Each context is different and therefore the determinants of handwashing behaviour will also be different in each context. That means that there is no one-size-fits-all approach to handwashing promotion. There are however some key points that are relevant to all settings:
Knowledge alone does not change behaviour
Understanding health risks is not enough to motivate handwashing, even during this pandemic.
Many people understand the health benefits of handwashing, especially during outbreaks when information about transmission and health consequences are shared daily through multiple media platforms. Unfortunately, health is not a very effective motivator of behaviour and may not be enough to get people to wash their hands with soap.
Consider a range of handwashing determinants
Handwashing promotion efforts need to do more than provide messaging about transmission and health consequences of disease.
Handwashing is influenced by a whole range of physical, social and cognitive determinants. Hygiene promotion programmes as part of a COVID-19 response need to consider the range of possible determinants in order to effectively overcome behavioural barriers. The image below highlights some of the determinants which influence handwashing behaviour.
Source: LSHTM
For more information about the theory behind diagrams like the one above we suggest reading the following articles which describe different behaviour change approaches: IBM-WASH, RANAS and Behaviour Centred Design.
All three of these behavioural frameworks argue that it is important to first identify behavioral factors in a specific target population and, based on the results, design interventions to change them. The diagram below shows a simplified theory of change that can guide hygiene programme design. Even though detailed formative research may not be possible in an emergency it is still possible to take time to gain quick and simple insights into what is driving behaviour. Not doing so may compromise the effectiveness of your programmes. See how this is done in other emergencies here.
Source: RANAS
As part of the RANAS approach to behaviour change, researchers have developed a catalogue of intervention components matched with specific factors that influence specific determinants of handwashing practices. Organizations and staff will benefit from reviewing the many possible behaviour change techniques that have been used in the past and how they can help motivate individuals to improve their own handwashing.
Handwashing Infrastructure enables behaviour
To enable consistent handwashing with soap, improvements to handwashing infrastructure and provision of necessary products are crucial.
- If households have access to a handwashing facility they are up to 60% more likely to wash their hands with soap. For more information see: Study 1, Study 2, Study 3, Study 4.
- If soap and water are always available at a handwashing facility, people are 2-3 times more likely to wash their hands with soap than if not. For more information see: Study 1, Study 2, Study 3.
- When handwashing facilities are conveniently located near the kitchen or toilet and are desirable and attractive (e.g. has bright colours, a soap container, a mirror) handwashing rates increase even further. For more information see: Study 1, Study 2, Study 3, Study 4.
If handwashing facilities and products are lacking, then hygiene messaging along (or ‘soft’ behaviour change programmes) are likely to be ineffective. Behaviour change requires both infrastructure and creatively designed hygiene promotion activities to bring about real change. There is also a risk that focusing on hygiene education or promotion alone may offend or disenge local populations because the behaviour being promoted is not feasible to practice.
If you want more practical guidance on developing handwashing facilities that change behaviour read this guide.
Change the environment to cue behaviour
Handwashing programmes should incorporate changes to physical environments to cue and reward handwashing behaviour.
Using ‘behavioural nudges’ is one way of cueing action.
- One study showed that painting footprints on the path between the toilet and the handwashing facility increased handwashing behaviour by 64% in schools.
- Another study placed an image of eyes above a handwashing facility. People were 10% more likely to wash hands in the presence of these eyes.
- This study in a displacement camp found that putting toys in soap made handwashing more fun for children and made them 4 times more likely to wash their hands with soap.
- Adding mirrors above handwashing facilities may encourage people to spend longer washing their hands and make it more desirable.
- You could also use cues to make people feel disgusted by certain surfaces. To do this try adding images of germs on door handles.
Below are some photos of small changes to the physical environment.
1. Footprints leading from the toilet to the handwashing facility to make it hard to avoid the behaviour.
Source: Dreibelbis et al 2016 (International Journal of Environmental Research and Public Health)
2. A sticker of eyes which can be placed above handwashing facilities to encourage positive social judgement.
Source: Biran et al 2014. The Lancet, Global health
3. Toys placed in soap to make handwashing more fun.
Source: London School of Hygiene and Tropical Medicine
4. Pictures of germs placed on surfaces that lots of people touch to cue handwashing.
Source: NudgingforKids.com
5. Mirrors placed above handwashing stations to make handwashing more desirable and encourage longer handwashing.
Source: WASHfunders
Motivativating Handwashing
The COVID-19 pandemic itself may prove a powerful motivating force for improving hand hygiene behaviours. In outbreaks handwashing behaviour often increases because of increased perceived risk and the formation of new social norms.
Handwashing is not a particularly memorable or noteworthy behaviour - it is just something we all should do routinely every day. So to increase handwashing behaviour it can be useful to elevate it’s status by linking it to other aspirational ideas. Research has shown that handwashing behaviour can be improved by associating handwashing with being a good parent, being respectful, being polite or fitting in with a social group. Often the best way of making handwashing aspirational can be through storytelling. Emotional stories tend to stick in our minds much more than facts, this is because storytelling has been a core part of all cultures for centuries.
The video below shows the SuperAmma campaign which aimed to promote handwashing in India. In this programme the creators tried to link handwashing with being a good parent (nurture) and increase the disgust around not washing hands. This approach resulted in 27% increase in handwashing. Similar motivations may be useful in crises too.
Programmes will be more effective if they are well resourced
Handwashing promotion requires investment (financial and human resources), persistence, and adaption to get programming right.
Handwashing promotion is often cited as one of the most cost-effective public health interventions.
- Time and cost - The evidence suggests that sustained handwashing behaviour change is not normally cheap – nor is it quick to design and implement. See here for more info: Study 1, Study 2.
- Repeated engagement - Most behaviour change programmes need to interact with target populations on multiple occasions, over an extended period of time, in order to be effective. This is because populations have a range of other priorities and may only be triggered to act after hearing messaging numerous times and through a range of sources. Here are some examples that show this: Study 1, Study 2, Study 3, Study 4.
- Multiple delivery channels - Handwashing programmes are more successful when they use multiple strategies to engage with the target audience.Ideally, programme implementers should consider combining mass media strategies with more personal approaches in order to engage populations, however personal and community engagement may be difficult or impossible during the pandemic (see our guidance on ‘Assessing risk locally’). Here are some examples explaining the value of multiple delivery channels: Study 1, Study 2, Study 3.
- Programme adaptation - Programmes are often not perfect the first time. It is important to set up mechanisms to learn about what is working and what could be improved. One simple way to do this is to set aside time at the end of each day where the whole hygiene promotion team can share their feedback and ideas. This way any learning does not stay with the individual but leads to systematic changes in programme design.
Create social norms around handwashing
Handwashing with soap is a socially desirable behaviour in all cultures. This means that people will want to be seen to be practicing handwashing.
- Studies have shown that people are more likely to wash their hands if there are other people present and the location for handwashing is visible to others. See some examples of this here: Study 1, Study 2, Study 3.
- Handwashing interventions which remind people that others might judge them on their handwashing behaviour have been shown to be effective.
Establishing handwashing stations in highly visible public places could help to create positive social pressure and encourage people to wash their hands.
Editor's note
Author: Sian White
Review: Hans-Joachim Mosler, Bethany Carurso
Last updated: 13.04.2020