Handwashing with Soap:

Saving Lives

Katie Greenland
London School of Hygiene & Tropical Medicine
Meet Liah
Liahs Short Life
Kg
15

14

13

12

11

10 M

9
D
ARI D
X
D
D ARI
8 D D ARI D ARI D
ARI D ARI
ARI
FEVER ARI ARI ARI
7
D
D D D D D D D ARI
6 D ARI ARI ARI
ARI KEY
5 D ARI Acute Respiratory Infection
D Diarrhea
4 M Measles
FEVER Fever Unknown Origin
3
ARI

0 3 6 9 12 15 18 21 24 27 30 33 36
AGE IN MONTHS
 Child Mortality
3 million U5s deaths a year from diarrhoea &
pneumonia
Indone
sia: Diarrhoea;
Diarrhoea;
15% 15%
Other diseases; 19%
Injuries; 2%
Congenital anomalies; 6%
Neonatal sepsis; 5%

Birth asphyxia; 11% Malaria; 1%

Prematurity; 20%

151,000 deaths a year

56,000 diarrhoea /
pneumonia
WHO/UNICEF, 2010
 Fluids

Fields
Faeces Foods Mouth

Flies

Fingers
 Fluids

Fields
Faeces Foods Mouth

Flies

Fingers
 Fluids

Fields
Faeces Foods Mouth

Flies

Fingers
Impact of handwashing with soap on
diarrhoea
A
B1
B2
C

D1
D2
F

J1

J2
47%
P
reduction
Combined
.4 1 2 4 10
RR

Curtis and Cairncross, 2003, IJE 2010

 Impact of handwashing with soap
on respiratory infection

Dyer, 2000

Ladegaard, 1999

Master, 1997

Niffenegger, 1997

Roberts, 2000

White, 2001

White, 2003

Luby, 2005

Sandora, 2005
23%
reduction
Combined

.5 1 1.5 2 2.5
Relative Risk

Rabie and Curtis 2005, updated with Luby and Sandora,

 Impact of handwashing with soap
on neonatal outcomes
4 million neonatal deaths a year, one third
infections
Nepal study: 44% reduction all cause mortality
Tetanus Sepsis
Clean Birth at home 30% 15%
Clean Birth in 38% 27%
facility
Postnatal Practices 40% 40%

Existing interventions 41-72% reduction in

mortality
Rhee, 2006; Darnstadt, 2006;
Blencowe, 2010
Handwashing with
soap can prevent:
diarrhoea (including
cholera), ARIs,
neonatal infections,
pandemic influenza,
malnutrition,
infections among AIDs
patients

... Handwashing with

soap could save a
million lives a year...
Handwashing with
soap could save a
million lives a year...

and is the single

most cost effective
public health
intervention bar none
When do people HW?
Country N HWWS HWWS HWWS HWWS HW with
after toilet after before before water
(%) cleaning feeding handling only after
child (%) index food (%) toilet (%)
child (%)
Ghana 500 3 2 1 - 39
India-Kerala 350 42 - - - -
Madagascar 40 4 - 12 - 10
Kyrgyzstan 65 18 0 - - 49
Senegal 450 23 18 - 18 -
Peru 500 14 - 6 - -
China- Sichuan 78 13 - 6 - 87
China- Shaanxi 64 12 - 16 - 14
Tanzania 30 13 13 4 - 33
Uganda 500 14 19 6 8 44
Vietnam 720 - 14 5 - 51
Kenya 802 29 35 13 15 57%
Average 17% 13% 5% 13% 45%
Formative Research to design
Interventions: New Mothers, Serang
When do Indonesian mothers hand-
wash? No. of HWWW HWWS
Events (%) (% )
Before food preparation* 38 0 5
Before serving food* 51 4 0
Food Before eating* 52 4 10
After cooking 34 6 9
After eating 39 21 23
After cleaning (e.g sweeping) 54 7 19
House &
After washing dishes 21 24 7
Environmen
t After doing laundry 23 30 9
After returning home 11 9 27
After cleaning baby's
Defecation faeces/napkin* 28 25 32
After own defecation* 1 100 0
Before breastfeeding* 148 1 1
Baby Before handling baby at other
time ... 0 1
 Current HWWS Practice:
Why?
every time do
most important
dirty things.
after washing
dirtiest is cooking
laundry and when
because you
handling the baby
touch chili, then
(rural)
can't touch the
baby, make its
skin hot (urban)

after eating and after baby

defecating to defecates so as to
remove the bad remove the smell
smell (HH27-rural) (rural)
Dirty Hands Study

N = 404

28% had faecal

contamination

Judah et al, Epidemiol. Infect., 2009

What does it take
to change behaviour?
WASH
YOUR
HANDS

Or you will get

sick!
 Female results by message
Message MessageType Soap use p value
Soap adds a fresh touch Comfort 62% 0.143
Blank Control 65% ref
Blank Control 65% ref
Toilet - sink - think: soap Cue 67% 0.562
Soap it off or eat it later! Disgust 67% 0.565
See sink? Use soap! Cue 69% 0.078
Washing with soap avoids 47% of disease Knowledge 69%* 0.051
Dont be a (dirty) soap dodger Status/Identity 70%* 0.014
Don't take the loo with you - wash with soap Disgust 71%* 0.013
Wash your hands with soap Positive control 71%* 0.015
WSAH YUOR HNADS WIHT SAOP Knowledge activation 71%** 0.007
Toilet germs soap hands clean Knowledge activation 71%** 0.004
Is the person next to you washing with soap? Norms/Affiliation 72%** <0.001
Water doesn't kill germs, soap does Knowledge 72%** 0.001
 Male results by message
Message Message Type Soap used p value
Blank Control 31% (REF)
Wash your hands with soap Positive control 34% 0.067
See sink? Use soap Cue 34% 0.073
Sticky hands? Get that soapy smoothness Comfort 33% 0.325
Knowledge,
Water doesn't kill germs, soap does perceived risk 33% 0.267
Toilet - sink - think: soap Cue 34%* 0.029
Washing hands with soap avoids 47% of Knowledge,
disease perceived risk 34% 0.033
Soap it off or eat it later Disgust 35%* 0.012
Wash your hands with soap Positive control 35%* 0.017
Dont be a dirty soap dodger Status/Identity 35%* 0.013
Don't take the loo with you - wash with soap Disgust 35%** 0.005
Soap adds a fresh touch Comfort 35%** 0.004
Is the person next to you washing with soap? Norms/Affiliation 36%** 0.001
What have we learned
about behaviour change?
Consider emotional, habitual and
cultural factors not just education
about germs!
o
Need culturally-specific messages about
disgust, norms etc.

Use the best available skills

o
Public-Private Partnerships
October 15th
Global Diarrhoea Initiative
(GDI)
6 July 2011 meeting of experts in London

Conclusion:
More dialogue across sectors
vaccination, hygiene, water, sanitation,
nutrition & treatment
New efforts should be built out of existing
initiatives stengthen global advocacy
Full scale, sustained
handwashing
can save lives