This Global Handwashing Day, Let’s Make Handwashing Normal

“Wash my hands again….?” my 5 1/2-year-old asks me incredulously. “Just wash your hands thoroughly with soap, sing that song, remember – its COVID times” comes my standard response from my work desk. After an exasperated “okay”, I hear the tap being turned on and off, rather quickly, and a sullen child emerging from the bathroom with hands dripping water. No song was sung, and I am confident that he did not scrub his hands for 20 seconds. I wonder – what happened to the child, who in April, enthusiastically made soap bubbles while humming, singing loudly, and even dancing when washing hands? He knows handwashing is important – we have talked about it, he has seen the many videos. So why has cleaning hands become a chore, a challenge for my handwashing champion?  

Undoubtedly, handwashing with soap is a powerful, low-cost public health remedy, protecting against a host of infections including COVID-19, saving lives and avoidable health care related expenditures. Despite these benefits, cleaning hands with soap is, undoubtedly, challenging. Evidence from community-based studies in India reveals fairly high levels of awareness on handwashing and soap use, particularly before meals and after toilet use. Data from demographic surveys show that 35.8% households report washing hands with soap before eating meals, and 74.1% wash hands after defecating (National Sample Survey 76 Round), with smaller studies suggesting low rates of handwashing for child care-related tasks and COVID-19 related exposures. Data further show that only 80.3% of urban and 49.4% of rural households with a handwashing space had water and soap to facilitate this practice (National Family Health Survey 4 [2015-16]). Insights also suggest that handwashing is guided by perceptions of visibly dirty hands, contaminating actions, and personal relevance of the behaviour, and social support for the action. 

Handwashing with soap is then more than …well…. washing hands with soap. This seemingly simple and life-saving behaviour requires efforts and investments to build and strengthen three pillars to enable long-lasting hygiene habits for all: 

Handwashing requires a dedicated space with sufficient water and soap, that is convenient to use 

Restricted water access and water scarcity results in domestic needs and chores, and handwashing competing for the same resource. This coupled with the lack of a specific space for handwashing undermines hand hygiene.  Further, some households ration soap, unable to afford cleansing agents for all personal and domestic cleaning tasks. 

Water supply is essential for handwashing in homes, education institutions, health care centres and worksites. The Jal Jeevan Mission, India’s flagship program for household piped water supply will work towards providing piped water to rural homes. The Mission recently announced a 100-day campaign focused on equipping schools and anganwadis with piped water to facilitate handwashing. 

To make soap more affordable and available for low-income families, soap may be considered as an item under the Public Distribution System, local soap production can be encouraged through SHGs, and partnerships with the private sector can facilitate soap access more widely. 

Handwashing stations need to be responsive to the needs of people who use them and to contexts. In schools and anganwadis, for instance, children need facilities that are at their height and convenient to use without assistance. In community toilets, several taps and soap are required for multiple users to wash their hands after using the toilets. The design of handwashing facilities has to be responsive to the context. COVID-19 has spurred designs of foot-operated stations for hands-free dispensing of soap and water. Water-scarce areas urgently need innovations for collecting, storing and dispensing water for regular handwashing that do not place additional burdens on household members charged with water collection tasks, most notably girls and women.

Handwashing requires knowledge of why, how and when all to wash hands 

Knowledge is a first step to engaging in a behaviour. At the very minimum, the information should be imparted on why and how cleaning hands protects us from diseases, how to wash hands properly with soap and water and specifying all the moments to clean hands to prevent disease transmission.

Information on hand hygiene must be imparted keeping the target audience in mind. Keeping the core messaging on the why and how of handwashing with soap consistent across groups and contexts, the manner in which the information is imparted must appeal to different audiences – children, adolescents, adults, keeping in mind gender and other socio-cultural, economic and geographic considerations.

Handwashing must be of personal relevance, a positively reinforced social norm, and requires  reminders

Sustaining hand hygiene over time calls for additional investments to reinforce this behaviour consistently, make it a personal and social norm. This requires messaging that goes beyond the health benefits of handwashing to appeal to the psycho-social or emotive drivers that guide action – nurture, status, affiliation and disgust. These drivers establish the personal relevance of the behaviour, changing the way we think about it and practice it even when faced with hurdles. Positive social norms related to hygiene behaviours further enable and support their practice reiterating that everyone cleans their hands to protect themselves, each other, and their community. 

Many of us use alarms to wake up, set reminders for meetings and tasks to be completed. Handwashing also requires relevant and appealing reminders to reinforce action-driving us towards action, and not towards indifference (i.e., pressing the snooze or dismiss button!). 
 
Handwashing with soap saves lives. This Global Handwashing Day, we must commit to making handwashing for all a reality - a widely practised and deeply embedded habit. We must come together to collaborate, innovate and implement feasible, relevant, scalable solutions that build the three pillars of hand hygiene. Let’s act to get water and soap to those who do not have enough or who lack it all together; let’s implement meaningful campaigns that make us all see the personal and societal value of this action. And as I sing to my son as I attempt to make giant bubbles with his soapy hands ….let’s turn that frown upside down!