WASHplus Year Five Annual Report, October 2015

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In its Year Five Annual Report, WASHplus has stories to tell, results to share, events to celebrate, and studies that add to the evidence base. WASHplus activities serve as the backdrop for many stories: the Zambian school girl who has access to privacy and menstrual supplies when she needs them, the Malian household that can now build an improved latrine on their rocky soil, the mother in Bangladesh who understands the importance of a feces-free environment, the Nepali home breathing cleaner air as it trials an improved cookstove. And perhaps more compelling than the individual stories are the results the project is beginning to record through endline data collection in Kenya and formative research on school enrollment and in Zambia. Providing water, sanitation, and hygiene (WASH) infrastructure to schools is having a notable impact on enrollment. Community-led total sanitation (CLTS) may be inoculating communities exposed to cholera. Numbers also tell the story of the project’s impact. Look for a snapshot of those figures throughout the report.

The conclusion of field activities in Uganda and Zambia this year provided opportunities to reflect, celebrate accomplishments through end-of-project (EOP) events, and share lessons learned. Several articles were published this year in peer-reviewed journals and others submitted on topics ranging from consumer preferences and willingness to pay for improved cookstoves to habit formation and costing of handwashing. WASHplus also played a key role in preparing the joint document on WASH and nutrition for publication and distribution.

WASHplus’s focus on integrating WASH into other development initiatives enabled the project to get in on the ground floor on subjects that are gaining traction at USAID and globally, such as WASH and nutrition, neglected tropical diseases, and MHM. This integration focus dovetailed nicely with the project’s mandate to serve a technical leadership role, and project staff had many opportunities this year to share its work and lessons from the field on a global stage, strategize with partners on important advocacy issues, inform policy, and develop guidance in multiple countries. Also toward that end, WASHplus launched its first two learning briefs on small doable actions and WASH and nutrition. This series details the variety of approaches WASHplus uses to improve WASH and household air pollution (HAP) across its portfolio of countries.

And finally, it’s been an exciting year for innovation with pilot projects underway in Ethiopia and Bangladesh focusing on sanitation marketing and sand envelopment. These two efforts will add to WASHplus’s body of knowledge on sanitation innovation and aligns closely with USAID’s global interest on the topic. WASHplus is also documenting its fecal sludge management work in Madagascar to tell the next chapter in that story.

The usefulness of a handwashing proxy in large household surveys

WASHplus’s Monitoring, Evaluation, Research, and Learning Advisor, Orlando Hernandez, co-authored a paper on the usefulness of a handwashing proxy in large household surveys. An abstract of the paper is provided below.

“Handwashing with soap is a cost-effective way of reducing diarrheal disease mortality in children under 5. Tracking this practice among child caretakers is a challenge, as the gold standard method – structured observations – is cumbersome, costly, and conducive to over-performance. The water, sanitation, and hygiene (WASH) field needs a valid, reliable proxy to track handwashing with soap in large surveys. This proxy is crucial as the new 2015–2030 Sustainable Development Goals (SDGs) may track hygiene. Using data from the Multiple Indicators Cluster Survey (MICS) and the Demographic Health Survey (DHS) from five countries, we conducted multivariate analyses to explore an association between the presence of functional handwashing stations (HWSs), (together with needed supplies) and the likelihood of lower reports of child diarrheal disease. A limited to moderate association exists in three of the five countries considered characterized by comparable rates of childhood diarrhea: Malawi, Sierra Leone, and Zimbabwe. The relationship was detected when controlling for potential confounding factors (other WASH elements, socio-demographic factors, nutrition practices, and immunization status) and when accounting for cluster effects. The likelihood of reported diarrhea among children under 5 increases when there is no HWS, just a handwashing device with no supplies or only water or only soap. The relationship is moderate in Malawi and less strong in Sierra Leone and Zimbabwe. No relationship was found in Ethiopia and Ghana. Further exploration of the usefulness of this proxy in other African and non-African contexts is warranted.”

Read the paper here.

Citation: Victoria Shelus and Orlando L. Hernandez, The usefulness of a handwashing proxy in large household surveys, Available Online 20 August 2015, DOI: 10.2166/washdev.2015.184

 

 

The Science of Habit: Creating Disruptive and Sticky Behavior Change in Handwashing Behavior

science of habit

Integrating basic science insights from psychology, cognitive science, and behavior change research, “The Science of Habit: Creating Disruptive and Sticky Behavior Change in Handwashing Behavior” presents six principles for creating greater initiation and maintenance of handwashing change. Read the new WASHplus report here.

Handwashing Resources from WASHplus

Make it a habitOn Global Handwashing Day and every day we dedicate ourselves to increasing awareness and understanding about the importance of handwashing with soap to prevent diseases and save lives. Please see below handwashing resources developed by WASHplus on: the small doable approach to handwashing; how to make tippy taps for handwashing; making a habit of handwashing; and integrating WASH  into nutrition and HIV programs.

HANDWASHING RESOURCES

sda thumbnailSmall Doable Actions: A Feasible Approach to Behavior Change, Learning Brief, 2015. This brief takes a look at how WASHplus has applied the Small Doable Action approach to handwashing, water treatment, improved sanitation, menstrual hygiene management, and food hygiene.

habitHandwashing and the Science of Habit, Webinar, 2014.  This webinar emphasizes ways to apply the basic science of habit and behavior change to real world health interventions and program delivery, with a focus on behavior change for handwashing with soap.

WASH HIVIntegrating Safe Water, Sanitation, and Hygiene into HIV Programmes: A Training and Resource Pack for Uganda, 2014. This training manual teaches the four key WASH practices: safely transporting, treating, storing, and serving drinking water; safe handling and disposal of feces; safe handling and disposal of menstrual blood; and handwashing with soap (or ash) and water.

WASH nutritionIntegrating Safe Water, Sanitation, and Hygiene into Infant and Child Nutrition Programmes: A Training and Resource Pack for Uganda, 2014. This resource pack can  aid health workers in helping household and community members to overcome, or change, the many daily obstacles to improved water, sanitation, and hygiene (WASH) practices in the home.

tippy tap makingHow to Make Other Types of Tippy Taps, 2014. This pamphlet shows how to make Tippy Taps for handwashing from mineral water bottles, tin cans, and hollow tubes. The tippy tap is a hands free way to wash your hands and is especially appropriate for areas where there is no running water.

Nutrition and Handwashing

This post is a re-blog and first appeared on the Global Public Private Partnership for Handwashing (PPPHW) website here.

March 22, 2015

By Layla McCay, Secretariat Director, the Global Public-Private Partnership for Handwashing (PPPHW)

Love is in the air – or rather, in the water. This World Water Day, nutrition and handwashing with soap may be the hottest ‘celebrity couple’. The two have been enjoying a close relationship for years, so what has propelled them into the public eye, as seen in recent developments such as the new policy in India mandating handwashing before the midday meal in schools? The answer is integration.

Integration means linking different sectors together to leverage synergies and achieve greater impact than could be achieved working alone. It is also the latest buzzword in international development. At first glance, nutrition and handwashing may not seem like obvious bedfellows. One is about ensuring affordable access to adequately nutritious food; the other is about soap, water and turning a behavior into a habit to prevent infections. But in fact, nutrition and handwashing are closely linked.

The World Health Organization (WHO) tells us that 50 percent of child undernutrition cases are due to repeated diarrhea and intestinal infections caused by poor sanitation and hygiene conditions or by a lack of safe water. This means that handwashing with soap is a critical determinant for achieving and maintaining good nutrition. It plays an important part in preventing micronutrient deficiencies, stunting, wasting and nutrition-related deaths. To properly address child undernutrition, we need to address hygiene.

We know that good nutrition is about more than consuming nutritious foods; it’s about the body’s ability to absorb nutrients. If people don’t wash their hands before handling food, disease-carrying germs have a direct route into their mouth and down into their gut where they can inhibit the body’s ability to use the food’s nutrients. In fact, germs can directly consume nutrients before they even get into the body.[i] They can also directly damage the intestinal lining (a condition called environmental enteropathy), which contributes to nutrients being lost in feces instead of being absorbed.[ii] Germs can furthermore irritate the gut lining so that toxins can get inside and cause inflammation – using up nutrients in the process.[iii] Since children who are undernourished are more susceptible to developing diarrhea when they come into contact with disease-causing germs, lack of handwashing and undernutrition can become a vicious cycle.

Good handwashing with soap can prevent nearly half of all cases of childhood diarrhea. It is also estimated that drinking clean water and handwashing with soap can reduce the loss of nutrients through diarrhea, and reduce stunting in children under the age of five by up to 15 percent.[iv],[v] Handwashing with soap should be an integral part of nutrition programs, and this World Water Day, let’s think seriously about their integration. #Wateris fundamental to good nutrition through handwashing. It’s time for handwashing and nutrition to take their relationship to the next level.

This World Water Day share what water means to you by using #WaterIs on social media. 

[i] Solomons NW. Pathways to the impairment of human nutritional status by gastrointestinal pathogens. Parasitology 1993; 107:S19–35.

[ii] Solomons NW. Pathways to the impairment of human nutritional status by gastrointestinal pathogens. Parasitology 1993; 107:S19–35.

[iii] Sharp TM, Estes MK. An inside job: subversion of the host secretory pathway by intestinal pathogens. Curr Opin Infect Dis 2010; 23:464–9.

[iv] Fenn, B. et al. (2012). An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia. Public Health Nutrition, 15(9), 1746-1754.

[v]  Dangour, A. D. et al. (2013). Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. The Cochrane Library.

Lessons From Zaragoza: Indicators, Integration, And Human Rights For Hygiene Post-2015

Woodburn_Hanna_2014This post, authored by Hanna Woodburn, has been reblogged from the Global Public-Private Partnership for Handwashing (PPPHW) website.

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We are only a few weeks into 2015, but the Global Public-Private Partnership for Handwashing and other actors within the international development community have been anticipating this landmark year for quite some time. Later this year, the Member States of the United Nations will agree upon a new set of global, Sustainable Development Goals (SDGs) to replace the expiring Millennium Development Goals. To learn, collaborate, and strategize, the UN-Water organization convened key water, sanitation, and hygiene (WASH) sector actors in Zaragoza, Spain. The gathered experts, including the PPPHW, attended and participated in discussions around what tools and challenges face implementation of the proposed SDG for water (to view this goal, please see Goal 6 on page 12 of this document).

At this conference we learned about the role of various stakeholder groups, such as business, governments, civil society, and academia, in addressing the challenges of implementing a water SDG. We advocated for hygiene where it was absent, and came away with a new appreciation for the role that integration will play in driving forward progress on WASH in the post-2015 era.

As we look toward the remaining months of 2015 and what needs to be accomplished in terms of advocating for a comprehensive WASH goal, complete with targets and indicators for hygiene, it is clear that there are specific areas where the PPPHW and hygiene supporters can be engaged.

First, indicators will be the way forward in advocacy and ensuring that all components of WASH receive their due recognition within the SDGs. Indicators will need to be measurable, actionable, and ambitious. Without an indicator for hygiene we will not know the progress made on this crucial public health intervention.

Second, at the planning, stakeholder, and programmatic levels, integration will become increasingly important to address the myriad and interrelated challenges facing global health and development. WASH does not exist in a silo. The benefits from good hygiene services and behaviors, for example, range from improving health and nutrition to reducing inequities and improving school attendance. As such, broad collaboration will help ensure that the benefits from WASH are fully realized.

Finally, but not least, the human rights approach toward water and sanitation (articulated here), will continue to be used to frame the importance of access to these life-saving services. The key elements of such an approach are equality and nondiscrimination; participation and inclusion; and accountability and the rule of law. Hygiene is, and should be, covered under the umbrella of the human rights approach, but we need to make this association clearer.

We know that WASH is going to be essential to making progress on the SDGs, that there are tools that can help achieve the proposed water goal, but we also know that there is much work to be done in the meantime, particularly around ensuring that hygiene does not fall off the agenda. The PPPHW is committed to continued advocacy around these efforts, and we hope you will join us. Sign up for our email list, learn more about the conference here, and learn what goals, targets, and indicators the WASH sector are supporting here. The challenges are large, but not insurmountable. Overcoming them will both save lives, and ensure a healthier, more productive world Post-2015. Together we can help make this vision become a reality.

About the Global Public Public-Private Partnership for Handwashing: The Global Public-Private Partnership is a coalition of international stakeholders that aims to give families, schools, and communities in developing countries the power to prevent diarrhea and respiratory infections by supporting the universal promotion and practice of proper handwashing with soap at critical times.

Hand Washing and the Science of Habit: A Webinar

Hand Washing and the Science of Habit: A Webinar

On December 4, WASHplus and the global Public Private Partnership for Handwashing (PPPHW) co-hosted a webinar with David Neal, Ph.D., from Catalyst Behavior Sciences and the University of Miami. Dr. Neal is a social psychologist specializing in behavior change and the advanced measurement of human decision making.  He discussed the usefulness of habit theory for health programming targeting households. Although he emphasized ways to apply the basic science of habit and behavior change to real world health interventions and program delivery, with a focus on behavior change for handwashing with soap, his ideas are relevant to anyone working on behavior change activities. The webinar was well attended by nearly 200 participants from 15 countries with more than 1,000 subsequent views. The countries included: Bhutan, Cambodia, Canada, India, Nepal, Pakistan, the Philippines, Uzbekistan, and Zambia. A recording of the webinar and slides are available here.  

The Theory and Practice of Handwashing Habits

At the 2014 UNC Water and Health Conference, the USAID funded WASHplus Project’s Monitoring and Evaluation Advisor, Orlando Hernandez, coordinated a panel session entitled “The Theory and Practice of Handwashing Habits.”  Organized by WASHplus and institutional partners WSP, LSHTM and PPPHW, the panel session focused on the seven principles of habit formation, explored how they could be applied to the handwashing arena, and discussed applications where enabling products have been developed and tried as cues to guide practices and habit formation. Potential implications for future handwashing programs were discussed, beyond the mere creation of cues. A summary of the panel session is provided below:

Diarrheal disease accounts for 11% of child mortality worldwide. Yet, there is a cost-effective way of reducing diarrheal disease in children under five and in turn reduce child mortality: handwashing with soap at critical junctures, especially among caretakers, grouped into two large categories, before food handling and after contact with fecal matter. Handwashing with soap at such junctures can reduce diarrheal incidence by up to 43%.

Handwashing promotion has been an important part of many WASH interventions and such programs have been able to increase handwashing practices among target populations using a variety of approaches. More recently, these approaches rely on conceptual framework that argue in favor of using psychosocial determinants and emotional appeals. Such frameworks have their origin in reflective psychology which suggests that behavior is volitional and guided by factors internal to the individual.

Handwashing programs constructed on reflective psychology theories and models have proven effective to generate behavior change. However, is there any evidence that they have been useful in helping to maintain the practice overtime? Research on the sustainability of handwashing practices overtime is inconclusive. Yet, interpretations of findings overtime suggests that factors in the context in which individuals behave may be partially responsible for their perdurance.

A couple of studies argue in favor of the presence of water and soap as contributing factors to handwashing sustainability. Such suggestions point in the direction of the science of habits which proposes that factors initiating practices are not the same as those that maintain them. Whereas reflective psychological models may explain the practice of new behaviors, reflexive models offer an explanation for keeping them alive.

Update from UNGA and TEDMED: Handwashing, Partnerships, Integration and Innovation

by Layla McCay

Cropped_headshot_reasonably_smallAbout the author: Dr. Layla McCay is the Director of the Public Private Partnership for Handwashing (PPPHW) Secretariat, housed at FHI 360. The USAID-funded WASHPlus Project supports the PPPHW in its efforts to promote handwashing and hygiene improvement. Follow Layla on Twitter: @LaylaMcCay

Partnerships and integration were the buzz words surrounding the UN General Assembly in New York in September. The Public Private Partnership for Handwashing secretariat delved into the deluge of international development players, with the purpose of seeking opportunities for handwashing, and learning about current issues in partnerships for international development.

A key message being reiterated in the development community over the course of UN General Assembly week is that as a community, we are becoming ‘post-public-private-divide’. There is increasing appreciation of the synergies and complementary roles of the different sectors, and an appetite to bring all players together to maximize impact. While that can be easier said than done, tendencies to either sanctify or vilify different sectors or particular players were deemed outdated; instead, the focus this September was on the benefits of working together to inspire and drive better practices all around. In terms of business, there was recognition that social good is starting to move out of the CSR/philanthropy departments to become business as usual, a business investment in efficiency and sustainability – which means we should expect more public-private partnering. Indeed, looking towards the successors to the Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs) are expected to be key drivers of the multi-sector partnerships that will be needed to deliver them.

Another persistent message during ‘UNGA’ was the importance of integration, as opposed to programming in silos. In the context of handwashing, this means exploring opportunities to integrate handwashing programs ‘horizontally’ into a range of sectors, such as sanitation, nutrition, maternal and child health, healthcare, HIV/AIDS, education, gender empowerment, economic development… but also considering how to integrate ‘vertically’, across the enabling environment, including investment in infrastructure and the social determinants of health. This approach is about harnessing the power of cross-sectoral partnerships to address a range of development challenges being experienced by a population, rather than focusing on single issues. It was striking how many of our development colleagues believed the barrier to meaningful, strategic integration was not just the practicalities of integrating on the ground, but the ‘single issue’ nature of funding for international development. For example, investing in school uniforms may help girls attend school – but to keep them in school, investing in menstrual hygiene materials and facilities may be needed too, but these two interventions may have entirely different funders and programs. The “celebrity couple” of nutrition and hygiene came up repeatedly, with the implication that this “couple” should think about taking their relationship to the next level, with greater integration of nutrition and hygiene work.

Integration across sectors for health promotion was also a theme at the TEDMED conference, which I got the opportunity to attend in September. You can read my general write-up of the whole event here. In terms of food for thought regarding handwashing, there was a compelling discussion about refreshing and diversifying messaging for health promotion. Using the example of breastfeeding promotion, one speaker noted that messages about breastfeeding for babies’ health are important but as these messages become increasingly familiar to people, they (a) risk losing their impact, and (b) only engage a subset of people. However by diversifying the messages to also make breastfeeding a women’s health issue, and a heart health issue (focusing on how breastfeeding reduces the mother’s risk of obesity and heart disease), new lines of engagement are opened, with the opportunity for new champions, new messages, new incentives, greater reach, more targeted appeal, and hopefully more uptake of the behavior. There may be useful lessons for diversifying hygiene messages to expand impact.

My first experience of seeing a ‘celebrity handwashing champion’ in action came in the form of Kajol, at Unilever’s Help a Child Reach 5 hygiene event with USAID. Her messages were simple, but her presence created a clear buzz. In addition to the keen interest of press in the room, some of whom told me they were there specifically to see her, it was interesting to see Kajol’s legions of fan clubs and fans around the world picking up and retweeting her handwashing messages (a tweet I sent about her reached over 100,000 people). This was an interesting insight into the potential reach of handwashing promotion messages from strategically selected and deployed celebrity champions.

Finally, the use of technology to improve hygiene is always an interesting question, and it tends to come up on these forward-looking platforms. It was inspiring, for example, to see examples from Unilever and MAMA of how mobile phones can be used to deliver hygiene education directly to pregnant women. At TEDMED, there was also some interesting discussion about crowdfunding health – using the web to set up facilities like Kickstarter to enable the public to directly fund specific health interventions in specific places. With the Millennials embracing this sort of targeted giving, there could be some interesting opportunities for crowdfunding hygiene in future. Throughout the events, there was significant talk about harnessing the voice, experiences, ideas, and energy of youth to drive progress.

Global Handwashing Day is just around the corner….ready, set, plan! 

This blog post is authored by Hanna Washburn. Hanna is the Deputy Secretariat Director for the Public Private Partnership for Handwashing (PPPHW). Follow Hanna on Twitter @WASH_Hanna.

Each year, on October 15, over two hundred million people gather together in countries around the world and celebrate Global Handwashing Day. This international day of advocacy and action shines a spotlight on the state of handwashing in each country or community where it is celebrated and helps to raise awareness about the benefits of handwashing. Why such a big focus on handwashing? This simple action, when practiced regularly can significantly reduce the risk of illness and death from diarrheal disease and pneumonia. With 1.7 million children dying from these causes each year, we certainly think that is a reason to celebrate!

To help individuals and organizations plan Global Handwashing Day celebrations in their community, region, or country, the Global Public-Private Partnership for Handwashing has developed a Planner’s Guide. This year, the Planner’s Guide was updated to reflect the changing nature of Global Handwashing Day celebrations and the corresponding needs of planners.

Based on consultations with partners and others who have utilized the guide, we have attempted to create an updated guide that is action-oriented and provides planners with resources and inspiration to help as they implement a successful Global Handwashing Day celebration, and to encourage handwashing promotion throughout the year.

Those who have used the Planner’s Guide in years past will be familiar with the overall structure of the document; indeed, some sections such as the Five Facts about Handwashing are still very much the same. The biggest changes are found in the hands-on portion of the Guide. Here planners will find a step-by-step guide to planning an event, which is supplemented by fact boxes, event ideas, and tips for success. The annexes feature ideas for celebrations depending on the audience, an event planning checklist, facts about handwashing, and more.

Whether you’ve celebrated Global Handwashing Day for years, or this is your first, we hope that the Planner’s Guide will have provide you with the tools and ideas necessary to make your event a success. Let us know how it goes by uploading pictures and stories to our interactive, online map. And don’t forget, always wash your hands with soap!