To increase handwashing and address Asia and the Pacific’s hygiene and health challenges, new skills, creative thinking, and the use of behavioral change research are all needed.
One of our most powerful weapons for fighting disease is literally at our fingertips: the simple act of handwashing. It alone could decrease the incidence of diarrheal disease by anywhere between 23% and 40%, by one estimate. And as we have all learned during the COVID-19 pandemic, proper hand hygiene is essential for the prevention and control of all types of infection.
Then why don’t people just wash their hands? It’s not that simple. In 2020, 30% of the population in Central and Southern Asia and 64% of the population in the Pacific did not have access to basic handwashing facilities—a dedicated place in the home where soap and water are available to wash their hands, according to the WHO/UNICEF Joint Monitoring Program.
There are also worrying gaps in basic handwashing facilities in schools and healthcare establishments in the region. In Asian primary schools, for example, less than half of the students have access to basic handwashing facilities. Improving hand hygiene in schools is not only crucial for public health, but is linked to other benefits, such as reduced absenteeism.
But even providing the facilities is not enough. Out of the 78% of the global population with access to a handwashing facility at home, researchers found that only 19% wash their hands with soap after contact with feces. In other words, even when people have access to handwashing facilities, they still do not practice proper hand hygiene at critical times.
Professionals working in water supply, sanitation, and urban development are increasingly realizing that investing in water supply and sanitation systems alone is not enough to bring about health improvements. A central question is what can be done to influence and to sustain people’s handwashing? While COVID-19 has likely brought an increase in the practice of handwashing, will people go back to their normal practices when the fear of the pandemic is no longer a motivating factor?
Water and sanitation infrastructure must be accompanied by hygiene initiatives as well as environmental and verbal cues to promote the desired behavior.
Why don’t people just wash their hands? It’s not that simple.
Evidence shows that changing people’s behavior to wash their hands with soap is far from simple, especially when handwashing is either not a habit or has not been learned. In other cases, studies have shown that knowledge about the health benefits of handwashing and/or the critical times to wash hands has not been enough to change people’s behavior. Understanding local customs and social norms is also needed to tailor messages so people understand, act, and make hygiene an implicit part of their lives.
There is also a growing body of research on behavior change approaches appropriate for handwashing. Behavior-centered design is one option to better understand the complex interactions between the environment, the human brain, and body as it impacts behavior. Central to this approach is the hypothesis that humans have three distinct mechanisms for controlling behavior: reactive or habitual behavior, motivated behavior, and rational (or executive) decision-making.
The first two mechanisms (habits and motivations) have equal or more weight as the third (rational decision-making). The study analyses how we can change these interactions by designing programs to influence behavior, adjust the setting, and create environmental cues that can be more effective than messaging alone.
One example is a pilot project by the Department of Education in the Philippines that uses low-cost behavioral nudges to encourage hand hygiene in schools. The project painted a bright footpath from the toilet to the wash basins. This environmental cue, or ‘nudge’, helped improve the students’ handwashing frequency. In another study in two primary schools in rural Bangladesh where nudges were used to encourage hand hygiene after toilet use, handwashing with soap among school children increased to 68% the day after nudges were completed and 74% after 2 weeks and 6 weeks, from 4% at the beginning. Poor adherence to hand hygiene procedures by Cambodian midwives and caregivers in maternal and neonatal healthcare contributes to neonatal mortality, despite the availability of facilities and the high-frequency of hand hygiene opportunities. However, behavior change to improve practices depends not only on infrastructure but also caregiver risk perception, workloads, norms, and knowledge.
Ensuring handwashing facilities that work, are available, are accessible, and have running water 24 hours a day is essential. But to change people’s behavior, it is important to do more than just build the facilities and teach people about the health benefits of washing their hands.
Professionals working in the water and sanitation sector need to take a holistic view of handwashing initiatives and appreciate that new skills, creative thinking, and use of behavioral change research are needed to better address the hygiene and health challenges in Asia and the Pacific.