PERIODIC OVERVIEW OF HANDWASHING LITERATURE: Practical guidance for implementers based on selected peer- reviewed and grey literature published January – June 2012 Purpose/Context The Global Public-Private Partnership for Handwashing (PPPHW) aims to publish overviews of handwashing literature twice a year that provide practical guidance for implementers. We compiled 23 peer-reviewed and grey literature publications (including e- publications and ahead-of-time publications) between January and June From these, we selected relevant articles which allowed for practical guidance for implementation. We excluded publications from high income and/or medical facility based settings. This document summarizes the takeaway points for implementers. A separate pdf document (available includes additional details and context from the selected publications. Authors note No single study is universally applicable. We strongly recommend considering the context of the study when interpreting results. Prepared for the PPPHW by: Jelena Vujcic (University at Buffalo), Pavani K. Ram (University at Buffalo), Dan Campbell (WASHPlus). August 2012.

Summary of research (January – June 2012) What we learned about HW and health outcomes Handwashing (HW) with soap may prevent cholera [1]. However, in this case-control study, handwashing was measured using self- report, which typically overestimates observed handwashing behavior. Also, case-control studies cannot definitively establish cause and effect. What we learned about determinants of HW behavior Facilitators/barriers for handwashing among school children may be different than for mothers and other caregivers. Understanding these determinants for a target population may help the implementer design a more relevant behavior change approach [2]. Qualitative methods, such as in-depth interviews and group discussions, are commonly used to understand motivators/barriers Presence of a handwashing place with soap and water at key places around the household (ex. near food preparation/feeding/eating area) and structurally appropriate facilities are a key facilitator for practice [2, 3]. A study among rural Bangladeshi mothers suggests [5]: Increasing the priority of handwashing as an important use of soap may be a useful objective. Programs should help caregivers to overcome barriers to handwashing by building problem-solving skills, through group meetings among mothers, or home visits by peer educators to overcome common barriers. Expanding programs to include influential individuals such as husbands, older women in family and/or community can contribute to lasting behavior change.

Summary of research (January – June 2012) What we learned about HW promotion nested in other programs Handwashing promotion can be inserted in health related programs such as child vaccination [7], antenatal care[8], and safe delivery[9]. However, research cited here not provide enough evidence of behavior change in such programs and provides variable evidence for neonatal mortality in one study. What we learned about using behavior theory in development Some researchers recommend using multiple behavior change communication techniques, including behavior theories or their components in logic frameworks, and setting guidelines for best practices [10, 11]. These publications do not outline specific approaches to including multiple behavior change techniques, or using behavioral theories and logic models in handwashing program development. What we learned about hand contamination One study found that new sanitation facilities may increase risk of hand contamination among school children, perhaps due to insufficient attention to provision of soap and water, or promotion of handwashing [12]. What we learned about how to promote HW Suggestions from the SHARE consortium [6]: Elicit feelings of disgust Remind mothers to teach good manners (nurture) Make people feel that “everyone is doing it” to create a social norm

Citations: 1. Mahamud, A.S., et al., Epidemic cholera in Kakuma Refugee Camp, Kenya, 2009: the importance of sanitation and soap. J Infect Dev Ctries, (3): p World Bank (WSP), Are your hands clean enough? Study Findings on Handwashing Behaviour in Kenya. 2012, 3. World Bank (WSP), Vietnam: a Handwashing Behavior Change Journey for the Caretakers' Program World Bank (WSP), Water and Saniation Program (Learning Note), Behavioral Determinants of Handwashing with Soap Among Mothers and Caretakers: Emergent Learning from Senegal and Peru,. 2012, 5. Affleck, W. and G. Pelto, Caregivers' responses to an intervention to improve young child feeding behaviors in rural Bangladesh: A mixed method study of the facilitators and barriers to change. Soc Sci Med, (4): p SHARE, Handwashing with soap: Why it works and how to do it Briere, E.C., et al., Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers. J Infect Dis, Suppl 1: p. S Russo, E.T., et al., Water treatment and handwashing behaviors among non-pregnant friends and relatives of participants in an antenatal hygiene promotion program in Malawi. Am J Trop Med Hyg, (5): p Seward, N., et al., Association between clean delivery kit use, clean delivery practices, and neonatal survival: pooled analysis of data from three sites in South Asia. PLoS Med, (2): p. e Briscoe, C. and F. Aboud, Behaviour change communication targeting four health behaviours in developing countries: A review of change techniques. Soc Sci Med, (4): p Aboud, F.E. and D.R. Singla, Challenges to changing health behaviours in developing countries: A critical overview. Soc Sci Med, (4): p Greene, L.E., et al., Impact of a School-Based Hygiene Promotion and Sanitation Intervention on Pupil Hand Contamination in Western Kenya: A Cluster Randomized Trial. Am J Trop Med Hyg, 2012.