada T., socscimed.2009.10.038 Perez-Escamilla R., Rao N., Ip, P., Fernald, L. C. H., MacMillan, H., Hanson, M., Aunger, R., White, S., Greenland, K. & Curtis, V. (2017). Behaviour centre design: Wachs, T. D., Yao, H., Yoshikawa H., Cerezo, A., Leckman, J. F., Bhutta, Z. A., & the A practitioner’s guide. Retrieved from https://www.lshtm.ac.uk/sites/default/ Early Childhood Development Interventions Review Group, for the Lancet Early files/2017-03/BCD%20Manual.pdf Childhood Development Series Steering Committee. (2017). Nurturing care: Promoting early child development. The Lancet, 389(10064), pp. 91-102. https:// doi.org/10.1016/S0140-6736(16)31390-3 THE HANDWASHING HANDBOOK 94 Conclusion and References

Brown, A-M. (2016). What is this thing called ‘Theory of Change’? USAID Learning Colgate-Palmolive. (n.d.) Community programs. Retrieved August 3, 2020, from B – C Lab. Retrieved from https://usaidlearninglab.org/lab-notes/what-thing-called- https://www.colgatepalmolive.com/en-us/core-values/community-responsibility theory-change Connelly, M., Gayer, M., Ryan, M. J., Salama, P., Spiegel, P., & Heymann, D. L. (2004). Buxton, H., Flynn, E., Oluyinka, O., Cumming, O., Esteves Mills, J., Shiras, T., Sara, Communicable diseases in complex emergencies: impact and challenges. The S., & Dreibelbis, R. (2019). Hygiene during childbirth: An observational study to Lancet, 364(9449), pp. 1974-1983. understand infection risk in healthcare facilities in Kogi and Ebonyi States, Nigeria. Contzen, N. & Mosler, H-J. (n.d). The Risks, Attitudes, Norms, Abilities, and International Journal of Environmental Research and Public Health, 16(7), 1301. Self‐regulation (RANAS) approach to systematic behavior change: Fact Sheet. https://doi.org/10.3390/ijerph16071301 EAWAG: Swiss Federal Institute of Aquatic Science and Technology. https://www. Centers for Disease Control and Prevention. (2012). Improving child development: eawag.ch/fileadmin/Domain1/Abteilungen/ess/schwerpunkte/ehpsy/RANAS_ A new CDC handwashing study shows promising results. Retrieved August 3, 2020, Methodological_Fact_Sheets.pdf from https://www.cdc.gov/handwashing/child-development.html Contzen, N., & Mosler, H.-J. (2013). Impact of different promotional channels on Centers for Disease Control and Prevention. (2016). Handwashing: A corporate handwashing behaviour in an emergency context: Haiti post-earthquake public activity. Retrieved August 3, 2020, from https://www.cdc.gov/handwashing/ health promotions and cholera response. Journal of Public Health, 21(6), 559–573. handwashing-corporate.html https://doi.org/10.1007/s10389-013-0577-4 Centers for Disease Control and Prevention. (2019). Hand hygiene in healthcare Contzen, N., & Mosler, H.-J. (2015). Identifying the psychological determinants settings. Retrieved August 3, 2020, from https://www.cdc.gov/handhygiene/index. of handwashing: Results from two cross-sectional questionnaire studies in Haiti html and Ethiopia. American Journal of Infection Control, 43(8), 826–832. https://doi. Centers for Disease Control and Prevention. (2020) The socio-ecological model: A org/10.1016/j.ajic.2015.04.186 framework for prevention. Retrieved August 3, 2020, from https://www.cdc.gov/ Coombes, Y., & Devine, J. (2010). Introducing FOAM: A framework to analyze violenceprevention/publichealthissue/social-ecologicalmodel.html handwashing behaviors to design effective handwashing programs. Washington, Centers for Medicare & Medicaid Services. ICD-9-CM diagnosis and procedure DC: World Bank Water and Sanitation Program Global Scaling Up Handwashing codes: abbreviated and full code titles, version 31 full and abbreviated code titles – Project. effective October 1, 2013. Retrieved August 3, 2020, from https://www.cms.gov/ Crane, R. J., Jones, D. J., & Berkley, J. A. (2015). Environmental enteric dysfunction: Medicare/Coding/ICD9ProviderDiagnosticCodes/codes. An overview. Food and Nutrition Bulletin, 36(10), pp. 76-87. Cho, H., & Witte, K. (2005). Managing fear in public health campaigns: A theory- Cumming, O., Arnold, B. F., Ban, R., Clasen, T., Mills, J. E., Freeman, M. C., Gordon, B., based formative evaluation process. Practice, 6(4), 482–490. Guiteras, R., Howard, G., Hunter, P. R., Johnston, R. B., Pickering, A. J., Prendergast, https://doi.org/10.1177/1524839904263912 A. J., Pruss-Ustun, A., Rosenboom, J. W., Spears, D., Sunberg, S., Worlf, J., Null … Clayton D. A., Griffith C. J., Price P. E., & Peters A. C. (2003). Food handlers’ beliefs Colford, J. M. (2019). The implications of three major new trials for the effect of and self-reported practices. International Journal of Environmental Health Research, water, sanitation and hygiene on childhood diarrhea and stunting: A consensus 12(1), 25–39. statement. BMC Medicine, 17(1), 173. https://doi.org/10.1186/s12916-019-1410-x Cogswell L & Jensen L. (2008). Guidelines for assessing the enabling environment Curtis, V., & Cairncross, S. (2003). Effect of washing hands with soap on diarrhea conditions for large scale effective and sustainable handwashing with soap projects. risk in the community: A systematic review. The Lancet Infectious Diseases, 3(5), Washington, D.C.: World Bank Water and Sanitation Program. https://www.wsp. pp. 275-281. org/sites/wsp.org/files/EEA_Guidance_HW_1.pdf THE HANDWASHING HANDBOOK 95 Conclusion and References

Curtis, V. A., Danuah, L. O., & Aunger, R. V. (2009). Planned, motivated and habitual Dodos, J., 2017. WASH’nutrition: A practical guidebook on increasing nutritional hygiene behaviour: An eleven country review. Research, 24(4), impact through integration of WASH and nutrition programs. Paris: Action contre la C – F 655–673. https://doi.org/10.1093/her/cyp002 Faim. https://www.actionagainsthunger.org/sites/default/files/publications/2017_ Cusik, S., & Georgieff, M. K. (n.d.) The first 1,000 days of life: The brain’s window of ACF_WASH_Nutrition_Guidebook_BD.pdf opportunity. UNICEF. https://www.unicef-irc.org/article/958-the-first-1000-days-of- Dreibelbis, R., Kroeger, A., Hossain, K., Venkatesh, M., & Ram, P. K., 2016. Behavior life-the-brains-window-of-opportunity.html change without behavior change communication: Nudging handwashing among Darmstadt G., Ahmed A., Saha S., Azad M., Alam M., Khatun M., Black, R. E., & primary school students in Bangladesh. International Journal of Environmental Santosham, M. (2005). Infection control practices reduce nosocomial infections Research and Public Health, 13(1), 129. https://doi.10.3390/ijerph13010129 and mortality in preterm infants in Bangladesh. Journal of Perinatology, 25(5), pp. Dreibelbis, R., Winch, P. J., Leontsini, E., Hulland, K. R. S., Ram, P. K., Unicomb, 331-335. L., & Luby, S. P. (2013). The Integrated Behavioural Model for Water, Sanitation, Davis Jr., T. P. (2004). Barrier analysis facilitator’s guide: A tool for improving and Hygiene: a systematic review of behavioural models and a framework behavior change communication in child survival and community development for designing and evaluating behaviour change interventions in infrastructure- programs. Washington, D.C.: Food for the Hungry. restricted settings. BMC Public Health, 13, 1015. https://doi.org/10.1186/1471- 2458-13-1015 De Buck, E., Van Remoortel, H., Hannes, K., Govender, T., Naidoo, S., Avau, B., Vande Veegate, A., Musekiwa, A, & Lutje, V. (2017). Promoting handwashing and sanitation Essity/Tork. (n.d.). Tork safe at home toolkits. Retrieved August 5, 2020, from behaviour change in low- and middle-income countries A mixed-method systematic https://www.torkusa.com/torkcampaigns/corona-virus review. 3ie Systematic Review 36. London: International Initiative for Impact Ejemot-Nwadirao, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A. Evaluation (3ie). https://www.3ieimpact.org/sites/default/files/2019-01/SR%20 (2015). Hand washing promotion for preventing diarrhea. Cochrane Database of 36-Behaviour-change-sanitation_2.pdf Systematic Reviews, 9, CD004265. https://doi/10.1002/14651858.CD004265.pub3 DeNoon D. J. (2012, May 22). The 6 dirtiest places in your office: where office Elhra. (n.d.) Promotion and practice handwashing kit. https://www.elrha.org/ germs lurk in break rooms, on desks. WebMD. https://www.webmd.com/a-to-z- project/promotion-practice-handwashing-kit/ guides/news/20120523/the-6-dirtiest-work-places Federal Ministry of Water Resources, UNICEF, DFID, European Union. (n.d.) Denny, L. (2020, April 15.) Ten immediate WASH actions in healthcare facilities for National hygiene promotion strategy. Abuja, Nigeria: Federal Ministry of Water COVID-19 response. Global Water 2020. Retrieved August 5, 2020, from https:// Resources. globalhandwashing.org/wp-content/uploads/2020/04/WASH-in-HCF-Actions-for- Food Security and Nutrition Network Social and Behavioral Change Task Force. COVID-19.pdf (2013). Designing for behavior change for agriculture, natural resource management, Demssie, A., Daniel, D., Tefera, A., Kindu, H., Abebe S., & Sanbata, H. (2017). health and nutrition. Washington, DC: Technical and Operational Performance Knowledge, attitude and practice (KAP) of hand washing among mothers of under Support (TOPS) Program. https://coregroup.org/wp-content/uploads/media- five children in Gotu Kebele Wondogenet Woreda Oromia Ethiopia. International backup/documents/Resources/Tools/DBC_English.pdf Journal of Environmental Sciences, 6(4), pp. 146-153. Freeman M. C., Stocks, M. E., Cumming, O., Jeandron, A., Higgins, J. P. T., Wolf, J., Devine, J. (2010). Beyond tippy-taps: The role of enabling products in scaling up Prüss-Ustün, A., Bonjour S., Hunter, P. R., Fewtrell, L., & Curtis, V. (2014). Hygiene and sustaining handwashing. Waterlines, 29(4), 304-314. and health: Systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine & International Health, 19(8), 906-916. THE HANDWASHING HANDBOOK 96 Conclusion and References

FHI 360. (2014). WASH friendly schools. Washington, DC: USAID WASHplus Project. Global Handwashing Partnership (2020, April 14). “How-to” brief: National and F – G FHI 360. (2020). Scale+: Systemwide collaborative action for livelihoods and subnational handwashing partnerships. Retrieved August 5, 2020, from https:// environment. http://scaleplus.fhi360.org/ globalhandwashing.org/resources/how-to-brief-national-and-subnational- handwashing-partnerships/ Friedrich, M. N. D., Kappler, A., & Mosler, H.-J. (2018). Enhancing handwashing frequency and technique of primary caregivers in Harare, Zimbabwe: A cluster- Global Handwashing Partnership. (2020, May 20). Tips on communicating for randomized controlled trial using behavioral and microbial outcomes. Social hand hygiene during COVID-19. Retrieved August 5, 2020, from https://www. Science & Medicine, 196, 66–76. https://doi.org/10.1016/j.socscimed.2017.10.025 wsp.org/sites/wsp.org/files/publications/WSP-Practical-Guidance-Measuring- Handwashing-Behavior-2013-Update.pdf Gautam, O., Schmidt, W-P., Cairncross, S., Cavill, S., & Curtis, V. (2017). Trial of a novel intervention to improve multiple food hygiene behaviours in Nepal. The Graves, N., Page, K., Martin, E., Brain, D., Hall, L., Campbell, M., Fulop, N., Jimmeison, American Journal of Tropical Medicine and Hygiene, 96(6), 1415-4526. N., White, K., Paterson, D., & Barnett, A. G. (2016). Cost-effectiveness of a national initiative to improve hand hygiene compliance using the outcome of healthcare Gibson, S., Sahanggamu, D., Fatmaningrum, D., Curtis, V., & White, S. (2017). ‘Unfit associate Staphylococcus aureaus Bacteraemia. PLoS One, 11(2), e0148190. for human consumption’: A study of the contamination of formula milk fed to https://doi.org/10.1371/journal.pone.0148190 young children in East Java, Indonesia. Tropical Medicine & International Health, 22(10), pp. 1275-1282. https://doi.org/10.1111/tmi.12927 Grayson, M. L., Melvani, S., Druce, J., Barr, I. G., Ballard, S. A., Johnson, P. D., Mastorakos, T., & Birch, C. (2009). Efficacy of soap and water and alcohol-based Global Handwashing Partnership. (n.d.a). Global handwashing resource hub. hand-rub preparations against live H1N1 influenza on the hands of human https://globalhandwashing.org/resources-main/ volunteers. Clinical Infectious Diseases. 48(3), 285-91. Global Handwashing Partnership. (n.d.b). Hand hygiene profile series. Retrieved Greenland, K., Chipungu, J., Chilekwa, J., Chilengi, R., & Curtis, V. (2017). August 5, 2010, from https://globalhandwashing.org/topic/rx-hand-hygiene/ Disentangling the effects of a multiple behaviour change intervention for diarrhoea Global Handwashing Partnership. (2017). Handwashing —vital for sustainable control in Zambia: a theory-based process evaluation. Global Health, 13(1):78. development. https://globalhandwashing.org/resources/hand-hygiene-in-health- Greenland, K., Iradati, E., Ati, A., Maskoen, Y. Y., & Aunger, R. (2013). The context and care-advocacy-pack/ practice of handwashing among new mothers in Serang, Indonesia: A formative Global Handwashing Partnership. (2017 November) Using nudges to research study. BMC Public Health, 13, 830. https://doi.org/10.1186/1471-2458-13- encourage handwashing with soap. Retrieved August 5, 2020, from https:// 830 globalhandwashing.org/wp-content/uploads/2020/05/GHP-Communications- Grimes, J. E. T., Tadesse, G., Gardiner, I. A., Yard, E., Wuletow, Y., Templeton, M. Brief-FINAL.pdf R., Harrison, W. E., & Drake, L. J. (2017). Sanitation, hookworm, anemia, stunting, Global Handwashing Partnership. (2018). Clean hands for all: A toolkit for and wasting in primary school children in southern Ethiopia: Baseline results handwashing advocacy. Washington, D.C.: Global Handwashing Partnership. from a study in 30 schools. PLOS Neglected Tropical Diseases, 11(10), e0005948. https://globalhandwashing.org/resources/clean-hands-for-all-a-toolkit-for-hygiene- Available at: https://doi.org/10.1371/journal.pntd.0005948 advocacy/ Grover, E., Hossain, M. K., Uddin, S., Venkatesh, M., Ram, P. K., & Dreibelbis, R. Global Handwashing Partnership. (2019). Hand hygiene in health care: (2018). Comparing the behavioural impact of a nudge‐based handwashing Advocacy pack. Washington, D.C.: Global Handwashing Partnership. https:// intervention to high‐intensity hygiene education: a cluster‐randomised trial in rural globalhandwashing.org/resources/hand-hygiene-in-health-care-advocacy-pack/ Bangladesh. Tropical Medicine & International Health, 23(1), 10-25. THE HANDWASHING HANDBOOK 97 Conclusion and References

Halder, A. K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R., & Luby, S. P. (2010). Institute of Development Studies. (2020, June 5). Handwashing compendium for Observed hand and other measures of handwashing behavior in rural low-resource settings: A living document. Retrieved August 3, 2020, from https:// H – K Bangladesh. BMC Public Health, 10, 545. globalhandwashing.org/resources/hand-hygiene-in-health-care-advocacy-pack/ Harper, D. (2020). Using social network analysis in WASH programs. Washington, International Rescue Committee. (2016) Social network analysis handbook. New DC: USAID Sustainable WASH Systems. York: International Rescue Committee. https://www.rescue.org/sites/default/files/ Hoekstra, R. M., Luby, S. P., Agboatwalla, M., Bowen, A., Kenah, E., & Sharker, Y. document/1263/socialnetworkanalysise-handbook.pdf (2009). Difficulties in maintaining improved handwashing behavior, Karachi, IRC WASH. (n.d.a). Regulation and accountability. https://www.ircwash.org/ Pakistan. The American Journal of Tropical Medicine and Hygiene, 81(1), 140–145. regulation-and-accountability https://doi.org/10.4269/ajtmh.2009.81.140 IRC WASH (n.d.b). IRC WASH Systems Academy. Retrieved August 5, 2020, from Hübner, N. O., Hübner, C., & Kramer, A. (2013). Impact of health campaign on hand https://www.washsystemsacademy.org/login/index.php hygiene with alcohol-based hand rubs in a non-clinical setting. Journal of Hospital IRC WASH. (2018a) Understanding the WASH system and its building blocks: Infections, 83(Suppl 1), S23–S28. building strong WASH systems for the SDGs. The Hague, the Netherlands: IRC. Hübner, N. O., Hübner, C., Wodny, M., Kampf, G., & Kramer, A. (2010). Effectiveness https://www.ircwash.org/resources/understanding-wash-system-and-its-building- of alcohol-based hand disinfectants in a public administration: impact on health blocks and work performance related to acute respiratory symptoms and diarrhoea. BMC IRC WASH. (2018b). Systems approaches and the WASH system: from theory Infectious Disease, 10:250. to useful application. The Hague, The Netherlands: IRC. https://www.ircwash. Humphrey, J. H., Mbuya, M. N. N., Ntozini, R., Moulton, L. H., Stoltzfus, R. J., org/news/systems-approaches-and-wash-system-complicated-theory-useful- Tavengwa, N. V., Mutasa, K., Majo, F., Mutasa, B., Mangwadu, G., Chasokela, C. M., application Chigumira, A., Chasekwa, B., Smith, L. E., Tielsch, J. M., Jones, A. D., Manges, A. Jengu. (n.d.) https://jengu.org.uk/ R., Maluccio, J. A., Prendergast, A. J., & the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team. (2019). Independent and combined effects of Joffe, H. (2008). The power of visual material: persuasion, emotion and improved water, sanitation, and hygiene, and improved complementary feeding, identification. Diogenes, 55(1), 84-93. https://doi.org/10.1177/0392192107087919 on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Judah, G., Aunger, R., Schmidt, W. P., Michie, S., Granger S, & Curtis V. (2009). The Lancet Global Health, 7(1), e132–e147. https://doi.org/10.1016/S2214- Experimental pretesting of hand-washing interventions in a natural setting. 109X(18)30374-7 American Journal of Public Health, 99(2), S405-S411. Husain, F., Hardy, C., Zekele, L., Clatworthy, D., Blanton, C., & Handzel, T. (2015). A Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Strauss and Giroux. pilot study of a portable hand washing station for recently displaced refugees Kamm, K. B., Feikin, D. R., Bigogo, G. M., Aol, G., Audi, A., Cohen, A. L., Shah, M. during an acute emergency in Benishangul-Gumuz Regional State, Ethiopia. M., Yu, J., Breiman, R. F., & Ram, P. K. (2014). Associations between presence of Conflict and Health, 9, 26. https://doi.org/10.1186/s13031-015-0053-6 handwashing stations and soap in the home and diarrhoea and respiratory illness, Huston, A., & Moriarty, P. (2018). Building strong WASH systems for the SDGs: in children less than five years old in rural western Kenya. Tropical Medicine & Understanding the WASH system and its building blocks. https://www.ircwash.org/ International Health, 19(4), 398–406. https://doi.org/10.1111/tmi.12263 sites/default/files/wash_system_and_building_blocks_wp2018.pdf Kittle, B. (2013). A practical guide to conducting a barrier analysis. New York, NY: Helen Keller International. https://pdf.usaid.gov/pdf_docs/PA00JMZW.pdf THE HANDWASHING HANDBOOK 98 Conclusion and References

Kleinau, E., & Pyle, D. F. (2004). Strategic report 8: Assessing hygiene improvement: Mackie, G., Moneti, F., Shakya, H., & Denny, E. (2015). What are social norms? How Guidelines for household and community levels. Washington, D.C.: Environmental are they measured? UNICEF and University of California – San Diego Center on K – M Health Project. Global Justice. https://www.unicef.org/protection/files/4_09_30_Whole_What_are_ Lauer, J. (2020). Environmental enteric dysfunction, WASH, and nutritional status of Social_Norms.pdf women, infants, and young children: Findings from Uganda, Sierra Leone, and Nepal Majorin, F., Freeman, M. C., Barnard, S., Routray, P., Boisson, S., & Clasen, T. (2014). [Webinar]. Boston University. Retrieved from https://vimeo.com/450264674 Child feces disposal practices in rural Orissa: A cross sectional study. PLoS One, Leontsini, E., & Winch, P. J. (2014). Increasing handwashing with soap: Emotional 9(2), e89551. drivers or social norms? The Lancet Global Health, 2(3), e118–e119. https://doi. Mahmud, M. A. Spigt, M., Bezabih, A. M., Pavon, I. L., Dinant, G. J., & Velasco, R. B. org/10.1016/S2214-109X(14)70030-0 (2015). Efficacy of handwashing with soap and nail clipping on intestinal parasitic London School of Hygiene & Tropical Medicine. (n.d.) About behaviour centered infections in school children: A factorial cluster randomized controlled trial. PLoS design. https://www.lshtm.ac.uk/research/centres-projects-groups/bcd#about Med, 12(6), e1001837. Love, A. & Weber, N. (eds.). (2020). Make me a change agent: An SBC resource for Marteau, T. M., Hollands, G. J., & Fletcher, P. C. (2012). Changing human behavior WASH, agriculture, and livelihoods activities. Washington, DC: SCALE and PRO- to prevent disease: the importance of targeting automatic processes. Science, WASH. https://www.fsnnetwork.org/sites/default/files/MMCA_27May2020_508_ 337(6101), 1492-1495. highres_FINAL.pdf Maternal and Child Health Survival Program. (2016). Clean clinic approach brief. LSP Consortium. (n.d.). Local systems practice user’s guide. Retrieved August 5, Retrieved from https://www.mcsprogram.org/resource/clean-clinic-approach- 2020, from https://sites.google.com/view/lsp-users-guide/home brief/ Luby, S. P., Rahman, M., Arnold, B. F., Unicomb, L., Ashraf, S., Winch, P. J., Stewart, C. Maulit, J.A. (2015). Triggering handwashing with soap in CLTS: Insights on what P., Begun, F., Hussain, F., Benjamin-Chung, J., Leontsini, E., Naser, A. M., Parvez, S. works in Malawi. UNICEF. https://www.unicef.org/esa/sites/unicef.org.esa/ M., Hubbard, A. E., Lin, A., Nizame, F. A., Jannat, K., Ercumen, A., Ram, P. K., Das, K. files/2018-09/UNICEF-Malawi-2015-WASH-Field-HWWS.pdf K., Abedin, J., Clasen, T. F., Dewey, K. G., Fernald, L. C., Null, C., Ahmed, T., & Colford, Mbakaya, C.B., Kalembo, F.W., & Zgambo, M. (2020). Use, adoption, and J. M. (2018). Effects of water quality, sanitation, handwashing, and nutritional effectiveness of tippytap handwashing station in promoting hand hygiene interventions on diarrhoea and child growth in rural Bangladesh: A cluster practices in resource-limited settings: a systematic review. BMC Public Health, 20, randomised controlled trial. The Lancet Global Health, 6(3), e302–e315. https://doi. 1005. https://doi.org/10.1186/s12889-020-09101-w org/10.1016/S2214-109X(17)30490-4 Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Luby, S., Agboatwalla, M., Feikin, D. R., Painter, J., Billhimer, W., Altaf, A., & Hoekstra, Eccles, M. P., Cane, J. and Wood, C. E. (2013). The behavior change technique R. M. (2005). Effect of handwashing on child health: A randomised controlled trial. taxonomy (v1) of 93 hierarchically clustered techniques: Building an international The Lancet, 366 (9481): 225-33. consensus for the reporting of behavior change interventions. Annals of Behavioral Luby, S.P., Agboatwalla, M., Painter, J., Altaf, A., Keswick, B., & Hoekstra, R.M. Medicine, 46(1), 81-95. (2006). Combining drinking water treatment and hand washing for diarrhoea Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: A prevention, a cluster randomised controlled trial. Tropical Medicine & International new method for characterizing and designing behaviour change interventions. Health, 11(4), 479-489. Implementation Science, 6, 42. THE HANDWASHING HANDBOOK 99 Conclusion and References

Mosler, H-J. (2012). A systematic approach to behavior change interventions for Penakalapati, G., Swarthout, J., Delahoy, M. J., McAliley, L., Wodnik, B., Levy, K., & the water and sanitation sector in developing countries: a conceptual model, a Freeman, M. C. (2017). Exposure to animal feces and human health: A systematic M – S review, and a guideline. International Journal of Environmental Health Research, review and proposed research priorities. Environmental Science & Technology, 22(5), 431-449. 51(20), 11537-11552 Mosler, H. J., & Contzen, N. (2016). Systematic behavior change in water, sanitation Rabie, T., & Curtis, V. (2006). Handwashing and risk of respiratory infections: A and hygiene. A practical guide using the RANAS approach. Version 1.1. Dübendorf, quantitative systematic review. Tropical Medicine & International Health, 11(3), pp. Switzerland: Eawag: Swiss Federal Institute of Aquatic Science and Technology. 258 – 267. Mwachiro, D. K. (2014). Challenges facing uptake of hand washing with soap Rabbi, S. E., & Dey, N. C. (2013). Exploring the gap between hand washing programme in schools in Tana Delta Sub County. IOSR Journal of Humanities And knowledge and practices in Bangladesh: A cross-sectional comparative study. Social Science, 19(11), 152-173. BMC Public Health, 1, 89. https://doi.org/10.1186/1471-2458-13-89 Neal D., Vujcic, J., Hernandez, O., & Wood, W. (2015). The science of habit: Creating Rahman, M. J., Nizame, F. A., Unicomb, L., Luby, S. P., & Winch, P. J. (2017). disruptive and sticky behavior change in handwashing behavior. Washington D.C.: Behavioral antecedents for handwashing in a low-income urban setting in USAID/WASHplus Project. Bangladesh: an exploratory study. BMC Public Health, 17(1), 392. NSM. (n.d.). What is social marketing? https://www.thensmc.com/content/what- Ram, P. (2013). Practical guidance for measuring handwashing behavior: 2013 social-marketing-1 update. Washington, D.C.: Water and Sanitation Program. https://www.wsp. Null, C., Stewart, C. P., Pickering, A. J., Dentz, H. N., Arnold, B. F., Arnold, C. D., org/sites/wsp.org/files/publications/WSP-Practical-Guidance-Measuring- Benjamin-Chung, J., Clasen, T., Dewey, K. G., Fernald, L. C. H., Hubbard, A. E., Handwashing-Behavior-2013-Update.pdf Kariger, P., Line, A., Luby, S. P., Mertens, A., Njenga, S. M., Nyambane, G., Ram, P. K., Rhee, V., Mullany, L. C., & Khatry, S.K. (2008). Maternal and birth attendant & Colford Jr., J. M. (2018). Effects of water quality, sanitation, handwashing, and handwashing and neonatal mortality in southern Nepal. Archives of Pediatrics and nutritional interventions on diarrhoea and child growth in rural Kenya: A cluster- Adolescent Medicine, 162(7), 603-608. randomised controlled trial. The Lancet Global Health, 6(3), pp. e316–e329. https:// Reynolds, K. A., Beamer, P. I., Plotkin, K. R., Sifuentes, L. Y., Koenig, D. W., & Gerba, C. doi.org/10.1016/S2214-109X(18)30005-6 P. (2015). The healthy workplace project: reduced viral exposure in an office setting. Omotade, O. O., Kayode, C. M., Adeyemo, A. A., & Oladepo, O. (1995). Observations Archives of Environmental & Occupational Health, 71(3), 157-162. on handwashing practices of mothers and environmental conditions in Ona- Sanitation and Water for All. (n.d.). Building blocks. Retrieved August 5, 2020, from Ara local government area of Oyo State, Nigeria. Journal of Diarrhoeal Disease https://www.sanitationandwaterforall.org/about/our-work/priority-areas/building- Research, 13(4), 224-228. blocks Oughton, M. T., Loo, V. G., Dendukuri, N., Fenn, S., & Libman, M. D. (2009). Hand Sanitation and Water for All. (2019). Mutual accountability mechanism. Retrieved hygiene with soap and water is superior to alcohol rub and wipes for August 3, 2020, from https://www.sanitationandwaterforall.org/about/our-work/ removal of Clostridium difficile. Infection Control & Hospital , 30(10), mutual-accountability-mechanism 939-44. P&G. (n.d.). Community impact. https://us.pg.com/community-impact/ THE HANDWASHING HANDBOOK 100 Conclusion and References

Savolainen-Kopra, C., Haapakoski, J., Peltola, P. A., Ziegler, T., Korpela, T, Anttila, P., Stedman-Smith M., Dubois C. L. Z., Grey, S. F., Kingsbury, D. M., Shakya, S., Scofield, Amiryousefi, A., Huovinen, P., Huvinen, M., Noronen, H., Riikkala, P., Roivainen, M., J., & Slenkovich, K. (2015). Outcomes of a pilot hand hygiene randomized cluster S – T Ruutu, P., Teirilä, J., Vartiainen, E., & Hovi, T. (2012). Hand washing with soap and trial to reduce communicable infections among US office-based employees. water together with behavioral recommendations prevents infections in common Journal of Occupational and Environmental Medicine, 57:374–380. work environments: an open cluster randomized trial. Trials, 13, 10. https://doi. Sustainable Services Initiative. (2020). Strengthening WASH systems: Tools org/10.1186/1745-6215-13-10 for practitioners. Bonn, Germany: Deutsche Welthungerhilfe e. V. https://www. Scobie, H. M., Phares, C. R., Wannemuehler, K. A., Nyangoma, E., Taylor, E. M., washagendaforchange.org/wp-content/uploads/2020/04/ssi_toolbox_08apr20. Fulton, A., Wongjindanon, N., Aung, N. R., Travers, P., & Date, K. (2016). Use of oral pdf cholera vaccine and knowledge, attitudes, and practices regarding safe water, Tamilarasi, R., Arunmozhi, R., Karthick Raja, V., & Rajajeyakumar, M. (2016). A study sanitation and hygiene in a long-standing refugee camp, Thailand, 2012-2014. to assess the knowledge and practice of hand washing among school going PLOS Neglected Tropical Diseases, 11(7). e0005810. https://doi.org/10.1371/ adolescents in Chennai. International Journal of Health Sciences and Research, journal.pntd.0005210. 6(8), pp. 147-152. Scott, B. E., Lawson, D. W., & Curtis, V. (2007). Hard to handle: Understanding Thaler, R. H., & Sunstein, C. R. (2008). Nudge: improving decisions about health, mothers’ handwashing behaviour in Ghana. Health Policy and Planning, 22(4), wealth, and happiness. New York: Penguin Books. 216–224. https://doi.org/10.1093/heapol/czm014 The Technical and Operational Performance Support (TOPS) Program. (2017). Scott, E., & Herbold, N. (2010). An in-home video study and questionnaire survey Designing for behavior change: A practical field guide. Washington, DC: The of food preparation, kitchen sanitation, and hand washing practices. Journal of Technical and Operational Performance Support Program. Environmental Health, 72(10), 8-13. Thi Anh Thu, L., Thi Long Thoa, V., Thi Van Trang, D., Phuc Tien, N., Thuy Can, D, Seimetz, E., Mosler, H.-J., & Boyayo, A.-M. (2016). The influence of contextual and Thi Kim Anh, L., Wertheim, H. F. L., & Truong Son, N. (2015). Cost-effectiveness of psychosocial factors on handwashing. The American Journal of Tropical Medicine a hand hygiene program on health care-associated infections in intensive care and Hygiene, 94(6), 1407–1417. https://doi.org/10.4269/ajtmh.15-0657 patients at a tertiary care hospital in Vietnam. American Journal of Infection Control, Sharp, T. M., & Estes, M. K. (2010). An inside job: Subversion of the host secretary 43(12), e93-e99. https://doi.org/10.1016/j.ajic.2015.08.006 pathway by intestinal pathogens. Current Opinion in Infectious Diseases, 23(5), pp. Tiberghien, J-E. (2012). Power Analysis Briefing Review of tools and methods. 464-469. Retrieved from https://www.alnap.org/system/files/content/resource/files/main/ Shukla, M., & Agarwal, M. (2016). Hand washing practices of mothers attending Tiberghien%2C%202012.pdf immunization clinic at a tertiary care hospital of Lucknow. International Journal of Torondel, B., Khan, R., Holm Larsen, T., & White S. (2019). Efficacy of the Contemporary Medical Research, 3(5), 372-1375. SuperTowel®: An alternative hand-washing product for humanitarian emergencies. Soon, J.M., Baines, R., Seaman, P. (2012). Meta-analysis of training The American Journal of Tropical Medicine and Hygiene, 100(5), 1278-1284. https:// on hand hygiene knowledge and attitudes among food handlers. Journal of Food doi.org/10.4269/ajtmh.18-0860 Protection, 75(4), 793-804. https://doi.org/10.4315/0362-028X.JFP-11-502 Townsend, J., Greenland, K., & Curtis, V. (2017). Costs of diarrhoea and acute Staniford, L.J. & Schmidtke, K.A. (2020). A systematic review of hand-hygiene respiratory infection attributable to not handwashing: The cases of India and China. and environmental-disinfection interventions in settings with children. BMC Public Tropical Medicine & International Health, 22(1), 74-81. https://doi.org/10.1111/ Health, 20. https://doi.org/10.1186/s12889-020-8301-0 tmi.12808 THE HANDWASHING HANDBOOK 101 Conclusion and References

UNICEF. (2019a). Leave no one behind: Connecting, collaborating, and cross U.S. Agency for International Development. (2018a). Toward a hygiene environment learning for inclusive WASH. Bangkok, Thailand: UNICEF East Asia Pacific and for infants and young children: a review of the literature. Washington, DC: USAID U – W Regional Office.https://www.unicef.org/eap/media/4616/file/water%20and%20 Water, Sanitation, and Hygiene Partnerships and Sustainability (WASHPaLS) sanitation.pdf Project. UNICEF. (2019b). Water under fire report. New York, USA: UNICEF. U.S. Agency for International Development. (2018b). Discussion note: Adaptive UNICEF. (2020). Handwashing stations and supplies for the COVID-19 response. management. https://usaidlearninglab.org/sites/default/files/resource/files/ Retrieved August 5, 2020, from https://globalhandwashing.org/resources/ dn_-_adaptive_management.pdf handwashing-stations-and-supplies-for-the-covid-19-response/ U.S. Agency for International Development. (n.d.) Evaluation toolkit. Retrieved UNICEF & Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). (2013). August 24, 2020, from https://usaidlearninglab.org/evaluation-toolkit Field guide: The three star approach for wash in schools. New York, NY: UNICEF. Wagner, E. G., & Lanoix J. N. (1958). Excreta disposal for rural areas and small https://www.unicef.org/wash/schools/files/UNICEF_Field_Guide-3_Star-Guide.pdf communities. World Health Organizations Monograph Series, 39, 95. UNICEF/WES, U.S. Agency for International Development, World Bank/Water and Wash’em. (n.d.a) https://washem.info/ Sanitation Program, Water Supply & Sanitation Collaborative Council. (2004). Joint Wash’em. (n.d.b). Wash’em tools and software. Retrieved August 5, 2020, from publication 8, The hygiene improvement framework: a comprehensive approach for https://app.washem.info/?_ga=2.214778004.2024118586.1591123009- preventing childhood diarrhea. Washington, D.C.: Environmental Health Project. 166128305.1586207333 UNICEF/World Health Organization. (2019): Position paper – Implications of WASHplus. (2014). Improving WASH behaviors to reduce diarrhea and improve recent WASH and nutrition studies for WASH policy and practice. https://www. the resilience of children, families affected by HIV/AIDS, and other vulnerable shareresearch.org/research/who-unicef-position-paper-recent-wash-and-nutrition- populations: WASHPlus Uganda end of project review. Washington, D.C.: WASHplus. trials WASHplus. (2016a). Behavior-centered approaches to improve health outcomes. Unilever. (n.d.a). Health handwashing habits for life. Retrieved August 5, 2020, from Washington, DC: USAID WASHplus Program. Retrieved from http://washplus.org/ https://www.unilever.com/sustainable-living/improving-health-and-well-being/ sites/default/files/BC%20brief%20final%20508.pdf health-and-hygiene/healthy-handwashing-habits-for-life/ WASHplus. (2016b). SPLASH School Outcome Study. The effect of WASH in Unilever. (n.d.b). Inspiring sustainable living: expert insight into consumer behavior schools on educational outcomes: Absenteeism and teacher-pupil contact time. and Unilever’s Five Levers for Change. London: Unilever. https://www.unilever.com/ Washington, D.C.: WASHplus. http://www.washplus.org/sites/default/files/ Images/slp_5-levers-for-change_tcm244-414399_en.pdf SPLASH%20Outcome%20Study%20Final%20508.pdf. Unilever. (2019). Lifebuoy way of life social mission report 2019. London: Unilever. WaterAid. (n.d.). Transforming health systems: the vital role of water, sanitation https://www.unilever.com/Images/lifebuoy_way-of-life_2019_annual-report_ and hygiene. https://washmatters.wateraid.org/publications/transforming-health- tcm244-418692_1_en.pdf systems-the-vital-role-of-water-sanitation-and-hygiene University of Iowa. (2013). Hand hygiene = healthier workplace. A health and WaterAid. (2017). Accelerating progress toward SDG 6: A system strengthening safety bulletin from UI HealthWorks and WORKSAFE IOWA. http://cph.uiowa.edu/ approach for water, sanitation, and hygiene that leaves no one behind. https:// worksafe/pubs/bulletin/Dec-2013.html sustainabledevelopment.un.org/partnership/?p=30208 U.S. Agency for International Development. (2014). Local systems: A framework WaterAid Australia. (2012). Towards inclusive WASH: Sharing evidence and for supporting sustained development. USAID: Washington, DC. https://www.usaid. experience from the field. http://www.inclusivewash.org.au/case-studies/ gov/sites/default/files/documents/1870/LocalSystemsFramework.pdf THE HANDWASHING HANDBOOK 102 Conclusion and References

Watson J., Dreibelbis R., Aunger R., Deloa, C., Kind, K., Long, S., Chase, S. P., & Wilbur, J. (2020). How can we ensure people with disabilities are included in Cumming, O. (2018). Child’s play: Harnessing play and curiosity motives to all COVID-19 hygiene promotion programmes? Retrieved August 12, 2020, W improve child handwashing in a humanitarian setting. International Journal of from https://resources.hygienehub.info/en/articles/4098118-how-can-we- Hygiene and Environmental Health, 222(2), pp. 177-182. https://doi.org/10.1016/j. ensure-people-with-disabilities-are-included-in-all-covid-19-hygiene-promotion- ijheh.2018.09.002 programmes Watson, J.A., Ensink, J.H.J., Ramos, M., Benelli, P., Holdsworth, E., Dreibelbis, R., & Willmott, M., Nicholson, A., Busse, H., MacArthur, G.J., Brookes, S., & Campbell, Cumming, O. (2017). Does targeting children with hygiene promotion messages R. (2015). Effectiveness of hand hygiene interventions in reducing illness work? The effect of handwashing promotion targeted at children, on diarrhoea, soil‐ absence among children in educational settings: A systematic review and meta- transmitted helminth infections and behaviour change, in low‐ and middle‐income analysis. Archives of Disease in Child Health, 101(1). http://dx.doi.org/10.1136/ countries. Tropical Medicine & International Health, 22(5), 526-538. https://doi. archdischild-2015-308875 org/10.1111/tmi.12861 Wood, W., & Neal, D. T. (2007). A new look at habits and the habit-goal interface. Watson, J., Dreibelbis, R., Aunger, R., Deola, C., King, K., Long, S., Chase, R.P., & Psychological review, 114(4), 843-863. http://dx.doi.org/10.1037/0033- Cumming, O. (2019a). Child’s play: Harnessing play and curiosity motives to 295X.114.4.843 improve child handwashing in a humanitarian setting. International Journal of World Bank. (2012). Behavioral determinants of handwashing with soap among Hygiene and Environmental Health, 222(2), 177-182. mothers and caretakers: Emergent learning from Senegal and Peru. Water and Watson, J., D’Mello-Guyett, L., Flynn, E., Falconer, J., Esteves-Mills, J., Prual, A., Sanitation Program Learning Note 66913. https://documents.worldbank.org/ Hunter, P., Allegranzi, B., Montgomery, M., & Cumming, O. (2019b). Interventions en/publication/documents-reports/documentdetail/794261468113089975/ to improve water supply and quality, sanitation and handwashing facilities behavioral-determinants-of-handwashing-with-soap-among-mothers-and- in healthcare facilities, and their effect on healthcare-associated infections caretakers-emergent-learning-from-senegal-and-peru in low-income and middle-income countries: a systematic review and World Health Organization. (n.d). Early child development. Retrieved August 3, 2020, supplementary scoping review. BMJ Global Health, 4(4). http://dx.doi.org/10.1136/ from https://www.who.int/topics/early-child-development/en/ bmjgh-2019-001632 World Health Organization. (2008). Safe water, better health: Costs, benefits, and Weisbord, M., & Janoff, S. (2010). Future search: Getting the whole system in sustainability of interventions to protect and promote health. Geneva: World Health the room for vision, commitment, and action. San Francisco, CA: Berrett‐Koehler Organization. Publishers. World Health Organization. (2009a). WHO guidelines on hand hygiene in health care. White, S., Hasund Thorseth, A., Dreibelbis, R., & Curtis V. (2020). The determinants Geneva: World Health Organization. https://www.who.int/infection-prevention/ of handwashing behaviour in domestic settings: An integrative systematic publications/hand-hygiene-2009/en/ review. International Journal of Hygiene and Environmental Health, 227. https://doi. org/10.1016/j.ijheh.2020.113512 World Health Organization. (2009b). Hand Hygiene: Why, How & When? Retrieved from https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_ White, S., Petz, J. F., Desta, K., & Holm Larsen, T. (2019). Could the Supertowel be Brochure.pdf used as an alternative hand cleaning product for emergencies? An acceptability and feasibility study in a refugee camp in Ethiopia. PLoS One, 14(5), e0216237. World Health Organization. (2009c). Guide to implementation: A guide to the implementation of the who multimodal hand hygiene improvement strategy. Geneva: World health Organization. https://www.who.int/gpsc/5may/Guide_to_ Implementation.pdf THE HANDWASHING HANDBOOK 103 Conclusion and References

World Health Organization. (2015a). Water Sanitation & Hygiene 2015–2020: A water, sanitation and hygiene in health care facilities. Geneva: World Health W – Z global strategy for accelerating and sustaining progress on Neglected Tropical Organization. Disease. Retrieved from https://www.who.int/water_sanitation_health/ World Health Organization & UNICEF. (2019). WASH in health care facilities: Global publications/wash-and-ntd-strategy/en/ baseline report 2019. Geneva: World Health Organization and UNICEF. https:// World Health Organization. (2015b). Building latrines and keeping water clean washdata.org/sites/default/files/documents/reports/2019-04/JMP-2019-wash-in- decreases diarrhea and under-nutrition in Mali. https://www.who.int/features/2015/ hcf.pdf water-sanitation-mali/en/ World Health Organization, UNICEF. (2020). Hand hygiene for all. Geneva: World World Health Organization. (2018a). 10 Facts on . Retrieved August 3, Health Organization and UNICEF. https://www.who.int/water_sanitation_health/ 2020, from https://www.who.int/features/factfiles/patient_safety/en/ sanitation-waste/sanitation/hand-hygiene-for-all/en/. World Health Organization. (2018b). The burden of health care-associated infection World Health Organization, UNICEF, & USAID (2015). Improving nutrition worldwide. Retrieved August 5, 2020, from https://www.who.int/gpsc/country_ outcomes with better water, sanitation and hygiene: practical solutions for work/summary_20100430_en.pdf. policies and programmes. Geneva: World Health Organization. https://www. World Health Organization. (2019a). Children: Reducing mortality. https://www.who. unicef.org/media/files/IntegratingWASHandNut_WHO_UNICEF_USAID_ int/news-room/fact-sheets/detail/children-reducing-mortality Nov2015.pdf#:~:text=This%20publication%2C%20jointly%20prepared%20 by%20WHO%2C%20the%20United,be%20integrated%20into%20nutrition%20 World Health Organization. (2019b). Minimum requirements for infection programmes.%20It%20provides%20practical. prevention and control. Geneva: World Health Organization. World Health Organization, UNICEF, World Bank Group. (2018). Nurturing care for World Health Organization. (2020). Hand hygiene for all initiatives: Improving early childhood development: A framework for helping children survive and thrive access and behavior in health care facilities. Geneva: World Health Organization. to transform health and human potential. Geneva: World Health Organization. World Health Organization & UN-Water. (2020). Hygiene UN-Water GLAAS findings https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng. on national policies, plans, targets and finance. Retrieved from https://www.who.int/ pdf?ua=1&ua=1. water_sanitation_health/publications/hygiene-glaas-findings/en/ World Health Organization & USAID. (2010). How to integrate water, sanitation and World Health Organization and UNICEF. (n.d.) Global estimates for basic hygiene hygiene into HIV programmes. Geneva, Switzerland: World Health Organization. services in households, schools and health care facilities. Retrieved August 5, 2020, https://www.who.int/water_sanitation_health/publications/9789241548014/en/ from https://washdata.org/ Xuan, L. T. T., & Hoat, L. N. (2013). Handwashing among schoolchildren in an World Health Organization & UNICEF. (2017). Progress on drinking water, sanitation ethnically diverse population in northern rural Vietnam. Global Health Action, 6, 1-8. and hygiene: 2017 update and SDG baselines. Geneva: World Health Organization https://doi.org/10.3402/gha.v6i0.18869 and UNICEF. https://www.who.int/water_sanitation_health/publications/jmp-2017/ Zhang, C., Mosa, A. J., Hayward, A. S., & Matthews, S. A. (2013). Promoting clean en/ hands among children in Uganda: a school-based intervention using ‘tippy-taps’. World Health Organization & UNICEF. (2018a). Drinking water, sanitation, and Public Health, 127(6). https://doi.org/10.1016/j.puhe.2012.10.020 hygiene in schools: Global baseline report 2018. Geneva: World Health Organization Zottele, C., Magnago, T. S. B. S., Dullius, A. I. D. S., Kolankiewicz, A. C. B., & Ongaro, J. and UNICEF. https://www.washdata.org/sites/default/files/documents/ D. (2017). Hand hygiene compliance of healthcare professionals in an emergency reports/2018-11/JMP%20WASH%20in%20Schools%20WEB%20final.pdf department. Revista da Escola de Enfermagem da USP, REEUSP, 51, e03242. World Health Organization & UNICEF. (2018b). Water and sanitation for health https://doi.org/10.1590/s1980-220x2016027303242 facility improvement tool: A practical guide for improving quality of care through THE HANDWASHING HANDBOOK

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