WASHplus Weekly: Handwashing research in 2014

Issue 174| Jan 16, 2015 | Focus on Handwashing Research

A Summary of Handwashing Research in 2014 – The Global Public-Private Partnership for Handwashing (PPPHW)

In 2014, 26 peer reviewed handwashing studies that focused on developing countries were published.  Global PPPHW Secretariat Director Layla McCay prepared this summary and Pavani Ram, University at Buffalo, reviewed it. WASHplus Knowledge Resources Specialist Dan Campbell conducted the literature search. handwashing

What We Have Learned about Handwashing in 2014: A Summary

Measurement of handwashing behavior: Based on a review of numerous studies using structured observation to measure behavior, hands are washed with soap after approximately 19 percent of events that involved using the toilet or coming into contact with a child’s excreta.1

Behavior change communication: The much-awaited results from the Super-Amma campaign, a handwashing behavior change intervention based on emotional drivers such as nurture and disgust, have started to come in. These results show that this approach to handwashing promotion has lasting impact and is achieving the diffusion of handwashing as a social norm.2, 3 The campaign provides further confirmation that the knowledge of handwashing benefits is linked to its practice4, 5 and that women’s participatory groups6 and handwashing education in schools,7 including students’ involvement in hygiene and sanitation clubs,9 are good settings in which to build that knowledge into action. Furthermore, the mere act of checking whether households have soap seems to increase their handwashing behavior.10

Handwashing hardware: The studies reviewed provide further evidence that the availability of appropriate handwashing stations and soap in schools,7 healthcare centers,8 and in the home12, 13 increases handwashing prevalence, as does having piped water and functioning sewage mechanisms.14 Research provided further evidence that soap and ash are equally effective at cleaning hands,15 and that 4g of moringa oleifera leaf powder shows promise as an effective alternative to soap or ash for handwashing.16

Benefits of handwashing: A review estimated that handwashing with soap reduces the risk of diarrhea by 40 percent.1 Excluding the studies that could theoretically have been biased (or unblinded)—researchers knowing which people were exposed to handwashing interventions and which were not— handwashing with soap was estimated to reduce the risk of developing diarrhea by 23 percent.1 Further evidence showed that having soap in the home reduces children’s episodes of diarrhea, acute respiratory infections, eye infections, helminth infections, and school absences.18,19,20,21 It was found that good handwashing interventions in school also reduce school absences (but only for girls in one study)7 and that school-based interventions reduce episodes of diarrhea in preschool-aged siblings.17

Contamination: Various studies measured hands contaminated with rhinovirus,22 E coli,5, 25and helminth eggs.23 One study inversely correlated prevalence of handwashing with the amount of influenza virus found on household surfaces.24 A final study showed that in the rural areas hands revert to baseline levels of contamination within one hour after handwashing with soap.26


  1. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wold J, Pruss-Ustun A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. 2014.  Hygiene and health: Systematic review of handwashing practices worldwide and update of health effects.Tropical Medicine & International Health. 19(8):906-16.
  2. Rajaraman D, Varadharajan KS, Greenland K, Curtis V, Kumar R, Schmidt WP, Aunger R, Biran A. Nov. 2014. Implementing effective hygiene promotion: Lessons from the process evaluation of an intervention to promote handwashing with soap in rural India. BMC Public Health. 14(1):1179.
  3. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V. March 2014.  Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): A cluster-randomised trial. The Lancet Global Health. 2(3):e145-54.
  4. George CM, Perin J, Neiswender de Calani KJ, Norman WR, Perry H, Davis TP Jr, Lindquist ED. Dec. 2014. Risk factors for diarrhea in children under five years of age residing in peri-urban communities in Cochabamba, Bolivia. American Journal of Tropical Medicine and Hygiene. 91(6):1190-6.
  5. Grimason AM, Masangwi SJ, Morse TD, Jabu GC, Beattie TK, Taulo SE, Lungu K. 2014.Knowledge, awareness and practice of the importance of hand-washing amongst children attending state run primary schools in rural Malawi. International Journal of Environmental Research and Public Health. 24(1):31-43.
  6. Younes L, Houweling TA, Azad K, Kuddud A, Shaha S, Haq B, Nahar T, Hossen M, Beard J, Copas A, Prost A, Costello A, Fottrell E. Dec. 2014. The effect of participatory women’s groups on infant feeding and child health knowledge, behaviour andoutcomes in rural Bangladesh: A controlled before-and-after study. Journal of Epidemiology & Community Health. pii: jech-2014-204271.
  7. Caruso BA, Freeman MC, Garn JV, Dreibelbis R, Saboori S, Muga R, Rheingans R. Oct. 2014.  Assessing the impact of a school-based latrine cleaning and handwashing program on pupil absence in Nyanza Province, Kenya: A cluster-randomized trial. Tropical Medicine and International Health. 19(10):1185-97.
  8. Sreenivasan N, Gotestrand SA, Ombeki S, Oluoch G, Fischer TK, Quick R. 2014.  Evaluation of the impact of a simple hand-washing and water-treatment intervention in rural health facilities on hygiene knowledge and reported behaviours of health workers and their clients, Nyanza Province, Kenya, 2008. Epidemiology and Infection. 27:1-8
  9. Assefa M and Kumie A. Sept. 2014.  Assessment of factors influencing hygiene behaviour among school children in Mereb-Leke District, Northern Ethiopia: A cross-sectional study. BMC Public Health. 14:1000.
  10. Arnold BF, Khush RS, Ramaswamy P, Rajkumar P, Durairaj N, Ramaprabha P, Balakrishnan K, Colford JM Jr. Nov. 2014. Reactivity in rapidly collected hygiene and toilet spot check measurements: A cautionary note for longitudinal studies. American Journal of Tropical Medicine and Hygiene. pii:14-0306.
  11. Iyengar K, Jain M, Thomas S, Dashora K, Liu W, Saini P, Dattatreya R, Parker I, Iyengar S. Aug. 2014. Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India. BMC Pregnancy and Childbirth. 14:270.
  12. Christensen G, Dentz HN, Pickering AJ, Bourdier T, Arnold BF, Colford JM Jr, Null C. Nov. 2014. Pilot cluster randomized controlled trials to evaluate adoption of water, sanitation, and hygiene interventions and their combination in rural Western Kenya. American Journal of Tropical Medicine and Hygiene. pii: 14-0138.
  13. Contzen N, Meili IH, Mosler HJ. 2014. Changing handwashing behaviour in southern Ethiopia: A longitudinal study on infrastructural and commitment interventions. Social Science & Medicine. 124C:103-114.
  14. Oswald WE, Hunter GC, Kramer MR, Leontsini E, Cabrera L, Lescano AG, Gilman RH. 2014. Provision of private, piped water and sewerage connections and directly observed handwashing of mothers in a peri-urban community of Lima, Peru.Tropical Medicine & International Health. (4):388-97.
  15. Baker KK, Dil Farzana F, Ferdous F, Ahmed S, Kumas Das S, Faruque AS, Nasrin D, Kotloff KL, Nataro JP, Kolappaswamy K, Levine MM. 2014. Association between moderate-to-severe diarrhea in young children in the global enteric multicenter study (GEMS) and types of handwashing materials used by caretakers in Mirzapur, Bangladesh. American Journal of Tropical Medicine and Hygiene. 91(1):181-9.
  16. Torondel B, Opare D, Brandberg B, Cobb E, Cairncross S. 2014. Efficacy of moringa oleifera leaf powder as a hand-washing product: A crossover controlled study among healthy volunteers. BMC Complementary and Alternative Medicine. 4;14:57.
  17. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. 2014. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: A cluster-randomized trial in Kenya. American Journal of Public Health. 104(1):e91-7.
  18. Nicholson JA, Naeeni M, Hoptroff M, Matheson JR, Roberts AJ, Taylor D, Sidibe M, Weir AJ, Damle SG, Wright RL. 2014. An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Tropical Medicine & International Health. 19(3):284-92.
  19. Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J, Freeman MC. 2014. Water, sanitation, hygiene, and soil-transmitted helminth infection: A systematic review and meta-analysis. PLoS Medicine. 11(3):e1001620.
  20. Kamm KB, Feikin DR, Bigogo GM, Aol G, Audi A, Cohen AL, Shah MM, Yu J, Breiman RF, Ram PK. Associations between presence of handwashing stations and soap in the home and diarrhoea and respiratory illness, in children less than five years old in rural Western Kenya. Tropical Medicine & International Health.19(4):398-406.
  21. Boubacar Mainassara H and Tohon Z. 2014. Assessing the health impact of the following measures in schools in Maradi (Niger): Construction of latrines, clean water supply, establishment of hand washing stations, and health education. Journal of Parasitology Research. 2014:190451.
  22. Luby SP, Lu X, Cromeans T, Sharker MA, Kadir MA, Erdman DD. 2014.Hand contamination with human rhinovirus in Bangladesh. 86(12):2177-80.
  23. Gulliver F, Jeandron A, Nguyen VA, Do HA, Ensink JH. 2014. Transmission of helminth eggs through hands in a high-risk community. Transactions of the Royal Society of Tropical Medicine and Hygiene. 108(10):670-2.
  24. Levy JW, Suntarattiwong P, Simmerman JM, Jarman RG, Johnson K, Olsen SJ, Chotpitayasunondh T. 2014. Increased hand washing reduces influenza virus surface contamination in Bangkok households, 2009-2010. Influenza and Other Respiratory Viruses. 8(1):13-6.
  25. Gil AI, Lanata CF, Hartinger SM, Mausezahl D, Padilla B, Ochoa TJ, Lozada M, Pineda I, Verastegui H. 2014. Fecal contamination of food, water, hands, and kitchen utensils at the household level in rural areas of Peru. Journal of Environmental Health. 76(6):102-6.
  26. Devamani C, Norman G, Schmidt WP. 2014. A simple microbiological tool to evaluate the effect of environmental health interventions on hand contamination. International Journal of Environmental Research and Public Health. 11(11):11846-59.


WASHplus Weeklies highlight topics such as Urban WASH, Household Air Pollution, Innovation, Household Water Treatment and Storage, Hand Washing, Integration, and more. If you would like to feature your organization’s materials in upcoming issues, please send them to Dan Campbell, WASHplus Knowledge Resources Specialist, at dacampbell@fhi360.org.


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