Highlights Webinar

Washington, DC February 11 12, 2014

Global Public-Private Partnership for Handwashing (PPPHW)

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

Handwashing Behavior Change Think Tank Objectives

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.

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

Overview of Handwashing Research (2012-2013)

Jelena Vujcic Dept. of Social & Preventive Medicine

Global disease prevalence

update

Liu et al., 2012 Lancet

Global disease prevalence

update
Fischer Walker et al., 2013, Lancet Diarrhea estimates (children <5) 1.7 billion episodes (2010) decline from 1.9 billion in 1990 (BMC) 700,000 diarrhea episodes lead to death (2011) High proportion occurred in first 2 years of life

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

Child growth was not different between groups

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

Suggests habituation of improved HW practices

but cannot be certain because using proxy indicators

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)

Dreibelbis et al., 2013

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

Implications of recent research

Diarrhea and pneumonia still large global health problem

Important trade-off between scale and intensity of handwashing promotion programs

Evidence of effectiveness of HW at scale still needed

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

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

Handwashing Products
Low rates of handwashing devices and soap in the household (DHS/MICS)

Products play an important role

Need more than tippy taps for sustainability Philippines developing handwashing kit Two commercial handwashing stations being developed/tested

Happy Tap Vietnam happytap.net

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

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

Make the behavior visible

Need to change other supportive behaviors Easier to build off of existing norm Collective discovery

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

Handwashing and Sanitation

Success integrated into sanitation (less success in parallel)

Handwashing increased by 69% from new UNICEF triggering tools

Many countries integrating into ODF protocols

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

Think Tank Topics

Overview of Handwashing Literature
Handwashing Products Social Norms Handwashing and Sanitation Handwashing Advocacy

JMP Proposed Targets

Vision: Universal access to safe drinking water, sanitationand hygiene Target by 2030: to eliminate open defecation; to achieve universal access to basic drinking water, sanitation, and hygiene for households, schools and health facilities; to halve the proportion of the population without access at home to safely managed drinking water and sanitation services; and to progressively eliminate inequalities in access.

Other Findings
What makes people start handwashing vs. what makes them keep washing their hands?

New handwashing toolkit from WSP www.wsp.org/hwws-toolkit/overview

New handwashing monitoring and evaluation toolkit from UNICEF (link sent separately) UNICEF launching three star approach in schools WSP/UNICEF 24 country report on child feces disposal Lifebuoy reduce diarrhea from 36% to 5% SuperAmma increase HW 31%

The Way Forward

The PPPHW could play a role in not only compiling and sharing the latest research, but communicating what progress has been made (i.e. roadmap) in our knowledge of different aspects of handwashing behavior change and any recommendations from that for implementers. Expand on existing handwashing ladder to provide incremental steps to improving handwashing behavior. Share handwashing social norms approaches and ideas Explore existing habits and social norms to build handwashing off of Articulate steps for successful integration of handwashing into sanitation program Host regional Think Tanks Share handwashing advocacy messages throughout the WASH sector

Questions?
Jelena Vujcic University at Buffalo jelenavu@buffalo.edu Katie Carroll PPPHW kacarroll@fhi360.org Hanna Woodburn PPPHW hwoodburn@fhi360.org