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 a 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 infectious disease responses 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: London School of Hygiene and Tropical Medicine
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 behavioural 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 emergencies here.
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.
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 alone (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 disengage 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 WASH'Em guide, this technical guide for handwashing facilities in public places and buildings by WaterAid, this technical brief for handwashing by Oxfam, plus the Compendium of Hygiene Promotion in Emergencies.
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.
Another study in a Belgium grocery store during the COVID-19 pandemic, found that introducing nudge signs (reading “please disinfect hands” and “Disinfecting hands saves lives. Will you disinfect your hands?” accompanied by an image of an elderly couple) at hand sanitiser stations, significantly increased the rate of observed hand disinfection (rates of 68.1% and 66.1% respectively, compared to 44% in the control).
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)
2. A sticker of eyes which can be placed above handwashing facilities to encourage positive social judgement.
Source: Biran et al (2014)
3. Toys placed in soap to make handwashing more fun.
4. Pictures of germs placed on surfaces that lots of people touch to cue handwashing.
5. Mirrors placed above handwashing stations to make handwashing more desirable and encourage longer handwashing.
6. A Study in the Philippines targeting COVID-19, found that introducing a series of nudges, including a footpath to the sink with “watching eye” stickers and arrows to the soap dish, increased rates of handwashing with soap after using the toilet by 17%.
In outbreaks handwashing behaviour often increases because of increased perceived risk and the formation of new social norms. For instance, the COVID-19 pandemic proved a powerful motivating force for improving hand hygiene behaviours.
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 to address enteric and respiratory infections. 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 through Oxfam’s Magic Hands is useful in crises too.
In 2021, No Strings International also utilized storytelling to motivate handwashing, through a puppetry film and craft activity intervention. The intervention was piloted in five Kenyan primary schools during the COVID-19 pandemic and achieved a 73% increase in observed handwashing behaviour. Puppets were also used in this case study from Kenya.
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.
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, Study 5.
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 an outbreak (see our guidance on ‘Assessing risk locally’). Here are some examples explaining the value of multiple delivery channels: Study 1, Study 2, Study 3, Study 4.
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, together with the engineering 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.
Handwashing interventions which remind people that others might judge them on their handwashing behaviour have also 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.
Five ideas for handwashing promotion during infectious disease responses
The simple act of handwashing with soap remains one of our best defences against a host of respiratory and enteric diseases. Here we provide some practical tips for how to encourage community-level handwashing behaviour with the aim of controlling and preventing the spread of infectious diseases . The activities described below have been selected for use in the early stage of responses because they are low-cost, low-risk, easy to do and because they can work across most contexts.
1. Make handwashing easier by increasing the availability of handwashing facilities, soap and water. The presence of a handwashing facility can make people much more likely to wash their hands. (See these studies for evidence: Study 1, Study 2, Study 3, Study 4.) For instance, during the COVID-19 pandemic, the WHO recommends that handwashing facilities are established at the entrance to every building and at all major bus and train stations, airports, and seaports. During outbreaks, we recommend that handwashing facilities are also stationed at all markets, food vending locations, and water points. Locally available durable and inexpensive materials are the easiest to use to assemble a handwashing facility in a short time. Make a team of people responsible for replenishing the water and the soap. Read the Wash’Em’s guide on how to design handwashing infrastructure that will actually change behaviour and our case studies, which communicate a range of novel and practical interventions (Example 1 – handwashing on wheels, Example 2- handwashing at border crossings). Additionally, technical guides from Oxfam and WaterAid provide an overview of handwashing infrastructure implemented during COVID-19 and other contexts. Note that whilst many of these examples and resources are COVID-19 specific, principles and activities can be applied to other infectious diseases where handwashing is a key preventative behaviour.
2. Make handwashing messages surprising. Placing messages (e.g. on posters or billboards) in key locations can act as a cue to remind people to wash their hands with soap at critical times. However, if the messages stay the same, they will begin to go unnoticed and may no longer trigger handwashing behaviour. Changing the handwashing message and possibly its location every few days will help to capture people’s attention time and time again. While outbreaks of infectious diseases, such as COVID-19 and Ebola are serious consequence, our handwashing messaging can still be aspirational and fun. Find out more about this activity here as well as examples of hygiene messages that can be used on rotation.
3. Remind people of the power of soap! Soap has been around since 2800 BC so it is easy to forget what a miracle product it is. People often just wash their hands with water - but only thorough handwashing with soap will result in truly clean hands. Below are several fun activities to show the power of soap. All you need are simple materials like pepper, glitter, spices, paint, Vaseline and water. These activities can be done in-person during house-to-house visits (make sure to assess the risk before doing any in person activities in the areas where you work), in public by the established handwashing facilities, or the videos can be shared via social media.
4. Normalise and celebrate handwashing. Controlling infectious disease outbreaks requires the whole community to work together and practice handwashing with soap regularly. Rewarding people when they do the right thing is more likely to encourage them to do it again and can lead to long-lasting habit formation. If you are working in a setting where social media is common, then share photos of people washing their hands with soap and praise them for doing the right thing. This was the concept behind the WHO’s #SafeHands Challenge during the COVID-19 pandemic. If you are working in a setting where social media is less common, then consider creating a champions wall where you feature similar photos on a wall in a public place (e.g. at a local market). Find out more about how to do these activities by following the links:
5. Share real experiences of the disease outbreak. When a new disease emerges, it can create a lot of fear. It is normal to be worried about an outbreak like COVID-19 or Ebola, but fear can cause people to act in unpredictable and harmful ways. During an outbreak such as COVID-19, we suggest that you partner with health authorities to interview people who have been exposed to the virus and who have either recovered or are experiencing long COVID-19. Sharing the lived experiences of these individuals (with their permission) with other community members will help them build a more accurate understanding of COVID-19 (Example 1, Example 2). Getting these individuals to speak out about the importance of the preventative behaviours (handwashing with soap, getting the vaccine, mask wearing) is likely to be much more believable and have a much more persuasive effect on the behaviour of others. For your own safety, we suggest that interviews are done over the phone or online and shared publicly. Find out more about how to do this activity here.
In summary, these 5 activities will help make frequent handwashing with soap a common practice and powerful social norm.
These practical tips come from the Wash’Em project which supports handwashing programme design in outbreaks and emergencies. The Wash’Em team have developed a range of COVID-19 resources at this link including:
The Wash’Em COVID-19 Guide in Arabic, French, Spanish and Portuguese.
Webinars in French, Spanish and Arabic describing these practical activities and others.
Videos of some of the activities in English, French and Spanish.
For other ideas on promoting handwashing and hygiene behaviours, see this guide and this slide deck produced by the British Psychological Society during the COVID-19 response.
Note that whilst the above resources are written with COVID-19 in mind, principles and activities can be adapted for responses to other infectious diseases where hand hygiene is a key preventive behaviour. Moreover, Wash’Em has a host of more general training resources available.
Author: Sian White
Review: Hans-Joachim Mosler, Bethany Carurso, Robert Aunger, Elli Leontsini
Last updated: 13.04.2020