World Bank – Promoting Handwashing and Sanitation Evidence from a Large-Scale Randomized Trial in Rural Tanzania

Promoting Handwashing and Sanitation: Evidence from a Large-Scale Randomized Trial in Rural Tanzania, 2015. World Bank.

• Full text, pdf

Authors: Bertha Briceño, Aidan Coville, Sebastian Martinez

The association between hygiene, sanitation, and health is well documented, yet thousands of children die each year from exposure to contaminated fecal matter. At the same time, evidence on the effectiveness of at-scale behavior change interventions to improve sanitation and hygiene practices is limited.

This paper presents the results of two large-scale, government-led handwashing and sanitation promotion campaigns in rural Tanzania. For the campaign, 181 wards were randomly assigned to receive sanitation promotion, handwashing promotion, both interventions together, or neither. One year after the end of the program, sanitation wards increased latrine construction rates from 38.6 to 51 percent and reduced regular open defecation from 23.1 to 11.1 percent.

Households in handwashing wards show marginal improvements in handwashing behavior related to food preparation, but not at other critical junctures. Limited interaction is observed between handwashing and sanitation on intermediate outcomes: wards that received both handwashing and sanitation promotion are less likely to have feces visible around their latrine and more likely to have a handwashing station close to their latrine facility relative to individual treatment groups.

Final health effects on child health measured through diarrhea, anemia, stunting, and wasting are absent in the single-intervention groups. The combined-treatment group produces statistically detectable, but biologically insignificant
and inconsistent, health impacts. The results highlight the importance of focusing on intermediate outcomes of take-up and behavior change as a critical first step in large-scale programs before realizing the changes in health that sanitation and hygiene interventions aim to deliver.

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. 

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 practice^{4, 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 home^{12, 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, 25}and 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

David Neal: Handwashing and the Science of Habit, Dec 4, 2014

David Neal: Handwashing and and the Science of Habit, December 4, 2014. This webinar was organized by WASHplus and the Public-Private Partnership on Handwashing.

• (Presentation Slides, pdf)

Validity of Rapid Measures of Handwashing Behavior: An Analysis of Data from Multiple Impact Evaluations

Validity of Rapid Measures of Handwashing Behavior: An Analysis of Data from Multiple Impact Evaluations in the Global Scaling Up
Handwashing Project, 2014. Water and Sanitation Program.

• Full text

Authors: Pavani K. Ram, Michelle W. Sahli, Benjamin Arnold, John M. Colford, Claire Chase, Bertha Briceño, Alexandra Orsola-Vidal, and Paul Gertler

This multicountry analysis has shown that observation of handwashing materials at the places where people wash hands, at the times most necessary for washing (after fecal contact and before food preparation), is a valid measure of handwashing with soap in multiple cultural and geographic contexts. There continues to be an overarching need for developing valid measures of handwashing behavior that can be collected in an efficient and inexpensive fashion. The structured observation data indicating low rates of soap use for handwashing at times of pathogen transmission reinforce the global imperative to improve handwashing behavior for prevention of the leading causes of death in young children.

Global Handwashing Day Planner’s Guide, 3rd Edition

Global Handwashing Day Planner’s Guide, 3rd Edition. 2014.

• Full text 
  

In addition to background information, the top five facts about handwashing you should know, and insights from the latest in handwashing research, the Planner’s Guide features:

• Detailed celebration ideas designed to help religious organizations, schools, healthcare centers and more plan effective messaging and events.
• An event checklist that helps planners organize and make sure their event planning is on track.
• Spotlights on:
  • Sustainability (p. 17)
  • Small Doable Actions (p. 20)
  • Social Norms (p. 22)
• And much more!

WASHplus Weekly: Focus on Handwashing

Issue 156 | August 1, 2014 | Focus on Hand Washing

This issue contains journal articles and reports published to date in 2014 on hand washing. Journal articles include an updated review of hand washing’s health effects, an evaluation on the use of soapy water, a new Community Handwashing Guide, and an article on the Super Amma campaign in India.

Reports include a review of hand washing in the perinatal period, a social media toolkit from the Global Public-Private Partnership for Handwashing, a report from the Institute of Development Studies on developing hand washing campaigns as part of community-led total sanitation programs, and others.

EVENTS 

What Does Sustainability Mean for Handwashing and Hygiene? Handwashing & Hygiene Track, Sustainability Forum, July 2014. Overview by J Rosenbaum, USAID/WASHplus. (Link)
The literature on improving hand washing practice and then sustaining or maintaining the practice suggests determinants such as social norms, policy, and presence of “enabling technologies” (like tippy taps and water treatment products) are the primary factors required to sustain behaviors rather than issues around functioning hardware, community maintenance, and local governance. These technology and systems issues lie within the household domain rather than with community or government. Availability of  key supplies and spare parts, and willingness to pay also factor into the equation, as does sustained maintenance of hand washing stations and water filters.

LITERATURE REVIEWS

Periodic Overview of Handwashing Literature: Summary of Selected Peer-Reviewed and Grey Literature Published July – December 2013. The Global Public-Private Partnership for Handwashing (PPPHW). (Link)
Twice a year, PPPHW publishes overviews of handwashing literature that provide practical guidance for implementers. This is a compilation of peer-reviewed and grey literature that were published between July through December 2013.

2014 JOURNAL ARTICLES BY PUBLICATION DATE

Hygiene and Health: Systematic Review of Handwashing Practices Worldwide and Update of Health Effects. Trop Med Int Health, Aug 2014. M Freeman. (Link)
From the 42 studies reporting hand washing prevalence the authors estimate that approximately 19 percent of the world’s population washes hands with soap after contact with excreta (i.e., use of a sanitation facility or contact with children’s excreta). Meta-regression of risk estimates suggests that hand washing reduces the risk of diarrheal disease by 40 percent; however, when they included an adjustment for unblinded studies, the effect estimate was reduced to 23 percent. Results show that hand washing after contact with excreta is poorly practiced globally, despite the likely positive health benefits.

Estimates on the WASH-related Global Burden of Disease

Below are abstracts and links to the full-text of articles in the August 2014 issue of  Tropical Medicine and International Health. 

Focus on the Global Burden of Disease from Water
While the methods of Global Burden of Disease (GBD) study continue to evolve, recent changes raise questions about the basis of new estimates of the risk associated with water, sanitation and hygiene and warrant consideration of alternative approaches.

• ​Inadequate water, sanitation and hygiene are estimated to have caused 842,000 deaths from diarrhoea in 2012, i.e., 1.5% of deaths worldwide. These include 361,000 deaths of children under five years.

• ​A systematic review of the global prevalence of handwashing with soap and its effect on diarrhoeal diseases estimates that only 19% of the world’s population washes hands with soap after contact with excreta and that handwashing reduces the risk of diarrhoeal disease by 23%–40%.

• ​Based on over 300 studies from a systematic review, an estimated 1.1 billion people are exposed to a drinking water source of moderate to high risk.

• ​A meta-regression shows that risks of diarrhoea from inadequate drinking water and sanitation could be reduced considerably through targeted interventions. Risk differences depend on type of intervention.

1 – Authors:  Clasen, Thomas, Pruss-Ustun, Annette, Mathers, Colin D., et al.

TI  - Estimating the impact of unsafe water, sanitation and hygiene on the global burden of disease: evolving and alternative methods
Abstract – http://onlinelibrary.wiley.com/doi/10.1111/tmi.12330/abstract
AB  – The 2010 global burden of disease (GBD) study represents the latest effort to estimate the global burden of disease and injuries and the associated risk factors. Like previous GBD studies, this latest iteration reflects a continuing evolution in methods, scope and evidence base. Since the first GBD Study in 1990, the burden of diarrhoeal disease and the burden attributable to inadequate water and sanitation have fallen dramatically. While this is consistent with trends in communicable disease and child mortality, the change in attributable risk is also due to new interpretations of the epidemiological evidence from studies of interventions to improve water quality. To provide context for a series of companion papers proposing alternative assumptions and methods concerning the disease burden and risks from inadequate water, sanitation and hygiene, we summarise evolving methods over previous GBD studies. We also describe an alternative approach using population intervention modelling. We conclude by emphasising the important role of GBD studies and the need to ensure that policy on interventions such as water and sanitation be grounded on methods that are transparent, peer-reviewed and widely accepted.

2 – Authors: Prüss-Ustün, Annette, Bartram, Jamie, Clasen, Thomas,  et al.

TI  – Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries

 Full text – http://onlinelibrary.wiley.com/doi/10.1111/tmi.12329/pdf

Objective – To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.

Methods – For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.

Results – In 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.
Conclusions – This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.