Handwashing

Fecal pathogens can enter the human body in multiple ways, causing intestinal infections, inflammation of the gut, or micronutrient deficiencies through reduced micronutrient absorption. An important way to stop the transmission of pathogens is to reduce the risk of accidentally ingesting soil and waterborne pathogens. Handwashing for all household members at key times can eliminate, or greatly reduce, the risk of ingesting pathogens from the physical environment; it has been shown to reduce diarrheal disease and respiratory illness (Ejemot et al. 2008; Ejemot-Nwadiaro et al. 2015; WHO and UNICEF 2013; Luby et al. 2011). It is important to note, however, that very young children do not practice handwashing very often. When young children practice handwashing, it may be an opportunity for soil or other contaminants to stick on the hands if they are left to air dry (Ngure et al. 2013).

Critical handwashing times are—

• before preparing food or cooking
• after cooking
• before eating food or feeding a child
• after cleaning a child’s bottom
• after defecating
• after sweeping and/or contact with animal feces.

Among these critical times, Luby et al. (2011) identified handwashing before food preparation as the best time to reduce childhood diarrhea. Hands should be washed with running water (preferably warm) and soap. If soap is not available, other cleansing agents, like ash or alcohol-based cleansers, can be used.

Measurement and data sources

Ideally, structured observations of handwashing practices at all critical time points would be used to collect information on household handwashing, but most available data rely on observing if appropriate handwashing facilities are available. In addition to rapid observations, surveys can ask respondents to self-report their handwashing practices, request a skills demonstration, conduct microbiological measures of hand contamination, carry out structured observations, or use sensors (Ram 2013).

Surveys usually report the percentage of households observed with a designated place for handwashing, dividing the indicator further if water and cleansing agents (e.g., soap) are available and/or its location within the household. The new Sustainable Development Goals include a target indicator (sanitation target 6.2.1) for the percentage of the population using safely managed sanitation services, including a handwashing facility with soap and water (UN Statistical Commission 2016). Luby et al. (2011) found that allowing hands to air dry, and the presence of water where respondents usually wash hands, were independently associated with fewer respiratory infections and could be important indicators to include in handwashing assessments.

Surveys that collect information related to the presence of handwashing facilities include—

• Demographic and Health Surveys
• Multiple Indicator Cluster Surveys
• National Micronutrient Surveys
• Knowledge, Practice, and Coverage Surveys
• other research or evaluation activities.

The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation maintains a database of information on the coverage of water, sanitation, and hygiene programs.

Methodological issues

• It can be expensive to collect data by observing household hygiene practices, may be impractical, and may change the behavior of the people being observed.
• Having a place for handwashing does not mean that proper handwashing practices are followed, nor does it identify who uses the handwashing facility, water quality used, or what the triggers are. However, this indicator has been found to be a good proxy for handwashing practice (Ram et al. 2014). Further questions or observation will usually be necessary to better understand how the facilities are used.