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Handwashing technical briefing note

Soap is what people ask for first Relevance of handwashing in


Faroza was displaced by the floods disease prevention
in Pakistan in 2010. She explained
to Oxfam staff what the best parts In developing countries the biggest
of our response had been. The killers of young children are
most useful item has been the respiratory infections and
soap for personal washing and for diarrhoeal diseases both can be
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washing clothes because our reduced with hand washing .
clothes were very dirty, our Hands are the last line of defence
children were very dirty and we in the chain of transmission of
didnt have any money to buy gastrointestinal germs either
these things. Before we got these directly by hand-to-mouth, or
indirectly by handling food or
Background kits we were so muddy we looked
water. Hands also play a part in
like sweepers because we were
always dirty, dirty, dirty. Now we the transmission of respiratory
It is now well known that handwashing have soap for handwashing, tract, skin and eye infections:
with soap has a greater impact on personal washing and for washing hands can be contaminated by
morbidity from diarrhoeal disease than babies. So we were very happy respiratory viruses, and infections
any other single intervention (see when we got these kits because transferred by rubbing the eyes.
chart below). Why then, do NGOs we felt so much better and happy
focus so many of their activities and when we were clean, our babies Handwashing is particularly
so much more money on supplying were clean and our clothes were important in disaster situations;
clean water and sanitation facilities? clean. The soap is also helping to displaced people may lack an
Why are these recognised as core prevent skin diseases and rashes, adequate supply of water, their
activities while handwashing is and other diseases, like diarrhoea. circumstances can put them in
considered a bolt-on activity? And My baby had diarrhoea but after situations where it is difficult for
why do NGOs always include water we had these kits I could keep my them to manage their hygiene, and
quality and latrine use as important baby clean and now the diarrhoea access to soap may be limited. It
indicators of success in logframes and has stopped. Before we got these is important to ensure that
monitoring strategies but rarely items, especially the soap, we promotion and provision of
include handwashing, even though it were praying that someone would handwashing facilities are
is known to be a better success come and give them to us. prioritised in all responses where
indicator? public health is at risk.

Handwashing at all times


Effective hand washing is a key consideration in all
WASH programmes, and at all phases in the
programme cycle:

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Assessment: it is important to know peoples
existing behaviour; whether they wash their hands Practical Considerations
after defecation and before food preparation and
eating. Do they use soap or other agents? Do
Peoples practices:
different groups - men, boys, women, girls etc have
different practices? PHP staff should include an Consultation with the population is important;
assessment of hand-washing knowledge, attitudes (including men, women and children) on their views
and practice in all rapid WASH assessments and on the types of devices used and their preferences,
baseline surveys to ensure they are appropriate; e.g. the taps
should not be too high or too difficult for children
Planning: involve the affected population in
elderly and people with disabilities to operate
planning and ensuring all responses are
appropriate and relevant to the situation. Funding
for handwashing devices, including soap, should
be included in budgets. Choice of handwashing
device should as much as possible be informed by
what is traditionally used by the community.
Appropriate behavioural change should be
incorporated as an important part of programme
planning
First-phase response: consideration must be
given to handwashing from the outset emphasis
should be at communal
latrines or defecation In some cultures men
areas at very least, as Work with the local culture and existing may not share the
well as at food practices same facilities with
preparation points. A During a serious cholera epidemic in West Papua, women, so facilities
campaign to our public health adviser noticed that funeral rituals should be appropriate
disseminate key (in which people touched the bodies before eating a for the cultural context
handwashing messages funeral meal) were likely to be spreading the Handwashing
may be appropriate. disease. Rather than attempting to stop the ritual, techniques may differ
Training hygiene the adviser consulted the local church leaders, and between communities.
promoters and together they successfully introduced an additional Several countries have
community mobilisers is practice handwashing with water and wood ash produced posters
a useful way to promote between the paying of last respects and the eating. describing the steps
handwashing; tools and Soap was not available locally and would have been involved in hand
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training materials have expensive and unsustainable to import. The washing, and the
been produced by the number of new cholera patients admitted to the Sphere handbook has a
WASH Cluster
2 Treatment Centre declined quickly and dramatically, chapter on the right
Maintenance: all as the direct result of this one intervention. techniques for
handwashing facilities handwashing to be
should have a effective (length of time
consistent supply of water and be well maintained rubbing your hands, what medium to use, length of
to ensure they are useable. In the first phase it may fingernails etc). All health promoters should know
be necessary to pay water suppliers or use and promote these techniques.
community mobilisers to
refill handwashing facilities, Handwashing Facilities:
but in the longer term all Its not what you know, its what you Handwashing facilities
facilities should have water do should be made available at
conservation systems or Staff in Pakistan ran a successful training sanitation areas at very least
continuous filling processes course in public health for community Consideration should be
as needed health committees, and all participants given not only to ensuring
Monitoring: observation demonstrated good understanding of the there are hand washing
and focus group discussions value of handwashing. However, over facilities at the latrines, but
can be used to monitor lunch, one of the facilitators kept watch also at the household level
handwashing practices; they over the prominently-displayed encouraging people to wash
complement each other in handwashing facility nearby, and noticed their hands at all key times,
highlighting what people that hardly any of the participants actually such as before feeding
really do vs what they say did wash their hands before eating! children, preparing food,
they do. Anecdotal eating etc. Soap is also less
information should be collected in conjunction with likely to get stolen at
other data. Ensure all data is written and analysed household level compared to communal hand
to monitor any changes in handwashing behaviour. washing areas. Different facilities will be suitable
Active listening to the views of the community is for different situations
key to understanding community attitudes Different handwashing facilities will be appropriate
for different situations; e.g. large drums for

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community facilities or smaller devices such as has a guidance note on motivating different groups
the Tippy Tap for households. to take action.
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Soap is a valuable commodity and might be taken Use shock tactics, if appropriate! To change a habit
from communal sites, so put some thought into you may have to shock people into doing
ways of minimising this risk eg tying it to string, or something different, giving them a powerful
diluting it in water message that really motivates them to think about
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All handwashing sites should have adequate what they are doing and change it
drainage to prevent muddy conditions.
Methods that have been used successfully for
Just water, soap, or ash? handwashing promotion include:
Soap is the ideal agent, but this is not always Drama, plays, dances
available or affordable. Songs
Antibacterial soap is not What if our facilities get stolen? Puppets
advised where there is a In Solo camp, Liberia, Oxfam was Clowns
high incidence of skin providing water, sanitation, and hygiene Games
diseases (such as in flood facilities in camps. Following the Door-to-door distribution of
situations) as it can be distribution of covered buckets with taps posters of leaflets
irritable. There also seems widely to household, the threat of Demonstrations
to be no difference in communal handwashing facilities being
effectiveness between taken Staff was noticeably reduced. They Places for handwashing
antibacterial soap and
4 then used the same buckets with taps to promotion include:
plain soap. provide water for handwashing at Schools
If no soap is available, communal points near latrines. It was Places of worship
washing hands with ash is because everyone already had a similar Community centres
preferable to no agent at bucket at home that no one felt the need Market areas
all. Soil, ash or mud as an to take the communal ones. Likewise, Health centres / clinics
alternative to soap may making soap readily available might In the home
have risks as they can be reduce peoples desire to steal communal
contaminated with
5 soap supplies. In summary, key criteria for ideal
pathogens - use fresh
handwashing devices are:
ash straight from the
source Low manufacturing cost
It is the rubbing of the Dont assume a lack of knowledge Lightweight/transportable
hands which is important. In the displaced settlements in Haiti, public Strong/durable
health staff put drums of water outside the High water conservation
Promoting handwashing latrines and people were very happy to Locally replicable
Promotion has to suit the use them without the need for any Unisex, and cross-generation
context culture, gender, awareness-raising. Making facilities easily appropriate
children, environment etc; available is often sufficient. Simple to operate
these issues should be Disability conscious
considered at the assessment stage, to help with Theft resistant
planning interventions Maximum water filling frequency of two times/day
It is important to know the target populations Culturally appropriate and acceptable by the
existing behaviours and preferences for community.
promotional material; e.g. Haitians enjoy music, so
a 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 out
Ensure the language / idiomatic expression and the
method used in the promotional material is
understood; e.g. not everyone can read
especially women in some communities
Encouraging handwashing should be included in all
latrine attendants and health promoters job
descriptions
Women are usually the cooks and carers, so it is
important to target them for promotional activities
Health 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 be
stronger driving forces. Refer to the chapter on
Hygiene Promotion in the Sphere handbook which

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October 15th is Global Handwashing Day At the absolute minimum
All institutional latrines constructed by Oxfam must
The annual Global Handwashing Day is a good have handwashing facilities provided with soap or a
opportunity to raise awareness of just how proxy agent, especially in the acute stage of an
important handwashing is. Useful tips for emergency response
marking the day include:
Ensure there is a budget in all proposals for Communal handwashing places should be constructed
some handwashing promotional activities on to raise awareness about the importance of
global handwashing day handwashing; demonstration facilities are useful
Activities could include fun, practical games Special focus should be given to children, since
for the children (ensuring teachers are children share information on handwashing with their
involved) as well as adults. Games like families. Demonstrations and monitoring in school are
quizzes, snakes and ladders, and useful to help children learn and practice effective
handwashing relays with prizes of bars of handwashing
soap (this has worked well in Pakistan and Promotion of handwashing should consider the
Indonesia) context; peoples behaviour, the culture, amount of
The Global Handwashing website has useful water available etc.
planning guidelines, games, posters and
other resources
1 Vulnerable groups, such as those with disabilities or
In 2009 there was also the Golden Poo HIV and AIDS need especially easy access to
awards, with several films using comedy handwashing facilities
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and shock to promote hand washing Monitoring, evaluation and learning activities must
Make handwashing day memorable! include assessments of changes in handwashing
Possibly seek media coverage, or record it practice and appropriate use of handwashing
yourselves at least, for Oxfams internal facilities.More details in the WASH Minimum
communications and learning. Requirement document.

References
1
WELL Factsheet on health impact of handwashing with soap: http://www.lboro.ac.uk/well/resources/fact-sheets/fact-
sheets-htm/Handwashing.htm
2
http://www.humanitarianreform.org/Default.aspx?tabid=343 , also Hygiene promotion training materials and visual
aids available on DVD. There are some relevant sessions in the Essential to know (part 1 of 3), such as key actions to
prevent diarrhoea, community involvement in the design of facilities.
3
An example of Hand washing steps poster: http://www.redcross.org/www-
files/Documents/pdf/Preparedness/ScrubClubHandWashing.pdf
4
Luby S. et al (2004) Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk communities in
Pakistan: A Randomised Controlled Trial The Journal of the American Medical association 292 (14)
5
Bloomfield, S. F. and Nath, K.J. (2009) Use of ash and mud for handwashing in low income communities.
International Scientific Forum on Home Hygiene
6
Sphere Project, (2011) Humanitarian Charter and Minimum Standards in Humanitarian Response,
www.sphereproject.org
7
Curtis, V. (2009) July Soapbox, the newsletter of the Global public private partnership for hand washing with soap
8
Oxfam GB, Water Sanitation and Hygiene Promotion Minimum Requirement (MR WASH).see Oxfam GB O Drive.

For more information and guidance, please contact any of the Regional or Humanitarian Department Public
Health Promotion Advisers

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