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Published by Oxfam
It is now well known that handwashing with soap has a greater impact on morbidity from diarrhoeal disease than any other single intervention.
This technical briefing note looks at the relevance of handwashing in disease prevention, as well as the practicalities and promotion of handwashing in developing countries.
It is now well known that handwashing with soap has a greater impact on morbidity from diarrhoeal disease than any other single intervention.
This technical briefing note looks at the relevance of handwashing in disease prevention, as well as the practicalities and promotion of handwashing in developing countries.

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Categories:Types, Research
Published by: Oxfam on Apr 26, 2013
Copyright:Attribution Non-commercial


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Handwashing technical briefing note
It is now well known that handwashingwith soap has a greater impact onmorbidity from diarrhoeal disease thanany other single intervention (seechart below). Why then, do NGOsfocus so many of their activities andso much more money on supplyingclean water and sanitation facilities?Why are these recognised as coreactivities while handwashing is
considered a „bolt
on‟ activity?
Andwhy do NGOs always include water quality and latrine use as importantindicators of success in logframes andmonitoring strategies but rarelyinclude handwashing, even though itis known to be a better successindicator?
Relevance of handwashing indisease prevention
In developing countries the biggestkillers of young children arerespiratory infections anddiarrhoeal diseases
both can bereduced with hand washing
.Hands are the last line of defencein the chain of transmission of gastrointestinal germs either directly by hand-to-mouth, or indirectly by handling food or water. Hands also play a part inthe transmission of respiratorytract, skin and eye infections:
 hands can be contaminated byrespiratory viruses, and infectionstransferred by rubbing the eyes.Handwashing is particularlyimportant in disaster situations;displaced people may lack anadequate supply of water, their circumstances can put them insituations where it is difficult for them to manage their hygiene, andaccess to soap may be limited. Itis important to ensure thatpromotion and provision of handwashing facilities areprioritised in all responses wherepublic health is at risk.
Handwashing at all times
Effective hand washing is a key consideration in allWASH programmes, and at all phases in theprogramme cycle:
Soap is what people ask for first
Faroza was displaced by the floodsin Pakistan in 2010. She explained to Oxfam staff what the best partsof our response had been.
most useful item has been thesoap for personal washing and for washing clothes because our clothes were very dirty, our children were very dirty and we
didn’t have any money to buy 
these things. Before we got thesekits we were so muddy we looked like sweepers because we werealways dirty, dirty, dirty. Now wehave soap for handwashing, personal washing and for washing babies. So we were very happy when we got these kits becausewe felt so much better and happy when we were clean, our babieswere clean and our clothes wereclean. The soap is also helping to prevent skin diseases and rashes,and other diseases, like diarrhoea.My baby had diarrhoea but after we had these kits I could keep my baby clean and now the diarrhoeahas stopped. Before we got theseitems, especially the soap, wewere praying that someone would come and give them to us.
Page 2 of 4
it is important to know people‟s
existing behaviour; whether they wash their handsafter defecation and before food preparation andeating. Do they use soap or other agents? Dodifferent groups - men, boys, women, girls etc havedifferent practices? PHP staff should include anassessment of hand-washing knowledge, attitudesand practice in all rapid WASH assessments andbaseline surveys
: involve the affected population inplanning and ensuring all responses areappropriate and relevant to the situation. Fundingfor handwashing devices, including soap, shouldbe included in budgets. Choice of handwashingdevice should as much as possible be informed bywhat is traditionally used by the community. Appropriate behavioural change should beincorporated as an important part of programmeplanning
 First-phase response
: consideration must begiven to handwashing from the outset
emphasisshould be at communallatrines or defecationareas at very least, aswell as at foodpreparation points. Acampaign todisseminate keyhandwashing messagesmay be appropriate.Training hygienepromoters andcommunity mobilisers isa useful way to promotehandwashing; tools andtraining materials havebeen produced by theWASH Cluster 
: allhandwashing facilitiesshould have aconsistent supply of water and be well maintainedto ensure they are useable. In the first phase it maybe necessary to pay water suppliers or usecommunity mobilisers torefill handwashing facilities,but in the longer term allfacilities should have water conservation systems or continuous filling processesas needed
observationand focus group discussionscan be used to monitor handwashing practices; theycomplement each other inhighlighting what peoplereally do vs what they saythey do. Anecdotalinformation should be collected in conjunction withother data. Ensure all data is written and analysedto monitor any changes in handwashing behaviour. Active listening to the views of the community iskey to understanding community attitudes
Practical Considerations
Peoples’ practices:
 Consultation with the population is important;(including men, women and children) on their viewson the types of devices used and their preferences,to ensure they are appropriate; e.g. the tapsshould not be too high or too difficult for childrenelderly and people with disabilities to operateIn some cultures menmay not share thesame facilities withwomen, so facilitiesshould be appropriatefor the cultural contextHandwashingtechniques may differ between communities.Several countries haveproduced postersdescribing the stepsinvolved in handwashing,
and theSphere handbook has a
chapter on the „right‟
techniques for handwashing to beeffective (length of timerubbing your hands, what medium to use, length of fingernails etc). All health promoters should knowand promote these techniques.
Handwashing Facilities:
Handwashing facilitiesshould be made available atsanitation areas at very leastConsideration should begiven not only to ensuringthere are hand washingfacilities at the latrines, butalso at the household level
 encouraging people to washtheir hands at all key times,such as before feedingchildren, preparing food,eating etc. Soap is also lesslikely to get stolen athousehold level compared to communal handwashing areas. Different facilities will be suitablefor different situationsDifferent handwashing facilities will be appropriatefor different situations; e.g. large drums for 
Work with the local culture and existingpractices
During a serious cholera epidemic in West Papua,our public health adviser noticed that funeral rituals(in which people touched the bodies before eating afuneral meal) were likely to be spreading thedisease. Rather than attempting to stop the ritual,the adviser consulted the local church leaders, and together they successfully introduced an additional  practice
handwashing with water and wood ash
 between the paying of last respects and the eating.Soap was not available locally and would have beenexpensive and unsustainable to import. Thenumber of new cholera patients admitted to theTreatment Centre declined quickly and dramatically,as the direct result of this one intervention.
It’s not what you know, it’s what youdo…
Staff in Pakistan ran a successful training course in public health for community health committees, and all participantsdemonstrated good understanding of thevalue of handwashing. However, over lunch, one of the facilitators kept watchover the prominently-displayed handwashing facility nearby, and noticed that hardly any of the participants actually did wash their hands before eating! 
Page 3 of 4
community facilities
or smaller devices such asthe Tippy Tap for 
Soap is a valuable commodity and might be takenfrom communal sites, so put some thought intoways of minimising this risk
eg tying it to string, or diluting it in water  All handwashing sites should have adequatedrainage to prevent muddy conditions.
Just water, soap, or ash?
Soap is the ideal agent, but this is not alwaysavailable or affordable. Antibacterial soap is notadvised where there is ahigh incidence of skindiseases (such as in floodsituations) as it can beirritable. There also seemsto be no difference ineffectiveness betweenantibacterial soap andplain soap.
 If no soap is available,washing hands with ash ispreferable to no agent atall. Soil, ash or mud as analternative to soap mayhave risks as they can becontaminated withpathogens
use „fresh‟
ash straight from thesourceIt is the rubbing of thehands which is important.
Promoting handwashing
 Promotion has to suit thecontext
culture, gender,children, environment etc;these issues should beconsidered at the assessment stage, to help withplanning interventionsIt is important to know the tar 
get population‟s
existing behaviours and preferences for promotional material; e.g. Haitians enjoy music, soa catchy song by a popular singer can work well.
Traditional childrens‟ games can be very
successfully adapted to include hygiene messages,and can be fun to carry outEnsure the language / idiomatic expression and themethod used in the promotional material isunderstood; e.g. not everyone can read
 especially women in some communitiesEncouraging handwashing should be included in alllatrine attendants
and health promoters
jobdescriptionsWomen are usually the cooks and carers, so it isimportant to target them for promotional activitiesHealth may not be the most important motivator for changes in hygiene behaviour. The desire for privacy & dignity, the observation of religious or cultural norms, or personal comfort may bestronger driving forces. Refer to the chapter onHygiene Promotion in the Sphere handbook whichhas a guidance note on motivating different groupsto take action.
 Use shock tactics, if appropriate! To change a habityou may have to shock people into doingsomething different, giving them a powerfulmessage that really motivates them to think aboutwhat they are doing and change it
Methods that have been used successfully for handwashing promotion include:
Drama, plays, dancesSongsPuppetsClownsGamesDoor-to-door distribution of posters of leafletsDemonstrations
Places for handwashingpromotion include:
SchoolsPlaces of worshipCommunity centresMarket areasHealth centres / clinicsIn the homeIn summary,
key criteria for idealhandwashing devices are:
Low manufacturing costLightweight/transportableStrong/durableHigh water conservationLocally replicableUnisex, and cross-generationappropriateSimple to operateDisability consciousTheft resistantMaximum water filling frequency of two times/dayCulturally appropriate and acceptable by thecommunity.
What if our facilities get stolen?
In Solo camp, Liberia, Oxfam was providing water, sanitation, and hygienefacilities in camps. Following thedistribution of covered buckets with tapswidely to household, the threat of communal handwashing facilities being taken Staff was noticeably reduced. They then used the same buckets with taps to provide water for handwashing at communal points near latrines. It wasbecause everyone already had a similar bucket at home that no one felt the need to take the communal ones. Likewise,making soap readily available might 
reduce people’s desire to steal communal 
soap supplies.
Don’t assume a lack of knowledge
In the displaced settlements in Haiti, public health staff put drums of water outside thelatrines and people were very happy touse them without the need for any awareness-raising. Making facilities easily available is often sufficient.

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