Within the sanitation agenda – a call for thoughtful integration of handwashing
The Swachh Bharat Mission has provided unparalleled impetus to toilet construction in India, promising improved health outcomes as a result. Safe toilets undeniably play a vital role in promoting health – they effectively separate faeces from human contact, cutting down one major route of disease transmission. But are toilets alone the solution? Consider this – a household builds a latrine, but family members do not wash hands with soap and water after defecating in the toilet. Can this affect their health? Yes, it can.
Handwashing with soap at five critical times – after defecation (irrespective of toilet use or open defecation), after cleaning a child’s bottom, before feeding infants/children, before eating and before food preparation – are estimated to reduce diarrhoeal diseases by 47% and respiratory infections by 23%. Research has found handwashing to be associated with reductions in bacterial infections, viral infections (like seasonal influenza), and helminth infections. Such reductions in infant and child mortality and morbidity, and improved child survival rates makes hand washing a highly cost-effective public health intervention.
So what do we know about handwashing practices in India? Who should be the focus of handwashing interventions? What are the most effective ways to bring about and sustain handwashing practices? Recent research provides some insights into these questions.
In a study by WaterAid India in four states (Bihar, Chhattisgarh, Odisha and Rajasthan), 99.3% and 91.9% of respondents reported washing their hands after defecation and before eating respectively. However, the proportion washing their hands before engaging in child care activities was significantly lower – among respondents who had a child under five in their home, only 26.3% washed hands before child feeding, 14.7% before breastfeeding, 16.7% after disposing of child faeces, and 18.4% after cleaning a child’s bottom. The use of soap and water to clean hands also showed a related trend with soap more likely to be used for handwashing after contact with faecal matter, but both soap and water alone are used to clean hands when engaging in other tasks, including child care related tasks (see graph below).
The overwhelming focus on sanitation was seen in handwashing messaging as well; of the 52.5% of the sample reporting the receipt of hygiene messages, the emphasis was on latrine use and handwashing after defecation, with little messaging on handwashing for child care associated tasks.
Strikingly, observations of handwashing spaces in the household strikingly found that in 87.9% and 96% of homes, soap and water were not found in or near the toilet and kitchen respectively, challenging reported handwashing practices after toilet use by respondents.
These findings suggest that handwashing promotion may be more in relation to latrine use, and less in terms of childcare associated asks and that the physical presence of handwashing facilities in the household has implications for washing hands at critical times.
So what works to promote handwashing, especially among caregivers of young children, and that too at relevant times? Knowledge is an important element of behaviour change and is the mainstay of most hygiene promotion programmes. Research suggests that while knowledge of the importance of hygiene (through traditional hygiene awareness campaigns) is important to communicate the benefits of handwashing, it is alone insufficient to bring about sustained behaviour change , . Further, the threat of death, diseases, and germs is a weak motivator for handwashing . Sustained change in hygiene behaviours can be engendered through a well-planned and evidence based-intervention that builds on emotional drivers (such as disgust, affiliation, nurture or status), triggers behaviour in the specific contexts in which it takes place, and implements activities that emphasize interaction, and have an element of surprise as seen from the Super Amma trial in Andhra Pradesh. The Super Amma (Super Mother) intervention involved community and school-based events that used animated films, street plays and public pledging ceremonies where mothers promised to clean their hands at critical times and encourage their children to do so as well. The study found that mothers receiving the interventions were significantly more likely to wash their hands at key occasions than mothers who did not receive the intervention.
An enabling environment is important to foster hygiene behaviour change, with evidence pointing to the importance of the availability of soap and water, and the presence of a designated and established handwashing space to encourage sustained handwashing practices,.
Studies on primary caregivers of children under the age of five have found benefits to children if their caregivers wash their hands. When mothers wash their hands with ash or soap, their children have a higher mean height-for-age than those who do not. However, research in India has found a discrepancy between knowledge of handwashing with soap and optimal handwashing by mothers caring for children in the home and in the community in urban and rural areas. Some research indicates that among mothers, the presence of handwashing facilities may facilitate handwashing with soap post defecation, yet handwashing may also be informed by the perceived threat of germs associated with that activity.
The study by WaterAid suggests that many people do have access to soap, but may prioritise its use at certain times, as a result of their knowledge of when soap is to be used, how much soap they have access to, and where the soap may be placed in the household setting. To improve handwashing with soap at critical times, people’s attitudes and perceptions regarding soap use at critical times must be understood and addressed, and the physical environment needs to be modified to make handwashing with soap easier and a habit. The difficulties of rural households, especially women in adhering to the principles of handwashing is an important consideration, and hence, ways to facilitate such practices within their complex situations need to be thought of.
Learnings from a review of the literature on hygiene promotion suggest that when handwashing with soap is promoted under the ambit of a larger awareness and infrastructure focused sanitation or WASH program, the hygiene behaviour change component receives less attention . In the context of the Swachh Bharat Mission, strategies to engender handwashing with soap must be considered alongside sanitation interventions to contribute to meaningful improvements in child health.
If sanitation interventions are to bring about improvements in child health, we will have to reconsider positioning of hand hygiene messages and rethink how hand washing interventions should be integrated into sanitation programs.
Arundati Muralidharan is Manager - Policy (WASH in Health & Nutrition, WASH in Schools) at WaterAid India. She Tweets as @arundati_md