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The Handwashing Handbook

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A guide for developing a hygiene promotion program to increase handwashing with soap. Hygiene is essential to the public health mission of reducing the transmission and consequences of disease. The sharp decline in deaths from infectious diseases observed in wealthy countries last century could not have been achieved without vastly improved public hygiene. Raising living standards allowed people to become more hygienic once clean water was piped into their homes, and soap became cheap enough to put at every sink. Eventually, the collective efforts of both the public health movement and private industry ensured that clean hands, clean homes, and clean lives, became a social norm.
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Content Preview
THE HANDWASHING HANDBOOK
A guide for developing
a hygiene promotion program to increase
handwashing with soap

The
Handwashing
Handbook
A guide for developing a hygiene promotion program
to increase handwashing with soap

TABLE OF CONTENTS
FOREWORD 5
EXECUTIVE SUMMARY 7
INTRODUCTION 8
Context and Purpose of This Handbook
The Leading Causes of Child Mortality
Handwashing with Soap: The Most Effective Vaccine Against Childhood Infections?
The Challenge of Handwashing Promotion
What’s New about This Approach?
SECTION 1 13
Laying the Foundation for
a National Handwashing Program
Getting Started: Is This the Right Place at the Right Time?
Conducting a Rapid Situation Analysis
Public-Private Partnerships
Making the Case for Handwashing
Making the Case to Government
Making the Case to Industry
Making the Case to Financiers
Financing Issues

Organization and Coordination
SECTION 2 21
Understanding the Consumer
The Marketing Approach
Understanding Behavior
Designing and Implementing the Consumer Research
Managing and Supervising the Consumer Research
Analysis and Reporting of the Results
2 The Handwashing Handbook

SECTION 3 33
Program Implementation
Designing the Campaign
Applying the Marketing Mix
Developing the Promotion
Target Audiences and Segmentation
Agencies, Concepts, and Testing
Multiple Strategies for Behavior Change
Public Relations and Advocacy
The PR Plan
The Media Mix

Monitoring and Evaluation
SECTION 4 43
Program Organization
The Partnership Mix
A General Partnership Model
The Business Plan

CONCLUSION 49
REFERENCES AND RESOURCES 51
TOOLS AND TERMS OF REFERENCE 53
ABBREVIATIONS 76
The Handwashing Handbook 3

LIST OF TABLES AND FIGURES
Figure 1:
Distribution of Global Child Deaths by Cause
Figure 2:
The F-Diagram: Major Transmission Routes of Fecal-Oral Diseases
Table 1:
Observed Rates of Handwashing with Soap Around the World
Table 2:
SWOT Analysis Factors
Table 3:
SWOT External Factors
Box 1:
The Cost-Effectiveness of Handwashing Programs
Box 2:
The Central American Initiative
Figure 3:
Consumer Research Process
Figure 4:
Drivers, Habits, and Environment in Behavior Change
Box 3:
Cultural Beliefs Inhibiting Handwashing with Soap in Senegal
Table 4:
Drivers, Habits, and Environments for Handwashing with Soap (Four Areas)
Table 5:
Identifying Barriers and Drivers to Handwashing with Soap at Key Events
Box 4:
Ghana Consumers Prefer Multipurpose, Long-Lasting Soaps at Economy Prices
Figure 5:
How Mothers Communicate in Kerala, India: Monthly Contact Profile
Box 5:
A Note on Schools
Table 6:
Summary Design for Consumer Research
Box 6:
Outline of Study Methods
Box 7:
Key Points for Contracting Consumer Research
Box 8:
Consumer Research: The Rational Bias
Box 9:
The Perfect Brief
Table 7:
Advantages and Disadvantages of Different Approaches to Communication
Box 10:
A Lesson in Public Relations: Handwashing in Kerala, India
Table 8:
The Ghana National Handwashing Initiative: Phase 1 Evaluation Results (in Percentages)
Figure 6:
Monitoring and Evaluation: Program Activities and Impact
Box 11:
Handwashing in Action: The Handwashing Partnership in Peru
Box 12:
Private Sector Handwashing Activities
Box 13:
Elements of the Business Plan
4 The Handwashing Handbook

FOREWORD
Hygiene is essential to the public health mission of reducing the transmission and consequences of disease. The sharp
decline in deaths from infectious diseases observed in wealthy countries last century could not have been achieved
without vastly improved public hygiene. Raising living standards allowed people to become more hygienic once clean
water was piped into their homes, and soap became cheap enough to put at every sink. Eventually, the collective efforts
of both the public health movement and private industry ensured that clean hands, clean homes, and clean lives,
became a social norm.
Unfortunately, the story in poor countries could not be more different. By the end of the 20th century, two billion
people still had inadequate access to sanitation, and one billion were without enough clean water to drink. Efforts at
promoting effective hygiene have been piecemeal and ineffective. Though industry has succeeded in getting soap into
almost every home, it has not consistently promoted good hygiene or handwashing to accompany their products.
This is a missed opportunity for public health. The two biggest killers of children in the developing world today are
diarrheal disease and respiratory tract infections. The simple act of washing hands with soap can cut diarrhea risk by
almost half, and respiratory tract infection by a third. This makes handwashing a better option for disease prevention
than any single vaccine.
If developing countries are to achieve their 2015 millennium development targets for reductions in child mortality, this
unfinished agenda of the 20th century must be completed. Not only must water and sanitation become universal, but
so must the habit of handwashing with soap. This requires Ministries of Health, Education, and Water, in addition to
non-governmental organizations (NGOs) and community-based groups, to exploit every opportunity to promote
handwashing with soap.
Moreover, private industry, which played such a large part in creating standards of good hygiene in rich countries, can do
the same as it expands its business in developing countries.
Handwashing with soap can and must become commonplace in developing countries. To do this we have to:
! Make sure everyone knows the importance of handwashing
! Build alliances between the public and the private sectors
! Mobilize the necessary resources and expertise
! Use proven high-impact communications outreach to promote handwashing to a mass audience
! Demonstrate that measurable changes in behavior can be achieved cost-effectively.
In a noisy world of competing messages aimed at people from all directions, only the most effective,
best-designed campaigns will lead to behavior change. This handbook seeks to meet this challenge.
It describes a new approach to handwashing promotion, building on the pioneering work of the
Public-Private Partnership for Handwashing with Soap. It explains how the latest thinking in industrial marketing can be
combined with the latest research in public health to provide powerful new insights to drive effective handwashing
campaigns. It offers lessons from national programs in Ghana, Peru, Senegal, and other countries. Early indicators
suggest that this may be the start of an exciting new field in public health in the 21st century.
Several members of the Global Public-Private Partnership for Handwashing Initiative must be acknowledged for making
this handbook possible. We would especially like to thank Beth Scott, Val Curtis, and Jason Cardosi for compiling this
guide. We are grateful to Ali Diouf, Rocio Florez, and Nana Garbrah-Aidoo for providing country examples. Special
thanks go to Peter Kolsky, Mariam Claeson, Stéphane Legros, and Nancy Lee for their in-depth peer reviews. Valuable
contributions were also made by Steve Luby, Eckhard Kleinau, Suzanne Reiff, Camille Saade, Myriam Sidibe, Barbara
The Handwashing Handbook 5

Evans, Sandy Callier, Joana Godinho, Wendy Wakeman, Merri Weigner, and Henk Van Norden. The private sector
partners, Yuri Jain from Hindustan Lever, Diana Grina from Colgate-Palmolive, and Tim Long from Procter and Gamble,
provided expertise and technical advice. Finally, we would like to acknowledge the guidance and leadership provided by
the Task Team Leaders, Jennifer Sara and Param Iyer.
Jamal Saghir
Jacques Baudouy
Director, Energy and Water
Director, Health, Nutrition and Population
6 The Handwashing Handbook

EXECUTIVE SUMMARY
Handwashing is one of the most effective means of preventing diarrheal diseases, along with safe stool disposal and safe and adequate
household water supply. Evidence suggests that improved handwashing can have a major impact on public health in any country and
significantly reduce the two leading causes of childhood mortality – diarrheal disease and acute respiratory infection. Because
handwashing with soap can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine or
hygiene behavior. Promoted broadly enough, handwashing with soap can be viewed as an essential do-it-yourself vaccine. Almost
every household in the world, regardless of economic status, has soap. Handwashing with soap at key times, however, is not widely
practiced. If the millennium development targets for reduction in child mortality are to be met, handwashing habits must be improved
along with access to safe water and sanitation.
The Global Public-Private Partnership for Handwashing has brought together various organizations and sectors to promote
handwashing with soap on a large scale. The partnership includes:
! governments who, by prioritizing hygiene, enable handwashing to move from piecemeal, village-by-village, efforts to national
programs;
! donor organizations who increasingly include handwashing in their water, sanitation, health, and education programs;
! the private sector which has brought state-of-the art marketing knowledge and techniques to the table;
! academic and scientific organizations who are contributing the latest behavior change theory and scientific evidence of the
effectiveness of handwashing; and
! non-governmental and community-based organizations who are aiming to integrate handwashing messages into their own
work programs.
The Handwashing Handbook lays out the experiences of this global partnership in a practical guide. While countries are still
optimizing and experimenting with approaches, it is important to disseminate what is currently known. This way others can begin
designing programs and contributing to the global body of knowledge and experience in the fight against child mortality. This guide
is for staff in governments and development organizations charged with carrying out handwashing programs. Decision makers in
ministries and funding agencies will also find assistance in this book for designing policies and programs to improve public health.
The approach to large-scale handwashing promotion covers the following components:
Laying the Foundation for a National Handwashing Program
To be successful, handwashing programs must address a recognized health need and have the support of key stakeholders.
Government, industry, and donors can all offer unique resources which are necessary to ensure the success of a large-scale
program. Conducting a situation assessment and, where needed, making the case for handwashing on topics ranging from cost-
effectiveness to health impact will give the handwashing program a solid foundation.
Understanding the Consumer
In order to change long-held habits related to behaviors such as handwashing, a firm understanding of the factors the drive and
facilitate behaviors in target consumers must be established. This means putting the needs of the target audience – primarily
mothers and caretakers of children under five years old as well as school-aged children – at the center and having their perspective
determine the nature and scope of all promotion activities. Carrying out consumer research provides a baseline for measurement
and understanding of the target audience by answering four broad questions: What are the risk practices? Who carries out the risk
practices? What drivers, habits, and/or environmental factors can change behavior? How do people communicate?
Program Implementation
The results of consumer research drive program implementation including which environmental factors related to handwashing
need to be addressed, what is the most appropriate and appealing way to promote handwashing, and what is best mix of
communication channels to reach the target audience. Implementation also includes the careful monitoring of the program and
periodic evaluation and adjustment.
Program Organization
When partners from different backgrounds and sectors are not accustomed to working together, establishing common aims and
trust takes time and effort. Placing a program coordinator in a trusted organization is an effective approach to steering diverse
partners towards a common objective.
Throughout the handbook, references, case study information, and tools are provided to support handwashing programs. Users
are encouraged to combine their creativity with existing knowledge in order to innovate and optimize approaches to large-scale
handwashing promotion.
The Handwashing Handbook 7

INTRODUCTION
Purpose of This Handbook
This handbook grows out of the experience of the Global Public-Private Partnership for Handwashing with Soap
(PPPHW) and its predecessor, the Central American Handwashing for Diarrheal Disease Prevention Program. These
efforts demonstrated that mass programs with public and private sector involvement can be successful in promoting
handwashing and reducing disease. With core support from the Bank Netherlands Water Partnership, the PPPHW has
brought together global public and private agencies to consolidate approaches while initiating large-scale handwashing
promotion in Ghana, Peru, Senegal, and Nepal.
While much has been learned about handwashing promotion in recent years, especially in the areas of research and
program design, countries are still experimenting with, and optimizing approaches to implementation. It is important to
lay out what is known so that others can begin designing programs and contributing to a global body of knowledge and
experience in the fight against child mortality.
This handbook is intended for staff in government and development organizations charged with carrying out handwashing
programs. Decision-makers in Ministries and funding agencies will also find assistance in designing policies and programs
to improve public health.
Context
Handwashing is one of the most effective means of preventing diarrheal diseases, along with safe stool disposal and safe
and adequate household water supply. This handbook focuses entirely on handwashing and advocates for stand-alone
handwashing-with-soap programs.
It is not the intention of this guide to detract from hygiene behaviors other than handwashing. On the contrary, each has
a place and should be addressed distinctly, carefully, and in the right context. However, it is axiomatic in communications
programs that messages have to be single and simple: economies of scale do not operate at the level of message
delivery. For example, conveying two messages in a single communication reduces the effectiveness of each by half.
Consequently, lumping the three key hygiene behaviors together is inadvisable.
The handwashing promotion approach described in this book involves careful consumer research followed by
up-to-date marketing efforts. This approach adapts itself well to other health issues, and lessons learned from
carrying out a handwashing program could clearly be applied to other programs using similar technical and
institutional approaches.
Current efforts to promote good hygiene, including handwashing, have not been sufficient to engender mass behavior
change. Many public health programs include improved hygiene among their objectives: in any country at any time,
one might find a diarrheal disease control program, a school health education program that includes hygiene, a water
supply and sanitation program that invests in raising hygiene awareness, and sporadic local-level hygiene education.
All these efforts share the weakness of treating hygiene as a side issue, rather than a central one. Sufficient resources
are lacking; imagination, human skills, and enthusiasm are not fully engaged; and the approaches may be outdated.
No one agency champions hygiene, and financing bodies do not see its importance. Objectives committed to paper
are never fully operationalized, resourced, evaluated, or monitored. Successes have largely been confined to individual
villages, achieved by approaches that cannot be scaled up countrywide. Worse, confusion reigns at the most basic
level as to what good hygiene is: different actors define it differently, and prejudice and local preference take
precedence over evidence.
The approach outlined here aims to resolve all of these problems: it raises awareness, enhances political commitment
and resource allocation for hygiene, offers a route to a coordinated national program, combining them all under one
umbrella. It also uses high-profile and up-to-date methodologies to change the hygiene behavior which consistently
demonstrates the greatest potential impact on overall public health; handwashing with soap.
8 The Handwashing Handbook

Just as every child has a right to vaccination, each should also have the right to protection from hand-
transmitted disease. This means simply washing hands with soap after using the toilet or cleaning a child and
before handling food.
The Leading Causes of Child Mortality
The World Health Organization (WHO) estimates that diarrhea and respiratory infections are responsible for two-
thirds of child deaths (figure 1). UNICEF estimates that diarrhea alone kills one child every 30 seconds. The vast
majority of child mortality occurs among the world’s poorest populations in low- and middle-income countries.
Figure 1: Distribution of Global Child Deaths by Cause
Measles
2%
Other
13%
Diarrheal
AIDS
Diseases
5%
35%
Malaria
13%
Acute
Respiratory
Infections
32%
Source: WHO 2001
Handwashing with Soap:
The Most Effective Vaccine against Childhood Infections?
Human feces are the main source of diarrheal pathogens. They are also the source of shigellosis, typhoid, cholera, all
other common endemic gastro-enteric infections, and some respiratory infections: just one gram of human feces can
contain 10 million viruses and one million bacteria. These pathogens are passed from an infected host to a new one via
various routes, as shown in figure 2. While the routes are numerous, they all emanate from one source: feces. While
secondary measures (food handling, water purification, and fly control) may have an impact, far more important are the
primary barriers – sanitation and handwashing – after fecal contact. These barriers prevent fecal pathogens from
reaching the domestic environment in the first place.
Handwashing interrupts the transmission of disease agents and so can significantly reduce diarrhea and respiratory
infections, as well as skin infections and trachoma. A recent review (Curtis and Cairncross 2003) suggests that
handwashing with soap, particularly after contact with feces (post-defecation and after handling a child’s stool), can
reduce diarrheal incidence by 42-47 percent, while ongoing work by Rabie et al. suggests a 30 percent reduction in
respiratory infections is possible through handwashing. This remains true even in areas that are highly fecally
contaminated and have poor sanitation. Another current study found that children under 15 years living in households
that received handwashing promotion and soap had half the diarrheal rates of children living in control neighborhoods
(Luby et al. 2004). Because handwashing can prevent the transmission of a variety of pathogens, it may be more
effective than any single vaccine. Promoted on a wide-enough scale, handwashing with soap could be thought of as
a ‘do-it-yourself’ vaccine.
The Handwashing Handbook 9

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