by Carlita Bevege, Evidence Action
When Global Handwashing Day was introduced 12 years ago, hand hygiene didn’t feature much in everyday conversation outside of the global health and WASH (water, sanitation, and hygiene) sectors.
COVID-19 has changed this. Now, messages on the importance of handwashing are mainstream, and nearly everyone who has access to a television, radio, or internet browser knows we should be singing happy birthday twice while washing our hands.
And yet, for those living in extreme poverty, significant barriers to effective handwashing remain.
Worldwide, one in three people lack access to safe drinking water, and two in five to a basic handwashing facility. Before the pandemic, unsafe water and poor sanitation and hygiene already claimed the lives of 827,000 people each year – and now, UN experts are warning that COVID-19 simply will not be stopped without clean, safe water.
Evidence Action’s Dispensers for Safe Water program provides over 4 million people in rural Kenya, Uganda, and Malawi with access to safe drinking water for just over $1 per person, per year. Underpinned by Nobel Prize-winning research, the program is recommended by The Life You Can Save, Charity Navigator, and GiveWell.
Dispensers for Safe Water is not a one-time hardware installation. Our maintenance and supply chain ensures our dispensers are always working, and we engage over 54,000 volunteer promoters, who are elected by their communities to stock, maintain, and guide the use of their local dispenser. In addition, our dispensers eliminate the need to boil water, allowing users to avoid hazardous indoor air pollution while reducing their carbon footprint.
When COVID-19 lockdowns began taking effect in March 2020, our Dispensers for Safe Water team rapidly compressed three months’ worth of program deliveries into just two weeks to ensure the communities we serve would have uninterrupted access to safe water if logistical networks shut down.
At the same time, we purchased soap and disinfectant from suppliers in major cities, and rented a fleet of trucks to transport them to our field offices. From there, our circuit riders – using motorbikes to reach even the most remote villages – passed the supplies on to our promoters.
We also conducted training for promoters on COVID-19 symptoms and prevention strategies (such as good handwashing practices and social distancing), and worked with them to identify frequently touched places in their area. Promoters then took responsibility for disinfecting these surfaces 3–4 times per day, and for distributing soap and key messages to households in their community.
Between March and July 2020, we delivered over 924,000 liters of chlorine for treating drinking water; over 3 million kilograms of soap for handwashing; over 99,000 liters of disinfectant; and nearly 44,000 informational stickers to promote good hygiene practices.
We are now focused on repairing and replacing dispensers and replenishing chlorine stocks after the initial COVID-19 disruptions. By the end of October, we will have repaired or replaced over 5,000 dispensers and delivered approximately 500,000 liters of chlorine; this will keep all of our 27,000 dispensers stocked and able to provide safe water until the end of January 2021.
Evidence Action’s COVID-19 response has been quite different from our standard approach to scaling high-impact and cost-effective programs. In line with our commitment to ‘thinking big and acting urgently’, we quickly pivoted to address critical gaps – and we’ve had to adapt our monitoring and evaluation approach accordingly.
Our monitoring protocols usually entail conducting household visits to collect information and test water samples for the presence of residual chlorine (households that test positive are assumed to have treated their water with chlorine from the dispenser). During the pandemic, we’ve had to limit in-person data collection to reduce the transmission risk for our staff and communities.
In addition, a lack of widespread COVID-19 testing in our catchment areas means we’ve had to rely on proxy measurements, such as self-reported incidences of respiratory symptoms. Though self-reported data may carry a ‘social desirability bias’ (respondents over-reporting socially desirable behavior), we have determined that this is the safest and most appropriate data collection method in the context of COVID-19.
Our Monitoring, Learning, and Evaluation team is conducting a correlational and trend analysis of self-reported behaviors, and validating these by comparing them to self-reported data on the incidence of respiratory and other COVID-19 symptoms. As part of this, they have conducted phone interviews with a sample of 451 promoters and 1,757 households in Kenya; 290 promoters and 1,104 households in Uganda; and 281 promoters and 1,106 households in Malawi.
Preliminary data indicates high levels of knowledge of handwashing with soap for 20 seconds as a prevention strategy, and most households reported our promoters as key sources of COVID-19 messaging. However, we are seeing a gap between high rates of handwashing knowledge and lower rates of effective handwashing practice. We’re continuing to investigate why this might be, including through additional data collection and analysis, and hope to have more to share soon.
Nonetheless, the rates of effective handwashing are considerably higher than those shown in recent Demographic and Health Surveys from the same areas; there may be an opportunity here to explore possible drivers of this behavior change, and whether these gains could be sustained beyond the COVID-19 crisis. In any case, it’s clear that Global Handwashing Day’s mission to increase awareness and understanding about the critical role of hand hygiene in disease prevention remains as salient as ever.