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Summary report: Changing hygiene behaviour through infrastructure
Summary report: Changing hygiene behaviour through infrastructure
Alexandra Czerniewska avatar
Written by Alexandra Czerniewska
Updated over a week ago

As of 2022, some 2.3 billion people lack access to handwashing facilities with soap and water globally. During outbreaks of infectious diseases, response organisations typically distribute very simple handwashing facilities, because the priority is to ensure maximum availability in public places (e.g. markets, travel hubs), households, schools and health centres. Whilst these simple handwashing facilities meet short term needs, they are often not durable enough to last, or not designed with long term behaviour change in mind. This resource provides an overview of how handwashing infrastructure can be designed, improved, and maintained to lead to more sustainable changes in hygiene.

How can handwashing facilities change behaviour?

Handwashing is not possible at all without basic facilities – usually at least water, soap, and a bucket/jug. Unsurprisingly, having access to a desirable and convenient handwashing facility with soap and water is one of the most important factors in determining handwashing behaviour. Handwashing facilities contribute to behaviour change by:

  • Cueing behaviour - Handwashing facilities can act as visual reminders, or ‘cues’ to wash hands. This is why it’s so important that handwashing facilities are placed where the hand washing should take place – e.g. next to food market areas, outside the toilet, next to food preparation areas, at an entrance of a school, shop, restaurant, distribution centre and or for when returning home. For instance, in this case study from Bangladesh, public handwashing stations were installed in key locations, such as markets and outside mosques during the COVID-19 pandemic and in this example from East Africa, handwashing stations were introduced at border crossings.

  • Making handwashing easy to do - In comparison to basic methods like a bucket or cup, conveniently located and easy to use handwashing facilities make it easier to be hygienic at critical moments. Partly this is because they allow all the key ‘ingredients’ like soap and water to be ready to use in one location, without having to hold them while washing. Hand washing facilities are also thought to be water saving as they typically control the amount of water being used.

  • Making handwashing enjoyable - People are more likely to practice behaviours that provide instant ‘rewards’. For handwashing, this might be because it makes your hands feel or smell nice, or the facility is fun to use, or it provides another benefit e.g. having a mirror attached. These instant rewards are more powerful than the potential (but not guaranteed) long/medium term health benefits that hygiene promotion often focuses on.

  • Helping to form habits - Once people start washing hands (because it is convenient, easy, and enjoyable), a good facility helps handwashing to become automatic, or habitual, by providing a place for people to repeat a set of actions over and over again. But keep in mind that these habits can easily be disrupted if broken parts are not mended quickly, soap is not regularly replaced, or the handwashing facility is moved.

What factors should be considered when selecting handwashing infrastructure?

There are several factors to consider when selecting or designing handwashing facilities for infectious disease prevention and beyond. The perfect design might not exist, but the criteria below helps to make decisions about which type of handwashing facility is best to promote in your context.

  • Desirability – Which designs do users like? Which will provide the instant rewards that help change behaviours? Consider using bright colours and decorations to make the facility stand out, or other ways to make facilities desirable, such as adding mirrors.

  • Ease of use and accessibility - Which designs will be usable by children, older people, people with disabilities, or other groups? Do you need different designs for different users? Do women and girls feel safe and comfortable using a public facility based considering their social-cultural norms? WaterAid and WEDC have developed these accessibility and safety audits to ensure the perspective of users whose requirements are often ignored in standard design.

  • Ease of placing handwashing messages – where can you fix posters, stickers, or a billboard on or in the vicinity of the handwashing station? Will the hygiene messages stay the same, or will they be changed every few days / weeks to capture peoples’ attention? If so, do you have resources – staffing, budget and creative methods to do so – remembering handwashing messaging can still be aspirational and fun?

  • Water availability - Will your facility be connected to a piped water supply or does it require a stored water container? Is water scarce in your area? Consider handwashing technologies that reduce the flow of water allowing hands to be washed with a minimal amount of water.

  • Hand cleaning products – Is your handwashing facility designed to be used with liquid, bar soap, soapy water or ash? Which designs will enable soap or other cleaning products to be kept at the handwashing facility? People often worry about theft or misuse of soap and other cleaning products, but it’s hard to create habits if they’re not kept there all the time.

  • Drainage– How will grey water from the handwashing facility be collected and disposed of, if not by pipe or drain? Nobody wants to stand in a puddle of water while they wash their hands.

  • Drying hands – How will people dry their hands? If drying materials are provided, where will they be disposed of?

  • Location - What is the best place for the handwashing facility to be located so that it is easy to access, convenient to use, and acts as a cue or a reminder to wash hands? Can your handwashing facilities also be a location for changing behaviour or shifting the way people think about hygiene? The addition of simple visual ‘nudges’ or simple messages could increase hygiene behaviours and encourage new norms.

  • Portability – Ideally, handwashing facilities should remain in the same place every day to facilitate handwashing habits. But if it needs to be moved (e.g. brought inside at night, moved throughout the day to keep shaded), how easy is this and who is going to do this?

  • Security - Is the handwashing facility in a location where it is at risk of being stolen? Are there certain parts of the facility (like taps) that might be removed and lead to the facility becoming dysfunctional? Are there measures you can take to reduce the risk of theft?

  • Distancing – How many users do you expect to use each handwashing facility? Do you need to consider the position of the facilities (or taps) to enable physical distancing while handwashing? If queues are likely to form by the facility, markings on the ground can encourage physical distancing while waiting to use the facility.

  • Perceptions - Are there any other local perceptions which need to be considered? For example, some people might be worried about touching the facility, so some designs can be operated by the foot, lower arm or elbow, or use sensors. The benefits of washing hands appear to outweigh risks of re-contamination, but perceptions are important for changing behaviour.

The following considerations are usually referred to as ‘operations and maintenance’, but we argue that these are very important to consider in the design or selection of your handwashing facility:

  • Consumables - How can you ensure that soap and water is regularly replenished? Who will pay for water charges or soap costs?

  • Cleaning - How easy is it to keep the handwashing facility clean? What products are needed and how will cleaning responsibilities be shared among facility owners or users?

  • Durability - Which designs will continue to function under regular or high use conditions? Are materials susceptible to deterioration with exposure to UV light, or could certain soaps cause rusting of metals? Are parts well secured to prevent people from dismantling parts of the facilities, leading to them becoming dysfunctional?

  • Repairs - Who will fix or replace parts if they break, or if the facility starts leaking? Using materials and parts available locally will make repairs easier if needed.

  • Cost - How expensive are the facilities and do they offer good value for money for response organisations and community members? It is important to focus on costs over the life of the facility: initial capital cost, cost of consumables, cleaning, and repairs.

  • Scalability – Which designs are easiest to produce at the necessary scale and speed?

  • Logistics - Can the handwashing facilities be easily transported and constructed in the locations where they are needed and with available equipment?

What existing technologies are available?

There are many handwashing facilities and technologies to choose from. The simplest designs include the tippy-tap, or a simple bucket/can with a nail pushed through to make a hole. These are affordable, easy to replicate quickly, and can be suitable for household use. However, they also break easily, and some people find them difficult to use or don’t like the way they look. If you’re choosing low-cost technologies like tippy-taps, you’ll need to plan to frequently replenish water and soap and conduct repairs.

There are many guides available to help choose and maintain the right handwashing facilities. Here are a few recommendations:

  • The Global Handwashing Partnership handbook provides a comprehensive overview of ‘making the case for handwashing’, designing and implementing handwashing programmes, implementing in specific contexts and addressing handwashing at a systems level.

  • The Handwashing Compendium provides guidance on handwashing facility designs for households and multiple users along with advantages and disadvantages of common designs. It includes information on accessibility, adaptability and operation and maintenance as well as links to other resources.

  • This guide by Wash’Em provides examples of handwashing facilities and describes how to work with communities to design handwashing facilities that improve behaviour.

  • UNICEF and GIZ’s Scaling up Group Handwashing in Schools compendium is a collection of exemplary designs for school handwashing facilities. It is intended as an introduction to the topic and the concept of school group handwashing, as well as the principles and the basic requirements for facilities.

  • The German WASH Network, IFRC, WASH Cluster and Sustainable Sanitation Alliance also published a Compendium of Hygiene Promotion in Emergencies in 2022. The compendium provides a detailed account of the components of hygiene promotion, tools and methods available, along-with frameworks and approaches.

  • SNV’s practical guide to hand-washing stations for promoters and producers of handwashing facilities includes useful cost estimates for different designs.

  • WaterAid’s guide for handwashing facilities in public places was developed over the course of the COVID-19 pandemic and features learnings from their work in numerous countries. This guide includes a strong focus on local ownership and operation and maintenance.

  • Oxfam’s guide for handwashing stations provides an overview of the principles to consider, options for local assembly or pre-made products, plus a critique (pro’s and con’s) across a range of handwashing stations available.

  • UNICEF India’s Guide for COVID-19 handwashing facilities pulls together designs that have been implemented across India during the pandemic. It includes detailed descriptions of materials and itemised costs.

  • UNICEF Fact Sheet on handwashing stations provides a useful comparison of handwashing facilities and their parts (e.g. taps).

  • The HappyTap is an affordable and easy to deploy handwashing facility that can be ordered in bulk and shipped worldwide.

  • The Jengu Handwashing facility is an open-source design that can be ordered in bulk or produced locally. It has been designed with behaviour and durability in mind.

  • The Oxfam Handwashing Stand can also be ordered and shipped worldwide. It is a multi-user handwashing facility suitable for public and crisis affected settings. See the Introducing the Handwashing station video by Oxfam.

    Image of a TippyTap. Source: Engineering for Change

Image of a TippyTap. Source: Engineering for Change

Image of a Handwashing on wheels in Bangladesh. Source: WaterAid

Image of a Handwashing on wheels in Bangladesh. Source: WaterAid

Video explanation of contactless handwashing station in Cox Bazar, Bangladesh.

Source: Oxfam

How can organisations work with communities to design or select handwashing facilities and promote their use?

Those who will be using the handwashing facilities should be involved at multiple stages of a project, including being involved in designing/selecting, constructing, and maintaining facilities. In some settings there might already be local innovations that can be used as a starting point for new designs.

Using ‘participatory’ methods to select or customise existing technologies or design something new from scratch can make a big difference to acceptability, accessibility, and sustainability. Here are two approaches you could follow, but it can be as simple as just asking people about their preferences, including people who often get ignored in design processes (e.g. older people, people with disabilities) and testing out different options with the community to see which really work to change behaviours.

  • The ‘Human Centred Design’ (HCD) process is often used by product designers and has become very popular in recent years. HCD tries to deeply understand and empathise with people you’re designing for. It involves generating lots of ideas, building prototype models, and testing them over and over with users until you find the best solutions for your setting. For an example of HCD being employed in handwashing station design in Nigeria, see this article.

  • ‘Trials of Improved Practice’ (TIP) are based on a similar idea of getting people to try out different products in their own homes and recommend improvements or see what improvements or alterations people make themselves. Compromising between the ‘ideal’ intervention as perceived by the response actor and the ‘ideal’ intervention according to the users, is at the heart of the TIPs methodology. The process was first used for complementary feeding programmes, but it has also been used for the design of handwashing stations.

Source: Washnet

How can organisations work with communities to ensure handwashing facilities are maintained and sustainable?

Whatever the design of your handwashing facility, it will need maintenance and repairs. The quicker these are done, the easier it will be for people to maintain handwashing habits. When you design or select a handwashing facility, consider how easy it is to repair or replace parts and how often you will need to do it. It will probably be a trade-off, with the most durable designs needing less frequent repairs, but more specialised people to do them. Irrespective of what type of handwashing facility is being promoted, take time to set up an operation and maintenance plan with owners or users to:

  • Replenish soap and water regularly (including paying for these items as necessary)

  • Ensure the facility is kept safe from theft or damage by weather, animals etc

  • Identify where parts can be sourced or fixed

  • Ensure that if the facility becomes damaged people report this and can organise parts and repairs.

  • Ensure that some funding is locally available to cover the cost of repairs.

  • Name the people who are accountable for each point above, and ensure users are aware of the roles and responsibilities of personnel responsible for operation and maintenance of the stations.

The following should be considered when setting up plans for operation and maintenance of facilities:

  • Are there existing mechanisms within your setting which are responsible for WASH related infrastructure (e.g WASH committees) and who may be able to extend their role to care for these facilities?

  • Are there local/institutional funding mechanisms that could contribute costs to cover consumables and repairs? The cost of repairs is likely to be minimal if shared between many.

  • Could a roster be established to clean the facility, replenish soap and water, and report any faults? Sharing responsibilities may make the process more feasible and create ownership. This has been shown to work for the cleaning of sanitation facilities.

  • Is there a logical person or organisation who can care for the facility (e.g. if the facility is outside a business it makes sense for that business to maintain the facility, if it is at a school or health centre try to advocate for costs to be included in budgets)?

  • How could you recognise those who contribute time or money to maintaining handwashing facilities? Providing social status and rewards and making people feel like they are contributing to a common good could help to motivate involvement.

When setting up plans, it’s important to be realistic about maintenance responsibilities, specifically, be frank about time and costs. Make sure the plan is fair and doesn’t place too much responsibility on any one person. Monitor and support those that are involved in maintenance over several months and work with them to troubleshoot challenges. Although local women's groups may seem an obvious entry point, it’s advisable to include all members of the community in the design, construction and maintenance of handwashing facilities, including boys and men and people with disabilities.

Do public handwashing facilities pose a risk?

Some public handwashing facilities do pose a small risk of re-contamination. However, the absence of them would create a much greater concern for transmission. Hand re-contamination is possible because at the end of handwashing, when your hands are clean, the tap has to be turned off - but this tap may be dirty from when you initially touched it. There have been some great examples of no-touch handwashing facilities to mitigate this issue. Most of these use foot pedals to control the water and soap. Others have created touch-free adjustments for standard handwashing facilities.

A more simple and well known touch-free handwashing device is the tippy tap. Instructions on tippy tap construction have been made available in a range of languages here.

Even if you are using bucket-style handwashing facilities, these normally come with an on/off lever to dispense water. The good thing about this (as opposed to a tap that turns on and off) is that it can be pushed with an elbow to switch it off, thus mitigating the contamination risk. Watch this video to see an example.

In several countries, individuals at the community level through their own initiative have set up handwashing stations near markets as small money earners or that organisations are paying ‘hygiene monitors’ to ensure that soap and water are always available at the public facilities they construct. In these situations, the person monitoring the station can switch the tap on and off for each person so that it is effectively touch-free. If your organisation is planning on paying people to monitor handwashing facilities, please do consider the sustainability of this approach or how you will phase this out. In addition, you may wish to promote regular cleaning of taps on public facilities.

Editor's note

Reviewed by: Jamie Myers, Janita Bartell, Astrid Hasund Thorseth, Sheillah Simiyu, Katie Greenland, Ammar Fawzi

Last update: November 2022

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