Questions & Answers from Participants in the Handwashing Behavior Change Think Tank Webinar Do we now know more

about the cost of effectively and sustainably improving handwashing with soap at a large scale? Unfortunately, we havent seen a lot of data on this. Part of the reason, I think, is that we havent seen a lot of successful, large-scale examples of handwashing behavior change programs. I do have some data from the Fit for School program, which has successfully scaled up a handwashing in schools programs, which has resulted in sustainable handwashing behavior. At our 2012 Think Tank, Fit for Schools shared that the cost of handwashing facilities per school is less than $40 and the cost per child for supplies (this program includes soap, toothbrush/toothpaste, deworming medicine) is $0.50 per child per year. We would have to follow up with them on the programming costs from the donor and government side. I know that the recently published SuperAmma handwashing campaign was created as pilot and looked at the cost for scaling up. Well find out if there are any results to share there. I will follow up with our friends at WASHCost and Lifebuoy to see if they have any data to share as well. The findings from SuperAmma and Lifebuoy are very encouraging. What were the methodology and approach adopted? SuperAmma used the motivators of nurture and disgust to promote handwashing. They used plays, posters, videos, and other media to convey the handwashing messages. They encouraged social norms by facilitating public pledges, special stickers for homes who took pledges, publically-posted lists of mothers who took the pledge. Follow-up visits and reminders were also used as it takes 14 to create a habit and reminders are very helpful during this period. More details are in the link here. Lifebuoys recent Help a Child Reach 5 pilot in India included household visits, Glo Germ demonstrations, School of 5 materials and presentations in schools, videos, and community events. More details are available here and here. How do you compare the quality and rigor of the UNICEF study compared with the Water and Sanitation Program (WSP) study in Vietnam? Both UNICEF and WSP are leading organizations in the area of monitoring handwashing behavior so I trust these results although I believe they are internal studies, not published studies. I think the major difference in results is due to the approach. WSP implemented separate sanitation and handwashing programs in the same communities with very little results in behavior change. UNICEF fully integrated handwashing into the community sanitation programs. I would guess that the approaches had something to do with the results. To learn more about the handwashing triggering activities that led to the positive results in UNICEF Zambia, please see this fantastic resource. Do you have contacts for the WSP/UNICEF 24 country report on child feces disposal?

For more information on child feces disposal, please see the Think Tank presentation on the topic, available here. Contacts are: Emily Rand (erand@worldbank.org) and Libbet Loughnan (lloughnan@worldbank.org). Im glad that there is some mention of evaluation handwashing behavior to see if it is sustained. We have been struggling with trying to see if the behavior is sustained after being promoted, and I would like to read some methodologies. There is a great new toolkit on monitoring and evaluation from UNICEF. Its built on the second a bit older document. Both should be very helpful to you: o UNICEFs Monitoring & Evaluation Toolkit o Practical Guidance for Measuring Handwashing Behavior: Can UNICEF play a role in handwashing behavior among children in India prior to mid-day meals by providing free soap? We are following up with UNICEF on this question. India has passed a policy about handwashing before the midday meal at schools. Well try to get a copy. What is the effectiveness of using ash in handwashing? Ash can be effective in removing pathogens from hands through the rubbing and friction step of handwashing. There is a nice report from WSSCC that dives into the issue more thoroughly. A great quote from that document, and our general advice, is In public health, it is generally accepted that handwashing with soap should be preferred over mud, soil or ash, which in turn is preferable to using water only. All of these options are preferred over no handwashing at all. In some communities ash may be used in the absence of soap to starting handwashing behavior hopefully moving to soap in the future. How is handwashing related to acute respiratory infections or pneumonia? Acute respiratory infections (ARIs), such as pneumonia, are caused by infectious agents, such as viruses or bacteria. These can be spread through touch (either person-to-person or by touching a contaminated object) and through air-borne ways. Handwashing with soap is a preventative measure against pneumonia as it reduces hand contamination. Are we considering a different behavior change communication approach for children, caregivers, and parents? Yes! We are finding that the motivations for washing ones hands at different times, such as before feeding a child or after defecation, are different. Likewise, different audiences respond to different messages. Within the home, for example, a father might be responsible for purchasing the soap while the mother will be the one who should wash

her hands before preparing the meal. We need to adjust our behavior change communication approach accordingly. In the SuperAmma campaign for example, nurture is a motivator for mothers while disgust motivator is targeted at children. Are there other diseases/illnesses that handwashing can prevent? Handwashing with soap can prevent many illnesses and diseases in addition to diarrhea and pneumonia. It can prevent the spread of influenza, skin infections, and infections around childbirth. A package of interventions to fight helminthes may include handwashing. Likewise, handwashing and face washing can help prevent eye infections, such as trachoma. Are handwashing stations typically in public or private households? If public, is there any problem with vandalism? Handwashing stations can be located both in the home and in public spaces. One way to prevent vandalism of public handwashing stations (such as those located at schools), is to build community support around the station. What are the experiences with the handwashing bag promoted/developed by BushProof/Butylproducts? (http://www.butylproducts.co.uk/catalogue/BushProof01/) We havent seen use of this particular product. We know that in the Vietnam Happy Tap example, they tested a bag technology like this product and the consumers did not like it as much as the free standing plastic container-type handwashing device. That said, every market is different and its important to find out what the consumer is willing to purchase. One challenge I see with the bag is storage and access to the soap for handwashing. Thank you for sharing! You can find a full library of handwashing devices here.