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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.
    Page 1 of 4 Handwashing technical briefing note Background It is now well known that handwashing with soap has a greater impact on morbidity from diarrhoeal disease than any other single intervention (see chart below). Why then, do NGOs focus so many of their activities and so much more money on supplying clean water and sanitation facilities? Why are these recognised as core activities while handwashing is considered a „bolt - on‟ activity?  And why do NGOs always include water quality and latrine use as important indicators of success in logframes and monitoring strategies but rarely include handwashing, even though it is known to be a better success indicator? Relevance of handwashing in disease prevention In developing countries the biggest killers of young children are respiratory infections and diarrhoeal diseases  –  both can be reduced with hand washing 1 . Hands are the last line of defence in 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 in the transmission of respiratory tract, skin and eye infections:  –  hands can be contaminated by respiratory viruses, and infections transferred by rubbing the eyes. Handwashing is particularly important in disaster situations; displaced people may lack an adequate supply of water, their circumstances can put them in situations where it is difficult for them to manage their hygiene, and access to soap may be limited. It is important to ensure that promotion and provision of handwashing facilities are prioritised in all responses where 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: Soap is what people ask for first Faroza was displaced by the floods in Pakistan in 2010. She explained to Oxfam staff what the best parts of our response had been.   “The most useful item has been the soap 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 these kits we were so muddy we looked like sweepers because we were always dirty, dirty, dirty. Now we have soap for handwashing,  personal washing and for washing babies. So we were very happy when we got these kits because we felt so much better and happy when we were clean, our babies were clean and our clothes were clean. 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 diarrhoea has stopped. Before we got these items, especially the soap, we were praying that someone would come and give them to us. ”       Page 2 of 4 Assessment : it is important to know people‟s existing behaviour; whether they wash their hands after defecation and before food preparation and eating. Do they use soap or other agents? Do different groups - men, boys, women, girls etc have different practices? PHP staff should include an assessment of hand-washing knowledge, attitudes and practice in all rapid WASH assessments and baseline surveys Planning : involve the affected population in 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 areas at very least, as well as at food preparation points. A campaign to disseminate key handwashing messages may be appropriate. Training hygiene promoters and community mobilisers is a useful way to promote handwashing; tools and training materials have been produced by the WASH Cluster  2   Maintenance : all handwashing facilities should have a consistent supply of water and be well maintained to ensure they are useable. In the first phase it may be necessary to pay water suppliers or use community mobilisers to refill handwashing facilities, but in the longer term all facilities should have water conservation systems or continuous filling processes as needed  Monitoring:  observation and focus group discussions can be used to monitor handwashing practices; they complement each other in highlighting what people really do vs what they say they do. Anecdotal information should be collected in conjunction with other data. Ensure all data is written and analysed to monitor any changes in handwashing behaviour.  Active listening to the views of the community is key to understanding community attitudes Practical Considerations Peoples’ practices:  Consultation with the population is important; (including men, women and children) on their views on the types of devices used and their preferences, to ensure they are appropriate; e.g. the taps should not be too high or too difficult for children elderly and people with disabilities to operate In some cultures men may not share the same facilities with women, so facilities should be appropriate for the cultural context Handwashing techniques may differ between communities. Several countries have produced posters describing the steps involved in hand washing, 3  and the Sphere handbook has a chapter on the „right‟ techniques for handwashing to be effective (length of time rubbing your hands, what medium to use, length of fingernails etc). All health promoters should know and promote these techniques. Handwashing Facilities:   Handwashing facilities should be made available at sanitation areas at very least Consideration should be given not only to ensuring there are hand washing facilities at the latrines, but also at the household level  –  encouraging people to wash their hands at all key times, such as before feeding children, preparing food, eating etc. Soap is also less likely to get stolen at household level compared to communal hand washing areas. Different facilities will be suitable for different situations Different handwashing facilities will be appropriate for different situations; e.g. large drums for Work with the local culture and existing practices During a serious cholera epidemic in West Papua, our public health adviser noticed that funeral rituals (in which people touched the bodies before eating a funeral meal) were likely to be spreading the disease. 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 been expensive and unsustainable to import. The number of new cholera patients admitted to the Treatment Centre declined quickly and dramatically, as the direct result of this one intervention. It’s not what you know, it’s what you do… Staff in Pakistan ran a successful training course in public health for community health committees, and all participants demonstrated good understanding of the value of handwashing. However, over lunch, one of the facilitators kept watch over 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 as the Tippy Tap for households .   Soap is a valuable commodity and might be taken from communal sites, so put some thought into ways of minimising this risk  –  eg tying it to string, or diluting it in water  All handwashing sites should have adequate drainage to prevent muddy conditions. Just water, soap, or ash? Soap is the ideal agent, but this is not always available or affordable.  Antibacterial soap is not advised where there is a high incidence of skin diseases (such as in flood situations) as it can be irritable. There also seems to be no difference in effectiveness between antibacterial soap and plain soap. 4  If no soap is available, washing hands with ash is preferable to no agent at all. Soil, ash or mud as an alternative to soap may have risks as they can be contaminated with pathogens 5  - use „fresh‟ ash straight from the source It is the rubbing of the hands which is important. Promoting handwashing  Promotion has to suit the context  –  culture, gender, children, environment etc; these issues should be considered at the assessment stage, to help with planning interventions It is important to know the tar  get population‟s existing behaviours and preferences for 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 has a guidance note on motivating different groups to take action. 6  Use shock tactics, if appropriate! To change a habit you may have to shock people into doing something different, giving them a powerful message that really motivates them to think about what they are doing and change it 7   Methods that have been used successfully for handwashing promotion include: Drama, plays, dances Songs Puppets Clowns Games Door-to-door distribution of posters of leaflets Demonstrations Places for handwashing promotion include: Schools Places of worship Community centres Market areas Health centres / clinics In the home In summary, key criteria for ideal handwashing devices are: Low manufacturing cost Lightweight/transportable Strong/durable High water conservation Locally replicable Unisex, and cross-generation appropriate Simple to operate Disability conscious Theft resistant Maximum water filling frequency of two times/day Culturally appropriate and acceptable by the community. What if our facilities get stolen? In Solo camp, Liberia, Oxfam was  providing water, sanitation, and hygiene facilities in camps. Following the distribution of covered buckets with taps widely 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 was because 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 the latrines and people were very happy to use them without the need for any awareness-raising. Making facilities easily available is often sufficient.    Page 4 of 4 At the absolute minimum…    All institutional latrines constructed by Oxfam must have handwashing facilities provided with soap or a proxy agent, especially in the acute stage of an emergency response   Communal handwashing places should be constructed to raise awareness about the importance of handwashing; demonstration facilities are useful   Special focus should be given to children, since children share information on handwashing with their families. Demonstrations and monitoring in school are useful to help children learn and practice effective handwashing   Promotion of handwashing should consider the context; people‟s behaviour, the culture, amount of water available etc.   Vulnerable groups, such as those with disabilities or HIV and AIDS need especially easy access to handwashing facilities   Monitoring, evaluation and learning activities must include assessments of changes in handwashing practice and appropriate use of handwashing facilities.More details in the WASH Minimum 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 Promotio n 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   October 15th is Global Handwashing Day The annual Global Handwashing Day is a good opportunity to raise awareness of just how important handwashing is. Useful tips for marking the day include: Ensure there is a budget in all proposals for some handwashing promotional activities on global handwashing day  Activities could include fun, practical games for the children (ensuring teachers are involved) as well as adults. Games like quizzes, snakes and ladders, and handwashing relays with prizes of bars of soap (this has worked well in Pakistan and Indonesia) The Global Handwashing website has useful planning guidelines, games, posters and other resources 1   In 2009 there was also the “Golden Poo awards”, with several films using comedy and shock to promote hand washing 1  Make handwashing day memorable! Possibly seek media coverage, or record it your  selves at least, for Oxfam‟s internal communications and learning.
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