The latest OA Ambassador Spotlight Blog is here!

Our OA Ambassadors raise awareness in their local communities about global OA movements as well as related opportunities through IWA Publishing. They are representatives of both the International Water Association and IWA Publishing and our joint goals to empower the next generation of water leaders and to shape the future of the water sector. These blog posts highlight their specialty and research focus, as well as emphasising the importance of Open Access publishing. 

Zeyu Yao is a postdoctoral fellow at the Sun Yat-Sen University. Her research background is in tacit knowledge communication in integrated urban water management. Connect with Zeyu on LinkedIn!

Global Handwashing Day, founded by the Global Handwashing Partnership, is an initiative advocating particularly for handwashing with soap (including bar soap, liquid soap, powder detergent, and soapy water but does not include ash, soil, sand or other handwashing agents), for it is the most easy, effective and affordable [1] method to prevent or reduce the risks to diseases and infections. The theme of Global Handwashing Day 2023 is “Clean Hands are within reach”. There has been a rise in hand hygiene commitment and action [2], and the COVID-19 pandemic highlighted the importance of having access to handwashing facilities and access to water and soap. However, there is still a gap between our hand hygiene behaviour and the global hand hygiene targets we are trying to achieve.

To take up a new research position, I returned to China at the height of the COVID-19 pandemic in 2021. I couldn’t help but notice something bewildering when I visited toilets in public spaces, especially heavier traffic spaces such as train and bus stations. I couldn’t stop thinking, why couldn’t I find soap in public toilets (Figure 1)? It is almost contradictory that on the one hand, there are strict rules regarding stopping the spread of COVID-19 virus, but on the other hand soap (solid, liquid or sanitizer) is not readily available in many public facilities with heavy traffic. I wondered whether this issue was caused by people not having a habit of washing hands with soap and therefore there has been no demand for such provision, problems with providing soap in public toilets, or possibly a combination of other reasons. This year’s theme “Clean hands are within reach” focuses on “access”, because people need to both have access to hand hygiene facilities and find them convenient and easy to use. Therefore, for this year’s Global Handwashing Day, I am interested in exploring how to promote handwashing behaviour and I want to start with the two aspects: Access and Use.

Figure 1: A pair of sinks at a bus station on a university campus, soap is not in sight

Access to facilities and soap – whether people have the means to wash with soap

Worldwide there are three billion people who do not have access to handwashing facilities with soap, and 2.3 billion people who don’t have handwashing facilities with water and soap at home [3]. In China, the percentage of people with basic handwashing facilities including soap and water at home has increased steadily (Figure 2), with the most recent figure being 97.2%, and the discrepancy between rural and urban setting is very small. The WHO/UNICEF Joint Monitoring Programme (JMP) does not collect Water Supply, Sanitation and Hygiene data specifically for public lavatories or restrooms (they do collect global data on households, schools, and health care facilities). Therefore, the percentage of water and soap provision in public lavatories is not clear. Xu et al [4] conducted a study in Hangzhou, China to measure the residents’ hygiene awareness and behaviour in public toilets during the COVID-19 pandemic. According to some focus group interviews [5] as well as anecdotes, there is still in general a lack of soap in public toilets in China. Although the study found that 74.3% (n=70) of toilets observed had soap provision, it did not specify the percentage of soap provision in different types of public spaces.

Figure 2: Percentage of people with basic handwashing facilities including soap and water (China) [6]

Handwashing culture – whether people have the habit of washing with soap

Now I want to look at the handwashing behaviour from the perspective of the culture of handwashing practice. Factors influencing poorer households and public spaces from having soap for handwashing include the cost of materials, and access to materials in the market, as well as other social factors, but if the study has shown that the cost is not the principal barrier to handwashing with soap, then what other factors should we consider? [7] A study by Tao et al [8] examined the handwashing behaviour among Chinese adults in five provinces. Among the 6,159 residents who responded to the research survey, the percentage of performing proper handwashing behaviour among rural and urban residents is 23.8% and 59.1%, respectively. It further found that females and adults living in urban areas were less likely to have poor hand hygiene compared to males and adults living in rural areas, and that the top three most prominent influencing factors of proper handwashing behaviour are 1) rural/urban, 2) knowledge of disease transmission by hand, and 3) education level.

A smaller scaled study [9] by Xu et al that longitudinally compared the handwashing behaviour of residents in Hangzhou (first round in 2018, and second round in 2020/2021), the increased health and hand hygiene education during the pandemic may have led to increased hand hygiene awareness, resulting in higher percentage of people washing hands with soap (51.9%, vs 43% prior to pandemic), as well as a higher proportion of people believed that not using soap to wash one’s hand after using the toilet would increase the risk of disease transmission (43.6% vs 29.8% prior to pandemic). However, one can see even among urban residents who have received a higher-than-average amount of hand hygiene education, the percentage in both behaviour and awareness of handwashing with soap is still only about half. Lastly, there is anecdotal evidence of soap being stolen from public soap dispensers, which discourages the placement of soap by management entities.

Soap contamination in public spaces

Many of the studies I found focus on the behaviour of people using handwashing facilities, but the contamination of soap dispensers is one of the concerns people have when considering whether to use soap in public toilets. To avoid dispenser contamination and thus cross-contamination, it is important to ensure that the soap dispenser is cleaned and refilled properly and regularly, and therefore the health and hygiene awareness and behaviour of people who are responsible for the cleaning and refill should be well studied as well [10].

Behaviour change implementation and data sharing

Hand hygiene is a complex issue, and it takes collaborative and coordinated efforts from different types and levels of stakeholders to provide an enabling environment and foster positive hand hygiene behaviour [11]. We can see that while we recognise the importance of handwashing with soap in reducing disease transmission, there are social, technical, cultural, institutional, and financial factors that determine whether such an act is regularly and properly performed. Focusing on the technology and infrastructure alone would not meet the hygiene and sanitation challenge, we need to also understand how they fit in the social, cultural, economic and institutional contexts and how behaviour is influenced and perhaps constrained [12]. This is especially necessary when we are looking at vulnerable communities or recently developing places.

Behaviour change interventions are important to achieving more effective and sustained behaviour change in handwashing, and more broadly, WASH, and the use of a behavioural change framework is considered to be the best practice [13]. The USAID produced a technical guide on the systematic process of the design, implementation, and monitoring of the interventions, through four stages: 1) Define outcomes,2) Understand context, 3) Build and Test intervention, and 4) Learn and Adapt. The second stage is especially crucial because we need to explore existing and new data in order to gain a deeper understanding of the behaviours, the behavioural influencing determinants, and factors that may block or facilitate change. Figure 3 shows the SWITCH framework, which is one of the behaviour change frameworks that can be used. The behavioural determinants are organized into three broad categories: Elephant (factors affecting an individual’s motivation to carry out a behaviour), Rider (factors affecting an individual’s ability to carry out the behaviour), and Path (external factors). There is also a number of WASH specific frameworks, and more details can be found in the Handwashing Handbook by the Global Handwashing Partnership [14].

Figure 3: SWITCH Framework

Open Access WASH data

Finally, I want to conclude by highlighting the importance of data sharing and Open Access WASH data. As we have seen above, the data needed and generated on handwashing behaviour and other WASH behaviours are often contextualised and localised. Therefore, while the WHO/UNICEP JMP global database (https://washdata.org/data) contains over 5,000 national data sources that monitor the WASH progress of households (since 2000), schools (since 2018), and healthcare facilities (2019), there is a lack of monitoring of handwashing and other WASH data in public spaces, and more importantly, data relating to behaviour and behaviour determinants, such as the data used in studies on specific provinces and cities in China that were cited in this blog. Therefore, it would be very helpful if more data, both quantitative and qualitative, could be made public and shared among the WASH community.

When I attended the World Water Week in Stockholm this year via Arup’s Youth Ticket Initiative, I was really keen on listening to professionals from all parts of the world talk about current challenges, research, and solutions in the area of Water, Sanitation and Hygiene. One particular idea that caught my attention is Openwashdata [15] (Figure 4) by Global Health Engineering (ETH), which is an initiative that promotes open science and data practice. What’s more exciting is that the first qualitative data package consisting of 61 semi-structured interviews has just been released [16]. Qualitative data such as interviews and observation data are valuable resources, especially because the collection of such data usually is more time and resource-consuming. I think it is inspiring that Openwashdata is building this community that encourages and empowers WASH professionals to engage open data and code, leading towards more knowledge discovery and innovation, and to bring it back to the topic of this blog, the handwashing behaviour and their determinants in different geographical, cultural, social, and technical contexts.

Figure 4: Openwashdata

So why couldn’t I find soap in public toilets at places such as train stations, highway rest areas and other rural public areas? We know there can be a combination of different reasons affecting whether soap is provided, accessed, and used, including the convenience of access, the quality of the soap and dispenser, the culture and habit of handwashing, etc., although the cost of soap is usually not the principal barrier to handwashing with soap [17]. But we don’t know enough. To address handwashing and strengthen the enabling environment for hand hygiene at a system level, we need to have a better understanding of how people are behaving and why and how the behaviour is being determined. For this, we need to expand the current WASH database beyond households, schools and healthcare facilities and include high-traffic places such as transportation hubs. We also need to incorporate in the database qualitative data that are crucial for the design, implementation, monitoring, and evaluation of handwashing programs and behaviour change interventions, and more importantly, publish open access data and share them with the WASH community and beyond to encourage more transparency and rigour in research and practice.

 

[1] https://globalhandwashing.org/about-handwashing/

[2] https://globalhandwashing.org/global-handwashing-day/

[3] https://www.unicef.org/wash/handwashing

[4] Xu et al (2022), Changes in residents’ hygiene awareness and behaviors in public toilets before and during the COVID-19 pandemic in Hangzhou, China: a two-round cross-sectional study

[5] Wu et al (2019), A mixed-methods study on toilet hygiene practices among Chinese in Hong Kong

[6] https://www.ceicdata.com.cn/en/china/social-access-to-services/people-with-basic-handwashing-facilities-including-soap-and-water--of-population

[7] Kumar et al. (2017), HANDWASHING IN 51 COUNTRIES

[8] Tao et al (2013), Handwashing behaviour among Chinese adults: a cross-sectional study in five provinces

[9] Xu et al (2022), Changes in residents’ hygiene awareness and behaviors in public toilets before and during the COVID-19 pandemic in Hangzhou, China: a two-round cross-sectional study

[10] https://maxshield.sg/soap-in-public-restroom-can-contaminate-your-hands/

[11] Global Handwashing Day 2023 Fact Sheet

[12] van Vliet, et al (2011). Sanitation under challenge: contributions from the social sciences.

[13] USAID Technical Brief 10, SOCIAL AND BEHAVIOR CHANGE FOR WATER SECURITY, SANITATION, AND HYGIENE

[14] Global Handwashing Partnership (2020) The Handwashing Handbook.

[15] https://openwashdata.org/

[16] https://openwashdata.github.io/biogasoutcomesmalawi/?utm_source=openwashdata&utm_medium=email&utm_campaign=openwashdata-news-02-data

[17] https://globalhandwashing.org/about-handwashing/

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