Impact of Infrastructure on Handwashing Behaviour

Research shows that simply providing infrastructure will not result in it being used. Handwashing is influenced by a range of social, physical and cognitive determinants. While providing handwashing facilities and soap are key to enable handwashing, this addresses just part of the determinants. It is important to ensure facilities are conveniently located, desirable and attractive as these increase handwashing rates. Behaviour change requires both infrastructure and creatively designed behaviour change intervention using people’s motivations.

Wash 'em has some good recommendations for providing infrastructure during crisis here.

• Make handwashing facility stand out
• Bright colours – getting crisis-affected populations, or local people involved in painting can increase a sense of ownership
• Add a ‘nudge’ to change physical environment and influence behavioural choices
• Create a home for the soap
• Make people feel like others are watching
• Adding a sticker with picture of eyes has been found to increase handwashing practices.
• Invest in quality soap

IDS has a handwashing compendium for low resource settings with examples and case studies in humanitarian settings.

Would be great to also hear others experiences with this!

I believe that handwashing behavior is hugely impacted by the existence of handwashing infrastructures or supplies. In terms of infrastructures, the design and location are important as well and is likely to reduce perceived barriers to handwashing practice. Example: In of our hygiene barrier analysis study in Mogadishu, our findings suggested that there has been an increase of handwashing behaviors in some of the camps in comparison to others. Most of the respondents described that their handwashing behaviors changed because of the existence of the infrastructure in their households and around the toilets. Due to these findings, we have increased the number of handwashing facilities within our programs specially using locally available materials like Jerry cans with taps. 

In terms of supplies, I’m also with the opinion that providing soaps might also help to reduce the perceived negative consequences of handwashing. There is a growing base of evidence that when people see soaps around the handwashing facilities, they tend to wash their hands using the soap more than when they don’t have it or soaps not available at the facility itself.

I think this is about enabling the environment as the main component of hygiene promotion programs. The first thing people ask when asking them to wash their hands is the existing clean and accessible handwashing facility, adequate water resources and other supplies like soap and paper towels. We applied this approach when targeting the quarantined people at quarantine centres and IDPs during the last aggression in Gaza. so that led to very good results in the endline findings related to handwashing practice.

I agree with my colleagues statements . In my experience I think will be a dream to be able to provide  soap for the whole affected population, or at least the ones  don't have access to it. In my 16 years experience in the field I never worked in an Emergency operation were we could distribute soap & have a replenishment strategy as soap is a very rapid consumable. Worst if we are talking about protracted crisis. My concern is that many times we are not able to provide soap for the whole affected population or/and when the intervention finalize what is this community going to do ?  back to not washing the hands without soap ? I worked 4 years in Malawi and in  the majority of the rural communities you don't have soap nearby the HW facilities but you can see ash. When we investigated why we discovered main reasons  :  soap is hidden from the HW to avoid the kids to play with it  or others to still. Soap is a beauty and luxury product only used for shower . Soap has too strong smell ( perfume) so people don't like to wash hands before eating only after toilet ( they eat with fingers and they dislike the perfume smell mixed with the food) . We tried to change our messaging campaign for the rural communities :   " WASH the hands with ash " . However was contradicting the Minister of Health of Malawi as they are promoting Hand washing with Soap and not with ash.  So I have 2 questions for you : Do you think we should contradict the Minister of Health and use WASH the hands with ash,  as our our study shows enough evidence that MHO messages will not  have any  impact in changing behavior's. If you think yes , what would be your approach in communicating this to the MoH ?

I completely agree with Alex. It will be a dream to always have soap available at all times and stages of emergencies. This is something that I have never seen. In some emergencies, soapy water has worked better than bar soap, but when the emergency becomes protracted or donors leave, soapy water is not available anymore. As Alex stated, this is very worrying as the community is likely to go back to their prior behavior. 

From my experience, if there are no infrastructure available/resources, for instance, HW stations with soap outside toilets, people will not wash their hands, and the incidence and prevalence of diseases would always be on the rise. 

Regarding Alex's comment on washing hands with soap and the specific case in Malawi. What was the reason why the MoH did not promote HW with ash? 

In some contexts, ash is not secure and can be contaminated. Some experts in the field state that ash wood can be exposed to heavy metals, pathogens, and helminths; this almost always depends on the location, type of firewood used, and contaminant in the firewood. Before promoting the use of ash for HW, the suggestion is to analyze the risks and be sure that the ash is safe. There is a fascinating discussion here:

https://forum.susana.org/23-hygiene-and-hand-washing/14741-is-handwashing-with-ash-safe

A large component of WASH in Iraq and Syria is focussed on providing assistance in IDP camps, informal settlements and collective centres. Similar to the challenges flagged above, the hand washing stations, water collection points, and showers are installed at a communal level. This creates a barrier, especially for women, who prefer to access such infrastructure in the safety of their tents. With budget constraints limiting the extent of installing HH level infrastructure, we conducted FGDs and came up with solutions such as household level shower and hand washing kits. While I haven't applied the WASH'EM tool, it would be great to hear if others in this group used it in camp settings in the Middle East. More specifically, how relevant were the recommendations and what was the biggest change you made to implementing HP programming?  

Limited access to water supply has been a major constraint in some locations where even storage containers were limited due to underfunding of among other things WASH NFIs. This would mean communities prioritize water for drinking and cooking and laundry had to be done in far-away open water sources or at infrequent periods. This resulted in water not being availed for handwashing even where handwashing stations are provided. At the household level, there would be prioritization of washing hands before eating only and often with recycled water. The situation would be worsened where only women and girls were tasked with fetching water and in the dry seasons where rainwater supplements were not available. It meant that handwashing was only reserved for those hands that appear dirty due to handling of for example mud and thus the practice was not adopted as it should. In Parts of South Sudan, women had to walk for more than 3 kilometers to fetch water which situation would mean there is no access to water for hygiene. The Wash'Em tool would be useful in prescribing a program design that would address such gaps

I believe, the presence of hand washing infrastructure has significant impact on the handwashing behavior of the community at any of their situation. If people have hand washing facility and water around their toilet, they are likely to wash their hands. If handwashing facilities and products are lacking, then hygiene messaging along  are likely to be ineffective. In addition to the creatively design hygiene promotion activities behavior change requires both infrastructure facilities  There is also a risk that focusing on hygiene education or promotion alone may offend  populations because the behavior being promoted is not feasible to practice. 

In very underserved areas, where you have to walk long distances with heavy containers in order to provide your household with water every day, it is understandable that people “prioritize” the uses of their precious liquid, and proper handwashing at all the needed times might not pass the cut. But I also agree with my colleagues that enabling handwashing with the infrastructure is just one step ensure the behavior, that needs to be complemented with other strategies, so people actually prioritize handwashing in all the needed moments without exceptions, based on their motivations.

I agree with Lara that behavior change requires both infrastructure and creatively designed behavior change intervention using people’s motivations. I work in northwestern Nigeria where according to the 2018 WASH NORM Survey (National Outcome Routine Mapping), only 34% of population in Sokoto State have access to basic water supply (improved water source within 30 minutes return journey), this is the lowest among the 36 states in Nigeria (Nigeria average is 73%). Women are primarily responsible collection of water for household among many other tasks. This means that in more than any other state in Nigeria, women in Sokoto State spend a lot of their valuable time and energy collecting water for domestic use at the expense of other critical tasks such as caring for children.

With the onset of the covid-19 pandemic this became a real nightmare because this scarcity of water meant that the hygiene protocols put in place to mitigate the risk of infection was going to be difficult to adhere to. Water after all had many competing priorities. It is to this end that the Nigerian government in collaboration with UNICEF, UNILEVER and DFID put in place a National COVID-19 Multi-Sectoral Pandemic Response Plan to control and curb the spread of the virus and protect vulnerable populations. The response plan was aimed at delivering COVID-19, prevention, and risk mitigation activities through WASH, including provision and sustainability of critical WASH facilities, infection mitigation measures and supporting coordination of national WASH response to unserved communities.

The response included national hygiene promotion campaigns through the distribution of IEC materials and broadcasting  of key hygiene messages and jingles that were carried out through an already established network of community Volunteer Hygiene Promoters, using mobile units and health facility staff/community health workers and partnership with media bodies, respectively. UNICEF in close collaboration with Sokoto state Rural Water and Sanitation Agency (RUWASSA) facilitated the construction of WASH infrastructure in focus areas. UNICEF focused on ensuring the sustainability of operations of WASH facilities through capacity building of established communal WASH Committees, WASH departments and VLOM units including local area mechanics and other community artisans and the provision of spare parts and tool kits. UNILEVER donated 700,000 pieces of soap to underserved/vulnerable communities and health facilities.

To ensure that the project provided the desired outcomes to vulnerable people, in depth consultations were carried out with community leaders in collaboration with relevant local structures at the start of the programme to ensure buy-in and ownership. Participation of women, people living with disabilities, elderly and other marginalized groups was ensured during these consultations and all project activities to ensure their needs were considered. Participatory feedback mechanisms and data disaggregation at local government areas and field monitoring level was used during routine programme monitoring, to enable the project to dissect the needs of women and men for better targeting. As a result, Sokoto has registered one of the lowest number of infections and deaths in the country attributed to the Covid-19 virus.

Sure I agree with most colleagues in that provision  of infrastructure is likely to increase /support a positive change, towards adopting good handwashing practices. However,  there re also situations where as we know people might still feel the infrastructure is not the main thing needed in the crisis situation. thus, even though people may be grateful for support, they may adapt handwashing facilities for other use/s.

while working in Syria shows somehow the opposite. most of the families we were targeting were mentioning clearly that they only need the water and soap as they know how to wash their hands but the current situation makes it difficult for them to wash their hands in the key times. or sometimes they don't have water, so they wash their hands less. this is the case with almost all of the adults targeted in our projects.

children and caregivers encouraged this kind of activities and how handwashing is important for kids and especially in schools, we are more focused on this aspect and this group in the communities.

I believe that understanding the context and limitations of handwashing is critical before deciding whether we are going to build handwashing stations, provide water, or soap. understanding the whole situation is important.

In Congo, due to floods, people were displaced in the forest and some remote areas. The supply chain for soap was not efficient so therefore, it impacts the behavior. Also, I have seen programme adressing handwashing but not having a water access component. If they have limited access to water, then it is used for "critical needs" as handwashing may not be perceived as critical compared to drinking and cooking. So, in humanitarian settings, we need to make sure that people have what they need : the desirable infrastructures, soap and water. I love the personal histories tool as it helps to capture other needs, priorities or issues that the people have and handwashing may not be a priority. Also, the infrastructures may not be desirable or user-friendly to people with disabilities, elders... It can be difficult for them to use it. Some designs don't take into account people with special needs. So, in my opinion, this may impact the handwashing behaviours.

In some past experiences, some communities had no or very limited access to water. So they preferred to keep the water for drinking and cooking, rather than doing the 5 key moments of handwashing, as we all advocate. It becomes surreal when we encounter particularly affected populations in the WASH field.

Just reflecting on all these comments, there is very little discussion on infrastructure! There is a lot about soap and other consumables, but not much on the technical side. There are also lots of examples of things going wrong or the need to maintain bucket hand washing stations leading to increased workload. 

The new Oxfam handwashing station and the Happy Tap show how the bucket device an be improved. The Oxfam bucket is such an improvement on the tippy tap. Have a look at:

https://www.ids.ac.uk/publications/handwashing-compendium-for-low-resource-settings-a-living-document/

for more ideas. (it was posted earlier but worth repeating)

There are also comments on that just providing a handwashing device is not enough by itself. yes, agree. But promoting handwashing without any infrastructure is even more wasteful! It is the essential component. A poor handwashing campaign may not work well, but if there is no water, the whole exercise is useless. If people are going to spend more than 30 minutes collecting water, are they really going to use much for handwashing? If you are being serious you need to adjust the minimum standards, so you are aiming for more than 15 -20 L per person per day. You need to look at the spacing of water points. 500m is not suitable - can you get it down to 50m? Are the water points suitable for handwashing? (because people will use them for that). Is the drainage OK? Could we have low flow taps that are no good for filling water containers but suitable for rinsing hands? 

When public, communal or neighbourhood toilets are being planned, is the location of a water supply being thought about as one of the location criteria? We might think about the use of dry toilets rather than flush toilets, but we still need water for ablutions, washing if you are changing menstrual hygiene materials and hand washing. 

In summary, if we went through the design criteria for water supply and sanitation facilities with a focus on hand washing, would the standard designs change? 

Yes, it impact to the community behaviors, how can tell them wash your hands and he don't have soap or water or even he or she doesn't has income to buy soap.  even if they have soap maybe the is no water source they just have water for drink or daily basic things, and some community the suffers to get water for that they see to washing their hands not necessary. 

In my context communities have been taught the importance of washing hands and how they should do it...they have been taught to design handwashing stations with locally available materials e.g 5-litre water bottles and a stand with a lever using logs..in the event that one does not have soap they can use ash as an alternative...these handwashing stations are put in designated areas like the entrance point into the compound and near the toilet...these easily accessible handwash stations have impacted positively to handwashing behaviours in my context.

In nutrition response we implemented a simple tippy tap for each household that increased HW by over 52% and when we added soap it increased to around 62% so definitely is important. It is a very definite cure to action 

I defiantly believe the handwashing practice & behavior is enormously impacted by the existence infrastructure and access of soaps. For instance, I am working refugee camps most community  have not hand washing  infrastructure  at HH level, but when come to the institution(health & school facilities) attractive handwashing facility with availability of soaps ,and observed most communities wash their hands with soaps properly after toilet.      

lack of water and soap will have a big impact on handwashing.  If HHs don't have enough water, they will use water for more priority uses such as cooking and drinking.  In the data I see one of the most reported negative coping mechanisms regarding lack of water is bathing less.  Not having basins next to latrines that have running water is also a big factor in handwashing.  The amount of water HHs need differs from context to context so practitioners need to understand what is sufficient for the context based on evidence gathered. For example, irrigation might take priority of handwashing. 

In hand washing behaviors two main things are involved; The knowledge on how to do it and the infrastructure or access to supply like washing equipment, soaps and detergents among others. The supply of equipment of equipment does not guarantee change of hand washing behaviours,however,capacity building the people on the need to wash the hands and walking them through through peer to peer influence may influence the attitude and behavior change and thus use of the supplies. If the behavior becomes inbuilt, the communities will be motivated to wash the hand s and by thinking globally and acting locally can improvise the hand washing facilities that are clean, organized, visible and useable.

lack of better infrastructures also may affect hand washing behaviour. For example people with disabilities are at a higher risk of during the COVID-19 pandemic. This is because they are not operating to the optimum given their physical limitations. An example is a blind person who is not sure where exactly the hand washing taps is will go about using his hands to locate the tap. Through this he/she may touch other surfaces before locating the exact spot he was intending to. This increases the chances of contamination. If there are taps and soap dispensers which are sensor triggered, this will be the best as such people will easily wash their hands. Lack of such facilities may result to fear of further contamination hence not washing hands in certain places. 

Access to Supplies may impact handwashing behaviours. Example is lack of soap which may be brought about by lack of economic strength in the household. This can force a family to be washing hands without soap hence they may contract a certain disease. The members may have a feeling that as much as they had positive behaviour practices but they have been infected although the hand washing was not perfect as they lacked soaps. This may lead to a misconception on the hand washing. 

In my point of view, to change the wash behaviour of the people firstly we need to observe them which helps us to know about their habits and behaviour  to the healthy life. Besides, I think hand washing behviour is extremely impacted by the hand washing infrastructures and other materials, but again providing all the necessary infrastructures also can't ensures that people uses it properly or in daily basis or we cannot even say that only by providing all the needed materials people change their habit over the certain period of time. Therefore, for that something creative plan should be made like,  

• Availability of sufficient water supply and soap bar in the hand washing station is the inevitable part
• Convenient hand washing station for all type of people (differently abled people as well)
• Attractive hand washing station can play a significant role to change the behaviour
•  Hand washing posters with a strong message in the wall
• Selecting and honoring the people who washes their hands whenever needed

One area is to do with access to soap. This has not been regular, and the quantity given to families is not enough to ensure regular hand washing with soap. Surveys conducted has shown soap is kept in shelters, away from nearby hand washing stations, which hinders families from washing hands with soap. secondly, is on ensure water is available at the hand washing station at all times. most of the times, the refill is done in the morning and by afternoon, no refill. this makes a challenge for those families who wants to wash hands.

Another area that is a challenge is vandalism of hand washing stations. When we installed 50 litre capacity hand washing stations in the camp, all containers were taken off the stands.  We changed to 20litre capacity tank. the vandalism was minimal. 

Noted was most households did not have storage containers, and thus the vandalism. it was also noted need for distribution of storage containers to families to ensure they have enough to store water for domestic use

Based on my experience with Megha Eathquil 2015 in Nepal, infrastructure or access to supplies have impacted handwashing behaviours because almost all people are concerned about surviving rather than forcing health hygiene. There is not any facility i.e water, soap and hand washing station so people don't wash their hands with soap and water because of unavailability of infrastructure as well as access of hand washing facilities.