What WaterAid can teach us about handwashing

IBT member, WaterAid, is one of the world’s leading experts on handwashing and hygiene promotion and the COVID-19 pandemic has given its work added urgency. Om Prasad Gautam shares his top tips on achieving the change in behaviour that is necessary if the pandemic is to be tackled successfully.

The current battle against the spread of the COVID-19 has highlighted in horrifically stark terms the fundamental importance of handwashing with soap and water in controlling the spread of infectious diseases. Three billion people across the world – and 75% of the population in the least developed countries – do not have access to somewhere to wash their hands with soap and water.

Even before the COVID-19 pandemic, this lack of the most basic of services together with a denial of rights to water and sanitation, led every year to tens of thousands of deaths from diarrhoeal and waterborne diseases, mostly hidden from the headlines and ignored by those with the power to change this situation.

Now in the face of a terrifying disease, everyone is having to learn quickly about putting hygiene at the heart of daily life. Currently, fear is acting as a powerful stimulus for people to drastically change their behaviour, but we know this may not last for long. Here are the key lessons that we have learnt from working in this field for almost 40 years.

1. It’s more than just soap and water

You can’t just give people soap and expect them to want to use it, know how to use it or why. If you are forced to decide between buying food or school books or soap, then just being told that soap is important is not enough to put it on the shopping list and change behaviour around washing hands.

We all know that knowledge only is not enough – otherwise we would all adhere faithfully to public health guidelines on exercise, diet, smoking etc. Key to bringing about lasting behaviour change is understanding and targeting the motives that drive people to change their habits – so they can move from knowledge to actual practice. When there is an outbreak of disease like now or during Ebola outbreaks, a motivation to change behaviour can be fear but it can be temporary stimulus.

But Ebola showed us that often behaviours adopted during a time of acute crisis do not become long term so WaterAid works with other motivations such as nurture –loving your family and wanting to protect them. Other drivers include a sense of wanting to fit in and so we work to make washing hands a social norm.

2. It has to include everyone

Gender, age, disability, ethnicity, race, religion and economic and health status all play a part in determining who will and won’t have access to the basic necessities of clean water, sanitation and handwashing facilities.

We are committed to tackling inequalities across all strata of society and our programmes always consider how everyone, especially those that are the most marginalised – can access them.

3. Go beyond your immediate sector

What’s clear is that there are strategic moments when messages and lessons around hygiene are most effectively transmitted and it is often by working in tandem with other sectors, such as health or education, that change is most successfully implemented. For example, we reached thousands of mothers with life-saving hygiene lessons in Nepal when they took their babies to be vaccinated in a government-run routine immunisation programme.

4. Schools, homes, hospitals – it has to be everywhere

Even the best designed behaviour change programme to get people to wash their hands will fail if there is nowhere to wash hands. So our work is community wide – helping to ensure that every home, school and healthcare centre has somewhere to wash hands with soap. Yet globally only around half of schools have somewhere for pupils to wash their hands with soap and water and over 40% of healthcare facilities have nowhere for doctors and nurses to wash their hands where they see patients.

5. A whole system needs to be in place

Water, sanitation and hygiene (WASH) programmes that focus solely on providing taps, toilets and one-off trainings are unlikely to deliver lasting outcomes. To be successful, you need a whole ecosystem in place – so you need taps that keep working because the utility company is well staffed and adequately financed, you need every teacher and every school child to receive training, you need the health centre to be able to rely on always having soap available. Otherwise, it is just not possible to keep the good habits going.

6. Support, influence and work with Governments

We have learnt that by supporting and working with governments, we can be most effective and implement at scale. This means making the case as to why investing in WASH pays dividends in terms of increased health, dignity and productivity. In the face of a global pandemic, the importance of good WASH is hard to overstate and so we are working with governments to rapidly increase the provision of handwashing facilities and also supporting mass media behaviour change campaigns.

7. Research, monitor and evaluate

Our behaviour change work is based on getting to know the community context – what matters to people, what holds back people for behaviour change, what motivates them and then monitoring over time to see if the programme has been effective. Then we evaluate and make changes as needed.

8. Use the media creatively

Most of our initial COVID-19 response has been using digital, social and mass media, in order to comply with social distancing requirements. For example, in Zambia we have worked with celebrities, athletes and artists to record hygiene promotion videos that have been posted on social media platforms. In India we launched a high profile campaign using text messaging, WhatsApp groups, community radio and local TV channels. In more normal times, we also use community-based projects like performing traditional dance and theatre in Ethiopia to pass on hygiene lessons.