Putting the fun into handwashing: A new approach to handwashing promotion for children

Author: Julie Watson

The burden of infectious diseases is high in humanitarian emergencies. Overcrowded living conditions, a lack of access to safe and sufficient quantities of water, sanitation, and basic health services, increased exposure to disease vectors, and food insecurity all create a fragile and highly contaminated environment, ideal conditions for disease transmission. Diarrhoea is particularly common in these settings and can cause up to 40% of all deaths in emergencies (Connolly et al., 2004).

The simple acting of handwashing with soap can prevent disease transmission and save lives, and systematic reviews have shown the benefits of promoting handwashing among adults and children (Ejemot-Nwadiaro et al., 2015). In fact, handwashing with soap is one of the most cost-effective public health interventions and is particularly successful in reducing diarrhoea and respiratory infections, such as influenza (Jefferson 2011). The provision of soap is also one of the WASH (water, sanitation and hygiene) interventions that may produce benefits in the growth of young children (Dangour 2013).

Yet, despite the scale of the problem and the potential benefits, handwashing practice in humanitarian emergencies remains low, especially among children. Numerous agencies deliver hygiene promotion to both adults and children across humanitarian emergencies, but interventions have had little success thus far.

One of the problems in humanitarian emergencies may be that traditional handwashing interventions for children have mostly focused on schools and fail to reach many out-of-school children. They have used education-based messaging which requires skilled health workers who are typically overstretched or undersupplied in emergency settings and messages have focussed on the health-related risks associated with germs, despite evidence that health is not a strong motivator for behaviour change. We need to find new ways to improve handwashing that are both effective and easy to implement in these challenging contexts.

Earlier this year, with a grant from the Humanitarian Innovation Fund, the London School of Hygiene and Tropical Medicine, together with Save the Children and Field Ready, conceived and tested, for the first time in a humanitarian setting, a motivation-based handwashing promotion intervention for children. This involved a modified soap bar and minimal, non-health-based, messaging.

We conducted a controlled proof-of-concept study in an internally displaced persons’ camp in Kurdistan. Children in forty households in the camp received five transparent soaps with a toy embedded inside, which was delivered in a short household session. The intervention was designed to require little formal training of the implementers, making it rapidly deployable. It was also delivered directly to households, to reach children both in and out of school. The concept was simple; the more the children washed their hands with the soap the faster they could reach the toy inside. In the control group, children received five plain soaps delivered in a standard health-based handwashing intervention.

We observed handwashing before and after the intervention and found that, after a month, children who received the toy-in-soap intervention were four times more likely to wash their hands with soap than if they had not received this intervention, based on comparison to the control group.

These results are very promising and suggest that this intervention has the potential to have a large public health impact in vulnerable populations during humanitarian crises. However, it’s still early days. Further research is needed to determine whether the intervention will be sustainable over time and whether it will work as well in other humanitarian contexts.

If you’d like to read more about our study, you can access the full report here.


Connolly MA, Gayer M, Ryan MJ, Salama P, Spiegel P, Heymann DL. Communicable diseases in complex emergencies: impact and challenges. Lancet 2004; 364:1974-83.

Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, et al. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database of Systematic Reviews 2013;(8):CD009382.

Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. Cochrane Database of Systematic Reviews 2015;(9):CD004265.

Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2011;(7): CD006207.

About the author: Julie Watson is a researcher in the Environmental Health Group at the London School of Hygiene and Tropical Medicine. Her current research explores the relationship between water, sanitation, hygiene (WASH) and health, and she is particularly interested in designing and evaluating innovative approaches to improving health in developing countries through behaviour change interventions. Recently, her work has focussed on WASH in humanitarian crises, in particular in humanitarian camps across Myanmar and Iraq.