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Global Vision: Proper handwashing with soap at critical times will be universally recognized, promoted, and practiced as fundamental to good health Objectives: 1. Advocacy and Leadership: Lead global handwashing advocacy efforts with governments, donors, and other handwashing practitioners 2. Knowledge Leadership: Establish a recognized global handwashing agenda and lead handwashing behavior change expertise and knowledge sharing
The Handwashing Behavior Change Think Tank brings together experts from government, donor, private sector, NGO, and academic organizations to
take stock of the best; identify the gaps; and articulate the way forward for handwashing behavior change.
Pneumonia estimates (children <5) 120 million episodes (2010) 1.3 million episodes lead to death (2011) High proportion occurred in first 2 years of life Ashraf et al., 2013 6% increased risk of pneumonia for every additional day of diarrhea for children under 5 (Karachi, Pakistan)
Health outcomes
Chase and Do, 2012, WSP Policy research working paper cRCT evaluating at-scale WSP program (Vietnam) Program: 1.5 million, targeted caregivers Evaluation: ~3,100 households Slightly higher availability of HW materials in household among exposed HWWS (observed) low and not different between groups No impact on health or productivity
Large-scale programs
Health outcomes
Warren-Gash et al., 2013 (HW and flu/ARI) Schools moderate to low-quality evidence of reductions with HW Childcare settings High quality evidence showed small reductions Squatter settlements High quality evidence showed large reductions Dangour et al., 2013 (WASH on nutritional status) No evidence of effect on weight-for-age Z-score, weightfor-height Z-score and borderline significant effect on height-for-age Z-score. Low methodological quality but larger trials are underway
Reviews
Health outcomes
Development
Bowen et al., 2012 (RCT in informal settlements in Karachi, Pakistan) Global development quotients of 0.4 SDs greater in children from households receiving HW promotion for 30 months than control group Gains comparable to at risk children enrolled in publicly funded preschools in the US
Long-term behavior
Bowen et al., 2013, TMIH 5 year follow-up of the Karachi Soap Health Study (Luby et. al Lancet 2005) Intervention households (weekly HW education, soap provision for 9 months) compared to controls
3.4 times more likely to have soap at the household HW station knew more key times to wash hands reported purchasing more soap
Handwashing determinants
Motivators
Kenya (WSP, UNICEF, Kenya MoPHS, 2012) disgust, nurture and comfort were identified as main motivators for handwashing among caregivers justification (the need to wash off germs that cause disease), fun and fitting-in emerged as motivators among school children In Kenyan schools, teachers serving as role models and active participants in promotion, and giving verbal reminders of importance of handwashing were facilitators of student handwashing Vietnam (WSP, 2012) Presence of a convenient handwashing place with soap and water was reported as an important facilitator of behavior may serve as a physical reminder Peru and Senegal (WSP, Learning Note, 2012) beliefs about soap, and access to soap and water correlated with having soap and water at a designated place
results were inconsistent when compared to different handwashing behavior proxy measures
Handwashing determinants
Barriers
Household level (Affleck et al., 2012 (Bangladesh), WSP, UNICEF, Kenya MoPHS, 2012 (Kenya)) lack of soap for handwashing (other activities prioritized) lack of a designated place for handwashing and easy access to soap long distance between toilet and water perfumed soap (tainting/affecting the taste of food) excessive household work load Mother feel soap only needed if childs hands appear very dirty Lack of autonomy Lack of support from household Poverty School- level (WSP, UNICEF, Kenya MoPHS, 2012) placement of handwashing facilities (too far from toilet ) impractical facilities for children (ex. sink out of reach) overcrowding lack of water drainage lack of support from teachers
Behavioral theory
Dreibelbis et al., 2013 (systematic review) 15 WASH frameworks/models aimed at guiding behavior change interventions Existing models
under-represent the role that technology on behavior change focus on individual behavioral outcomes, ignore physical and environmental determinants
Behavioral theory
Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH)
Measurement
Halder et al., 2013, BMC Public Health Comparison of 90 minute vs 5 hour structured observation Disproportionately lower number of fecal contact events and eating events in 90 minute observation Soap more frequently used early in 5-hour observation Minimal progress on improving handwashing behavior measurement
Moving beyond health messaging trying more engaging behavior change approaches Including structural or environmental factors that influence behavior Better measures of handwashing behavior (same as 2 years ago) Designing interventions to promote handwashing habit/long term behavior
Thank you.
jelenavu@buffalo.edu
Handwashing Products
Low rates of handwashing devices and soap in the household (DHS/MICS)
Social Norms
A social norm is a rule that applies to a certain situation (e.g. wash hands after using the bathroom) You follow the rule if others do and others think you should Inform people of what others think/do Engage reference network/influencers
Zambia follow up: 76% toilets with HW facilities, 51% washing with soap, 34% with ash
Broad agreement to include hygiene in CATS, but most difficult to sustain
Other Findings
What makes people start handwashing vs. what makes them keep washing their hands?
Questions?
Jelena Vujcic University at Buffalo jelenavu@buffalo.edu Katie Carroll PPPHW kacarroll@fhi360.org Hanna Woodburn PPPHW hwoodburn@fhi360.org