It's a wash: Hands-on hygiene in Peru

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Science  12 Sep 2014:
Vol. 345, Issue 6202, pp. 1262-1263
DOI: 10.1126/science.345.6202.1262

A simple fix proves elusive.

Mass hand-washing campaigns in Peru did not cut disease as anticipated.


Few public health interventions promise an easier payoff than getting people to wash their hands with soap. It's easy, and studies suggest it could prevent up to two-fifths of all diarrheal disease and one-fourth of pneumonia, the two biggest childhood killers in poor countries, saving up to 1 million lives every year. With hand-washing, there's none of the controversy surrounding condoms and birth control. Yet despite decades of effort and millions of dollars, only between 3% and 34% of people in poor countries regularly wash their hands. Simple routines, it turns out, are not always easy to instill.

In 2008, the Peruvian government, with support from the World Bank and the Bill & Melinda Gates Foundation, launched a media campaign called “clean hands, healthy children” to improve hygiene in 40 randomly selected districts across Peru. Radio spots, brochures, and posters, targeted at millions of mothers and children, stressed the importance of washing hands after going to the toilet or changing a baby and before cooking and eating. In 44 more districts, the media campaign was launched together with further interventions: Primary schools added hand-washing lessons, and teachers and local leaders educated mothers. More than 80,000 simple hand-washing stations designed by the company Duraplast and fashioned out of old plastic bottles—one filled with water and one with soap—were distributed to households. The campaign even introduced a cartoon superhero, Super Jaboncin, who fights germs using water and soap.

But the results were far from superpowered. A 2012 evaluation found that the media campaign alone did not change behavior at all. In communities with the more intensive interventions, hand-washing before food preparation increased from 10% to 17%. But researchers did not find a decrease in either diarrhea or pneumonia. (A campaign in Vietnam had similar results.)

That is not surprising, says Valerie Curtis, who directs the Hygiene Centre at the London School of Hygiene & Tropical Medicine. “You have to get a fairly large behavior change to pick up a significant health effect,” she says. And that is a lot harder than it sounds.

Partly, it's a question of timing, says Jacqueline Devine, who was involved in the project at the World Bank. People are more likely to adopt new habits during major life changes, so, for instance, targeting women expecting their first child might be more effective than trying to influence all mothers and children, she says.

The bigger problem is that long-term health considerations do not drive behavior, Curtis says. What does are things like love, fear, and wanting to be accepted and admired—to “look sexy,” Curtis says. “Most of what we do is not a rational response to a perceived threat.” Public health messages that engage disgust, like “soap it off—or eat it later,” might have a better chance of sparking behavior change, she says.

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