New Delhi: Today the Global Handwashing Day is being observed world over to draw attention to the growing issues related to handwashing habits and their effect on health and illness. The World Health Organization (WHO) in 2013 attributed a total of 297,000 deaths to poor handwashing, mostly from low-income countries. A recent body of work has revealed several reasons for poor hand washing (or hand hygiene) – from the availability of basic infrastructures such as washbasins, soaps, and water, to low awareness on handwashing practices or simple unwillingness of to wash hands after critical times. Socio-economic factors such as caste, income, and education play a key role in shaping poor handwashing habits. In fact, the culture of handwashing is an interplay between these factors.
Statistics on handwashing in India also align with this theory. While almost all households in India (as high as 97% according to recent surveys) have washbasins, only richer and more educated households in urban areas use soap to wash hands. The gap between rich and poor households is huge – only 2 out of 10 poor households use soap compared to 9 out of ten rich households. Caste and class play an equal role in deepening disparities, with Scheduled Castes and Tribes reporting the lowest use of soaps for handwashing in India.
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But the dissection of handwashing practice in India will remain incomplete without addressing the gender differences. Handwashing (and cleanliness) habits between men and women differ starkly. Internationally, women show more positive handwashing practices than men. Sporadic evidence in India supports this claim, and women seem to be more open to adopting improved habits. For instance, women are more aware of the critical times for handwashing (after defecation, after cleaning a child’s bottom, before feeding a child, before eating and before preparing food or handling raw meat, fish, or poultry). Also, handwashing compliance rates among women are better than men. But the reasons or factors fueling this positive change remain elusive. Moreover, it remains uncertain whether handwashing habits for the youth in India (and globally) fit this claim.
Building on the insights, one can infer that poor handwashing habit is not a generic issue. Poor and vulnerable households in rural areas are much more likely to practice poor or no handwashing, and men seem to be more susceptible. The problem context calls for a targeted approach by development initiatives to improve handwashing behavior. In the past decade, several such initiatives have been tested in India and globally and have provided critical insights around DOs and DON’Ts to designing programs to change handwashing behavior.
Evidence around DON’Ts observes that the link between presence of washbasins and soap and actual handwashing in the absence of dedicated behavior change messaging is weak and often counterintuitive. However, the content and method of delivery that makes behavior change messaging successful needs careful contextualization to trigger a positive response. In India, several initiatives have aimed at emotional messaging that is more acceptable to rural settings, e.g., a positive female fictional character and a negative male character. Findings from the study conducted in Chittoor district of Southern Andhra Pradesh by Wellcome Trust and SHARE in 2014 also suggest that emotional drivers can lead to substantial improvement in handwashing practices among children. Some recent initiatives have also looked at the “complexity” of messaging around handwashing practices and the steps to handwashing. A simpler 3-4 step handwashing process compared to 10-11 steps, is more likely to see compliance from people.
Besides creating awareness and constructing facilities for handwashing, multiple stakeholders, including the government, national and international NGOs, donor agencies, and private players through Community Social Responsibility (CSR) initiatives are engaged in implementing innovative solutions to provide the necessary push to use and maintain these facilities. Under the flagship program Swachh Bharat Mission-Gramin, the Government has ensured provisions of providing an incentive amount of INR 12,000 to Below Poverty Line (BPL) / identified Above Poverty Line (APL) households in rural areas. This incentive aims at facilitating a positive change in behavior for people to undertake the installation of handwashing facilities and construction of toilets on their own. NGOs, INGOs (International NGOs), and CSR initiatives are also using public platforms such as community meetings, school events, household and neighborhood visits, emotional messaging, and pledging to create awareness and influence behavior on improved handwashing practices.
Behavior change is usually complex and takes sustained efforts to convert awareness and knowledge into habit formation and realize health benefits. The use of simple and effective messages should not only be confined to WASH platforms, but health and nutrition-related platforms also to propagate benefits of handwashing. Locally relevant drivers can also be leveraged to bring about a change in the community. Evidence from different programs can be shared on public platforms to understand ‘what works’ and ‘what does not’ in different social contexts.
While several initiatives have seen a positive breakthrough in the Indian context, the jury is still out on whether any of these initiatives can be considered as the “best fit” for the Indian context. Though the sanitation and hygiene sector has witnessed an intellectual deepening and exploration, a lot more remains to be unpacked around the factors influencing handwashing habits in India.
(Abhishek Sharma and Vijay Avinandan work for Sambodhi Research & Communications. Sambodhi is a multidisciplinary research organization offering data & evidence driven insights to stakeholders in the national and global social development sector. They work in areas such as Public Health & Nutrition, Water Sanitation & Hygiene (WASH), Poverty & Livelihood, Energy & Climate Change, Education and Skill and Agriculture, Livelihoods and Natural Resources.)
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