An Assessment of Handwashing Promotion in South Asia during COVID-19

"Evidence generation on the impact of behaviour change campaigns and advocacy for continued resourcing and implementation of hygiene campaigns must be prioritised to ensure progress made to change behaviour is not rolled back."

During the response to the COVID-19 pandemic, governments and development partners in South Asia (and elsewhere) have been promoting handwashing with soap through mass and social media campaigns and other channels. To assess national campaigns in order to provide feedback to inform and guide ongoing hygiene responses, WaterAid conducted rapid research studies in Bangladesh, India, Nepal, and Pakistan. The purpose was to collect real-time information on the reach and effectiveness of these campaigns, with a focus on those who are hardest to reach and in more vulnerable settings. Full details of the research are available in separate reports for each country; see below. In addition, the regional synthesis report, summarised here, presents common findings, highlights where differences occur, and puts forward a series of policy and programme recommendations for actors involved in hygiene behaviour change.

At the time of data collection (May 13 - June 12 2020), a strict lockdown was still in place in Bangladesh and Nepal; in Pakistan and India, the nationwide lockdown had shifted to regional and local lockdowns in hotspot areas. The study comprised: (i) household interviews, based on a structured questionnaire - given the need for rapid and timely insights, relatively small sample sizes were used ranging from 111 to 797 per country; and (ii) between 8 and 15 key informant interviews with local government, partners, community leaders, and health workers in each country.

Key findings include:

1. The overall reach of mass media campaigns has been very high, with the majority reporting having received messages about handwashing in the past 15 days, multiple times, and from a wide range of sources. For example, in India, the proportion of people recalling a message relating to handwashing was 67%.
2. The main sources of information on handwashing were television, social media, family/friends/neighbours, and mobile phones. Only a small proportion received information from radio (with the notable exception of Nepal) and from printed media (newspapers, leaflets, billboards). Unpacking some of these findings, WaterAid notes that, in some countries, exposure to messages through social media was much lower amongst some groups, e.g. only 6.5% in Bangladesh's urban slums. Also, the finding about face-to-face messaging channels underlines the importance of communication between peers who are (presumably) a trusted source and who also provide two-way dialogue to question and discuss messages being promoted. At the same time, it could result in some instances in the spread of inaccurate information or rumours. In fact, a key informant in Pakistan noted that some clerics spread false rumours relating to COVID-19, which suggests the need to reach out to them to provide accurate information. Religious leaders can have a significant influence on people's behaviour, and their role could be encouraged more in the next phase of the response.
3. While the majority of respondents reported that handwashing messages were clear, those who said they were not cited reasons including: too many different messages, illiteracy, font was too small, blind/partially-sighted, too busy to read/listen, or message didn't seem relevant.
4. Knowledge on washing hands using both soap and water, and for at least 20 seconds, was very high.
5. However, the study identified gaps - in particular, awareness of critical times for handwashing to protect against COVID-19 transmission, exposing the limitations of mass media campaigns in communicating new and more nuanced behaviour. Key times may be poorly understood without accompanying support - for example, training by community health workers.
6. Immediate behaviour change has primarily been triggered by fear, which may not be sustained as the risk (or perceived risk) of COVID-19 reduces. It is essential that large-scale hygiene promotion continues and applies different emotional triggers to motivate hand hygiene practice and sustain behaviour change.
7. A significant proportion of some marginalised and vulnerable communities face challenges in washing their hands at home. Access to a reliable water supply, affordable soap, and accessible handwashing devices needs addressing.
8. In public places, handwashing facilities frequently do not exist or are non-functional; this will require substantial financing and appropriate management models to rectify, facilitating good hand hygiene outside the home.

The report offers a series of recommendations; for example: Hygiene campaigns should be designed to reach the most marginalised, who may not be able to access mass media, digital, or social media campaigns, and those who are most vulnerable to COVID-19, including people with disabilities, the elderly, young children, and those living in remote or hard-to-reach areas. Messages need to be adapted to accessible formats and demonstrate behaviours that are achievable (e.g., for people with limited resources, in high density areas, or with different impairments). Communication styles and media need to be appropriate to different ages so that they reach, are understood by, and motivate behaviour change across different groups. People representing different marginalised or vulnerable groups must be involved in the design of such campaigns.

The regional synthesis and individual reports are available as follows:

• An Assessment of Handwashing Promotion in South Asia during COVID-19 [27 pages, PDF]
• Hygiene Messaging and Practice during COVID-19: Rapid Assessment on Effectiveness and Sustainability in Bangladesh [38 pages, PDF]
• Hand Hygiene for COVID-19 and beyond in India: Insights and Recommendations from a Rapid Study [17 pages, PDF]
• Rapid Research on Handwashing Promotion during COVID-19 Pandemic in Nepal [89 pages, PDF]
• Rapid Assessment of Handwashing Practices in Pakistan during COVID-19 [49 pages, PDF]