Could new icddr,b interventions finally achieve “Clean Hands for All”?


Handwashing is an important part of keeping food safe, preventing diseases, and helping people - especially children - lead healthier lives. While the practice of handwashing may be of second nature to many, for others it needs to be learned behaviour. Globally, only 26% of the world’s population wash their hands with soap after coming into contact with fecal matter, exposing many to potentially life-threatening diseases. In Bangladesh, the statistics are grim; washing hands with soap before eating, or feeding a child, ranged from 1-6%.


Handwashing with soap has been considered one of the most effective ways of reducing infectious diseases and it is imperative to identify the barriers to handwashing behaviour to improve adherence. The Centers for Disease Control and Prevention recommends five steps as part of the handwashing process, while the World Health Organization and UNICEF recommend 10–11 steps. The complexity of adherence negatively impacts compliance, which perpetuates the cycle of infectious diseases. Two recent studies by icddr,b scientists explored less complicated solutions to encourage handwashing.


The first intervention divided the handwashing instructions into three categories and assigned 300 households to adhere to each instruction. The instruction sequences are:


  • simple (three steps)
  • moderate (six steps)
  • complex (nine steps)


Handwashing demonstrations were conducted separately with children and their mothers during the intervention. Both of the instructions were provided once (during the initial visit), and no visual or verbal reminders were provided after the initial visit. Most of the households (95%) had access to water at the handwashing station but only 25–33% had soap across the groups.


The findings are promising. After the intervention, all mothers in the simple, moderate, and complex instruction groups were able to reproduce all three handwashing steps provided in the simple instruction set. In the moderate instruction set, all (100%) mothers could reproduce the first four steps after the intervention across all groups. Among the nine complex handwashing instruction steps, all (100%) mothers were able to recreate the five steps after the intervention. Two instructions, “drying hands by waving in the air” and “cleaning under the finger nails” were found to be the least adhered-to instructions among all handwashing steps. Dr Nuhu Amin, assistant scientist at icddr,b and the principal author suggests “this indicates that when taught the basic handwashing steps, mothers could easily recall and practice these steps, thus there is a need to devise simpler handwashing instructions to increase adherence”.



A second study examined possible channels for disseminating handwashing messages to key audiences throughout the country. Mobile health (mHealth) is a low-cost, scalable approach where messages can be sent to a large number of households at minimal cost and can serve as valuable cues to action to facilitate behaviour change. The scientists implemented and analysed the feasibility of an mHealth intervention to their long-standing CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-Days) programme, which could potentially be scaled by the Ministry of Health and Family Welfare. The intervention developed five key behaviours (including preparing soapy water using water and detergent powder and handwashing with soap at food- and stool-related events), tailoring messages accordingly for diarrhoea patient households and government stakeholders.


The response to the intervention was very positive by both groups; with some participants suggesting both voice and text messages to be sent. Voice messages were viewed as better than text messages for understanding message content, while text messages could be saved and shared within the community for awareness dissemination. Current programmes on water, sanitation and hygiene (WASH) focuses solely on educational modules related to diarrhoea prevention, and does not take into account the psychosocial, technological, and contextual factors that could influence behaviour. Dr Munirul Alam, senior scientist at icddr,b and the principal investigator of the CHoBI7 mHealth programme added that “the use of mHealth for promoting WASH behaviours presents a low-cost approach for programme delivery that does not involve the cost of frequent in-person home visits. Furthermore, it could be integrated into the existing mHealth programmes being delivered by the government”.


This year, Global Handwashing Day is observed with the promise to deliver “Clean Hands for All”. icddr,b has been relentless in its pursuits to ensure disease-free and healthy lives for all. Children are especially vulnerable and afflicted with serious infectious diseases due to lack of appropriate hygiene practices. These recent interventions could be pivotal if scaled-up nationally, establishing handwashing approaches which have proven to work.