The State of Handwashing in 2017, a review of 117 handwashing-related research papers published last year, reveals some positive overall trends in the state of handwashing. From 2006 to 2016, the number of global deaths attributable to unsafe water, sanitation, and hygiene (WASH) decreased by 25 percent, while rates of unsafe sanitation and unsafe water (as well as child growth failure) declined significantly over the period spanning from 1990 to 2016. However, researchers estimate that inadequate hand hygiene still results in nearly 300,000 deaths annually, with the majority of deaths occurring among children younger than five years old. In low-income countries, unsafe WASH remains the third-largest contributor to the global burden of disease.
This research summary was conducted by the Global Handwashing Partnership (GHP), a coalition of international stakeholders working to promote handwashing with soap (HWS) and recognize hygiene as a pillar of international development and public health. USAID is a founding member of the partnership and has contributed funding annually to the coalition since 2001.
In the 2017 U.S. Government Global Water Strategy, USAID acknowledges the importance of HWS at critical times. HWS is among the most effective and inexpensive methods for preventing diarrhea and pneumonia –– the leading causes of death for children under the age of five. In principle, handwashing may seem like a simple behavior, but in practice it remains a complex issue that demands research and collaboration on a global scale.
The research summary presents the overarching findings of the literature and explores specific data and context, with findings categorized by six key themes:
Diseases and Acute Respiratory Infections
A systematic review of HWS for children under 5 shows that interventions promoting HWS and hygiene education can lead to a 27 percent decrease in the risk of diarrhea. Another review concludes that multi-level handwashing interventions for children in developing countries can reduce the incidence of diarrhea, respiratory infections, and in turn, school absenteeism.
A review indicates that hand hygiene interventions reduce school absenteeism related to gastrointestinal illness, but inadequate evidence is available to draw the same conclusion about respiratory illness. A survey conducted in Bangladesh highlights the importance of having adequate unlocked toilets with handwashing stations for adolescent girls to help them effectively manage their menstrual hygiene at school instead of needing to stay home during menstruation.
An experimental study comparing six different handwashing protocols shows that soap and water is as effective as alcohol-based hand sanitizers, sodium dichloroisocyanurate, hypochlorite, and sodium hypochlorite solutions in removal and inactivation of nonpathogenic model organisms. Chlorine use adds extra benefits by reducing persistence of organisms in rinse water.
A mixed-methods study in Lofa County, Liberia, found that during the West Africa Ebola outbreak, no cases of Ebola virus disease were found in open-defecation-free (ODF) communities that had engaged in community-led total sanitation (CLTS) and in only one CLTS community that had not reached ODF status. These CLTS ODF communities attributed their avoidance of Ebola to WASH behaviors, especially HWS and safe disposal of feces.
Evidence from the studies shows that handwashing compliance remains a challenge, and reveals a gap between knowledge about HWS and optimal handwashing behavior by staff and patients in health care settings, by students in schools, and by mothers and other caregivers of children at home and in the community. Measuring hand hygiene accurately remains a challenge, and variations in indicators and definitions make it difficult to compare studies and thus develop best practices.
Hand Hygiene in Health Care Settings
More than 30 articles in this summary examine handwashing compliance within health care facilities and teaching hospitals, including practices of health care workers, medical students, patients, and visitors.
Several articles specifically focus on hand hygiene compliance of nurses, as they are often the health care workers who have the most contact with patients. A systematic review of 10 studies that measure hand hygiene knowledge finds that nursing students from Slovakia, Jordan, India, Singapore, Nepal, and Saudi Arabia had moderate or insufficient knowledge of hand hygiene.
Using video demonstrations, a handwashing intervention for nurses in neonatal and pediatric intensive care units and nurseries in Nepal increased compliance in all steps of handwashing to 69 percent post-intervention from 9 percent at baseline.
Knowledge about the benefits and practice of proper hand hygiene alone does not necessarily translate to uptake of those behaviors. Psychological factors are found to mediate the effect of WASH interventions on health behaviors. Several studies suggest that interventions using emotional drivers (such as nurture, disgust, affiliation, and social status) may be more effective than those that teach about health benefits.
Community-based approaches to promote handwashing and sanitation efforts appear to work better than other types of approaches. Programs that combine hygiene and sanitation measures have synergistic effects, tending to show a greater impact than either one alone. Studies using a community-based approach that includes sanitation were shown to increase HWS at key times, as well as use of latrines, safe disposal of feces, and reduction of open defecation.
A key takeaway for future research is the need for a more uniform method of measurement (e.g., type of outcomes, assessment methods, and timing of assessment) and reporting on handwashing and other WASH outcomes. This will make it simpler to draw conclusions on the effects of different approaches to promoting handwashing.
Successful handwashing behavior change requires both the availability of functioning facilities (e.g., a handwashing station with soap, a source of clean water, and materials for drying hands) and adoption of good handwashing habits. Insufficient and inaccessible handwashing infrastructure and hardware are a barrier described in many of the studies, especially in health care facilities, as well as in schools and households. Education and training often helps improve handwashing, although these behaviors are not always sustained.
Access to adequate handwashing hardware and WASH infrastructure, including a reliable supply of water and soap, is paramount for ensuring that daily handwashing can be practiced at recommended times in households, schools, communities, and workplaces. Placement is key in hospitals and other health care facilities, as well as in public and household food preparation areas, and near toilets and child-changing areas.
Measuring Soap Efficacy
Increasing the availability and promotion of affordable alternatives to bar soap, such as soapy water, may close the gap in access to soap for handwashing in low-income households. Soapy water preparation is easy, low cost, and equivalent to soap in terms of its antimicrobial efficacy. Soapy water is currently used at a relatively small scale, but should be considered for future interventions.
Mobile applications may aid in teaching and promoting good hand hygiene, and new technologies such as nonwearable or wearable sensor systems can be helpful for hand hygiene monitoring. Including users in the design, and pretesting the acceptability of technologies (such as automatic sinks), may increase uptake and efficacy.
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