Handwashing awareness campaign - Does it work?

The national hygiene survey report released in 2014 showed that in Bangladesh nearly 60 per cent of the households do not have facilities to wash their hands with soap after toilet. Of the 40 per cent households having handwashing facilities with soap and water, children lack intention to wash their hands. The report further shows that only 35 per cent of the schools have handwashing facilities with soap and water. Nearly one-third of the restaurants in the country have arrangements for workers to wash hands with soap and water after toilet. More interestingly, while 90 per cent of the hospitals have toilets with soap and water, the survey says between 2-29 per cent of the users actually use soap to wash their hands after toilet. The picture is of great embarrassment for the country and hence there is a need to find a way to change our habit. However, some of us might find their solace that this is not the problem of Bangladesh only. The whole world has this problem and so every year on October 15 the world (mostly developing countries) observe the World Handwashing Day.
This year it has been observe throughout the world -in developing countries - with the slogan 'Our hands our future!" Not sure whether any of these people understood this but quite a large number of NGOs, and private organisations along with the governments of the world used this 'occasion' in a mood of festivity. The festivity of Lifebuoy was the most dramatic. It has created a world record for Bangladesh and made its way into the Guinness World Records Book for forming the "Largest Human Image of a Hand" with 11000 students in the playground of Dhaka's Residential Model School. Understandably, some of the comments on facebook on this news was not very friendly! It had, however, 1300 likes.
Durnibar Foundation, an NGO (non-government organisation) organised a half-day programme on this day and distributed kits for handwashing in Dhaka slums. Their public announcement was posted on their facebook page. 139 persons linked it - according to their webpage - and 113 showed up in the programme. The page has more than 29,000 followers. Another network called 'Global Handwashing Day Celebration Network in Bangladesh' had 700 followers while they had only four to 11 likes on their handwashing day poster! Another organisation called Water and Life hired 100 students from four schools in Dhaka and went to Bhashantek slum to make the people aware about handwashing benefits. There are many other NGOs, INGOs and also the government of Bangladesh which organised 'colourful' rallies to celebrate the day in Dhaka and elsewhere in Bangladesh.
All these events (and there are many others!) are mentioned here to pose few questions? While we are now in the Guinness Book of Records and many 'learned' people and 'busy' officials attended the rally - did it change our habit? What is the impact of organising such events? Clearly there is a cost of doing all these! Imagine, simply, how much money we spent to organise these, the amount of money used to advertise the day on radio, television, and newspapers?What benefits did it bring in terms of changing our habit?
In Bangladesh, the largest number of infant deaths happen due to pneumonia and diarrhea before the age of 5. This problem is severe, the solution is simple - improve hygiene conditions at home. It is killing 55 of every 1000 children born in Bangladesh. On this day, you might have noticed many banners and festoons on the streets and roads across the country. I have no idea about the money spent on this occasion but I can assume it is more than a six digit figure. Few benefits from such expenses are, however, clearly evident - a) lifebuoy became a champion, b) Bangladesh entered the Guinness Book of Records for the second time, and c) many ad-firms and marketing companies earned their profits. Few years ago, while I was driving by the Residential Model School on Mirpur Road in Dhaka, I noticed a poster pasted on the wall of the school facing the PM's official home - Ganabhan about the handwashing day. Who is the poster addressing? The PM? Why is this poster pasted here? There is no slum here. It is not even in front of the school gate! Similarly, I often wonder why the rally in front of the Press Club? Whom they are making aware? Will the slum people read the newspaper next day?
I decided to ask one of my students Shampa Rozario to do her research on impact of the awareness campaign on handwashing in 2014. It was not an easy task for a student of her age to do this research, because I asked her to work on the following questions. What type of handwashing awareness campaign can change people's habit? We found that despite all of these so-called day-long programme on October 15, the handwashing awareness campaign is not observed on one day in Bangladesh and that many other organisations in Bangladesh are working on this in slums. We haveunderstood that there are three broad methods used for raising awareness in the slums. These are: a) using handouts/posters; b) using video programmes/dramas and c) conducting campaign using microphone, loudspeakers, etc.
Shampa used the same campaign materials used for them and decided to conduct an experiment in three slums in Dhaka. In the first slum, she used the Meena video to make the families aware about washing hands before taking food and after using the toilet. In the second slum she went to families and explained (verbally) the benefits of washing hands and in the third slum she provided a poster with pictures on how to wash hands and the benefits of handwashing. The poster was pasted on the wall of their houses. In order to show that the water they use is full of bacteria - she also collected water samples from each of these houses. After a week of culture, she brought back the bottle of water to the same houses and showed them what was in the water. Then she campaigned hoping that after seeing the bacteria they will change their habit. The result we found was amazing and might surprise many of you.
We had two questions: a) Did the family change their habit of handwashing before taking food after watching the water quality and listening to the campaign? b) Did the family change their habit of handwashing after using toilet? We went back to them after 30 days in order to understand whether they changed their habit of handwashing or not. The reason we used a 30-day gap was to find out whether the change was a lasting one - meaning whether they continued to do so even after a month. On the first question - we saw that of the 100 households involved in the experiment only 9.0 per cent changed their habit and started washing their hands before taking food. On the second questions we also found nearly 11 per cent of the families started washing hands after toilet due to her campaign. We were very happy! However, the key question remained unanswered. Which of the campaign materials was the most effective one in terms of changing the habit? Due to many other factors including the habit of watching TV, access to radio, household size, education of the children and few other socio-economic ones, we found something that we were not expecting! In changing the handwashing habit before taking food, the video campaign was the least effective one. Verbal communication using the door-to-door campaign was 12 per cent more successful in changing the habit compared to video campaigns. The most successful campaign, however, was the "poster" which was pasted on the wall inside their house where children can see it regularly and perhaps during taking their food. Compared to the video campaign the success rate was 47 per cent more effective. This was a surprise for us because we just realised that compared to audio or even a Meena video the age-old poster was found to be the most effective one. It was the least costly of all and was less 'modern' compared to other campaigns. We also observed that the families living in these slums in Dhaka had no clue about the International Handwashing Day! This kept me wondering about our festivities in celebrating the international handwashing day. We realise that in countries like Bangladesh, facebook-based campaigns are not for the slums and posters and festoons on major streets are useless! Press Club-based rallies have no real meaning to millions who need to know about it! The largest hand and its publicity on TV have no meaning! The posters on their walls are the most effective means of communication to the poor people in Bangladesh. These were effective because they were in front of the children which they continue to see for a month or more. It could also save millions from taxpayers' money. Effective communication may not always be the smartest communication of the 21st century!

Dr. AK Enamul Haque is Director, Asian Centre for Developmen,t and Professor of Economics, East West University.
akehaque@gmail.com