Optimal Handwashing

Handwashing has been documented as an effective means of preventing diarrhea if it is done properly at appropriate times. Hands are a main vector of diarrheal pathogens, transferring them from surface to surface and from person to person. A recent review of all the available evidence suggests that optimal handwashing with soap could reduce diarrhea incidence by 42-46 percent (Curtis et al., April 2003, The Lancet).

Times and technique are crucial in handwashing for diarrheal disease prevention. Hands must be washed at a minimum of three critical times: (1) before cooking or preparing food, (2) before feeding a child or eating, and (3) after defecation, cleaning a baby, or changing a diaper. The three elements of proper technique are to use water and soap, rub one’s hands together at least three times, and dry them hygienically (e.g. with a clean towel or by air drying).

While soap is found in most households, it is often reserved for washing clothes, dishes and bathing. Handwashing with soap is not common, though practice varies from country to country. For example, a study in urban Burkina Faso observed only 1 percent of mothers using soap to wash their hands after using the toilet, and only 18 percent after cleaning up a child’s bottom. In rural Nigeria, observations showed only 10 percent of mothers were using soap to wash their hands after cleaning up a child. In slums in Lucknow, India, 13 percent of mothers were observed using soap after cleaning up a child and 20 percent after going outside to defecate.

Nevertheless, knowing that an intervention is effective is not equivalent to having programmatic approaches that can reliably and sustainably implement such approaches at scale. While approaches such as soap distribution in refugee settings have been shown to improve handwashing and decrease fecal-oral transmission of disease, there is relatively little experience in large-scale efforts to change handwashing behavior as part of routine public health programs in developing countries.

To this end, from 1996 to 1999, USAID supported a public-private partnership among Ministries of Health, donors, and national as well as multi-national soap manufacturers to promote handwashing with soap for the prevention of diarrheal disease among children in Central America, implemented through the EHP and BASICS projects. Data collected during the baseline surveys confirmed a dramatic difference in prevalence of diarrhea in children based on mothers’ handwashing behavior – more than a factor of two reductions between the inadequate and optimal behavior. Only 9 percent of mothers demonstrated optimal handwashing behavior at baseline.

The Central America handwashing activity had four key results:

1. First, there were improvements in handwashing behavior and decreases in diarrheal disease. For example, in Guatemala, the fraction of mothers using good handwashing behaviors increased by more than 30% over the course of the initial twelve-month campaign, corresponding to roughly a 7% decrease in overall diarrheal disease prevalence at national-scale.
   
   
2. Second, the partnership involved significant co-leveraging of resources by USAID, the public sector, and private sector, with recognition that the achievements are far greater than what any single partner would have been able to accomplish individually.
   
   
3. Third, there has been sustained involvement of the private sector in ongoing campaign activities and adaptation of the approaches and partnership to other campaigns, such as diarrheal disease prevention in the wake of the 2001 earthquake in El Salvador.
   
   
4. Finally, other organizations with whom USAID collaborated on this activity have adopted the approach for new work in other geographic areas. A key opportunity for the EH activity is continued collaboration with and support of the resulting Global Public-Private Partnership to Promote Handwashing with Soap.

The Central America handwashing initiative demonstrated how a partnership could pool resources, share risk, and provide added value over and above what each party could achieve alone. Clearly, organizations will only join a partnership if they stand to gain from it. In the case of handwashing, there are obvious benefits for both public and private partners; industry may sell more soap and benefit from the public health agencies awareness-raising efforts, while agencies concerned with public health benefit from the private sector’s expertise in designing effective communications and having financial resources to implement such communications efforts.