Handwashing in the post-2015 era: the equity case and the measurement challenge
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1 Handwashing in the post-2015 era: the equity case and the measurement challenge Pavani K. Ram, MD School of Public Health and Health Professions University at Buffalo
2 What is hygiene? The science concerned with the maintenance of health Clean or healthy practices or thinking British Dictionary Handwashing Bathing Washing dishes Sweeping the house Wearing footwear Disposing feces Disinfecting drinking water Commonly applied definitions Handwashing with soap Food hygiene Menstrual hygiene management JMP Hygiene Working Group
3 Making a case for handwashing: the child survival, education, and equity agendas Diarrhea School absenteeism Umbilical cord infections Malnutrition Respiratory infections (Pneumonia, Influenza) Equity Neonatal mortality
4 Handwashing: the equity perspective Africa and Middle East South/East Asia and the Pacific CEE/CIS Latin America/ Caribbean Percentage of households observed to have soap for handwashing anywhere in the dwelling, MICS,
5 Poorest Second Middle Fourth Richest Percentage of households observed to have soap for handwashing anywhere in the dwelling, by wealth quintile, MICS, , Africa and the Middle East
6 Africa and Middle East South/East Asia and the Pacific CEE/CIS Latin America/ Caribbean Percentage of households observed to have a handwashing place with soap and water, MICS and DHS,
7 Poorest Second Middle Fourth Richest Percentage of households observed to have a handwashing place with soap and water, by wealth quintile, MICS and DHS, , South/East Asia and the Pacific
8 Opportunities to improve handwashing do exist worldwide, even where materials are widely available Region # studies Prevalence of handwashing with soap (%) (95% CI) Africa (11,18) Americas HI 7 49 (33, 65) Americas LMI 2 16 (7, 33) Eastern Mediterranean HI - 44 (34, 57) Eastern Mediterranean LMI - 15 (9, 24) Europe HI 5 44 (29, 56) Europe LMI 1 15 (6, 30) South-East Asia (7, 36) Western Pacific HI 2 43 (25, 57) Western Pacific LMI 2 13 (6, 25) World (8, 39) Freeman, TMIH, 2014
9 Measuring handwashing Self-report Structured observation Video observation Behavior at recommended times Handwashing demonstration Soap consumption Accelerometer -embedded soap Use of cleansing agent Presence of soap anywhere in the home Hand microbiology Soap and water at a handwashing place Observed hand cleanliness Proxies of handwashing behavior
10 The future could look just a bit cleaner. Sustainable Development Goal 6: Ensure availability and sustainable management of water and sanitation for all. Target 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations
11 Potential handwashing-related indicators Percentage of population with basic hand washing facilities in the home Access to soap and water at hand washing facilities in the home, using WHO- UNICEF JMP definitions Percentage of pupils enrolled in early childhood development programs providing basic drinking water adequate sanitation and adequate hygiene services Percentage of beneficiaries using hospitals, health facilities, and clinics providing basic drinking water, adequate sanitation, and adequate hygiene
12 Moving the equity needle for handwashing: P 4 + R Handwashing-related policies are few and far between. Universal access to handwashing facilities can only be achieved if regulations are enacted and matched by enforcement. All stakeholders must uphold the need for improved hygiene as a core public health and wellbeing function. Unfunded mandates will not do. Affordable options are needed to facilitate handwashing with soap for all. Policy Prioritization Pricing While infrastructures can be mandated, individual behaviors cannot. Efforts to change behavior must target those at highest risk of hygiene-preventable disease. Promotion Changing behavior is difficult. We need to understand better how to foster habits, how to change social norms, and which interventions work. Research
13 Acknowledgements Swapna Kumar Libbet Loughnan Rolf Luyendijk Orlando Hernandez Fred Arnold Attila Hancioglu Therese Dooley
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