Washing hands with soap under running water for 20 seconds or more is a critical intervention recommended for preventing the spread of COVID-19, and seemingly an easy undertaking. But like many sub-Saharan countries in Africa, where only 15% of the population has access to the most basic handwashing facilities, washing hands in Ethiopia can be a challenge, and is therefore easier said than done. When the pandemic hit, there was a big push from the government, development partners and the private sector on making handwashing facilities available, along with creating awareness through various outlets. 

Clearly, COVID-19 posed a heightened risk for people living in highly dense communities and who struggle with limited access to water, soap, and other compounding challenges (i.e. respiratory challenges). Crowded living spaces often lack sanitation facilities and populations living in these areas risked quickly becoming ‘hotspots’ for the spread of the virus throughout other areas. It was important to mount interventions that needed to identify and provide targeted WASH solutions for these hotspots early on so as to ensure reduced risk of mortality and morbidity linked to COVID-19.

Memes and short videos used on social and mainstream media incorporated messages on the importance of handwashing and application of correct techniques to fight COVID-19. The national telecom operator even has a COVID-19 message that plays every time you made a call, replacing the standing ringing tone. We also saw many remarkable innovations in touchless handwashing basins that put into consideration the challenge in water and electricity supply as well as addressing universal accessibility, including through UNDP’s COVID-19 innovation challenges.

Here at the Accelerator lab, we were curious about how this newfound push for the accessibility of hand washing facilities and awareness creations for the pandemic has contributed to hand washing practices. More importantly, we wanted to know how we might take this initial momentum to catalyse a lasting change in social norms because handwashing is a critical intervention for COVID-19 as well as other communicable diseases that still exist in Ethiopia. 

We started with a day of observation to understand the current handwashing practices in Addis Ababa after five months of the first case was reported in Ethiopia. The observation areas span across the city with the high movement of people and where public handwashing facilities were likely to be available.

During the observation, we saw different types of handwashing stations installed outside available to anyone at bus/taxi stations, government offices, public places and various service providers including banks, malls, restaurants and coffee shops etc.  We noticed handwashing devices from a bucket or water tank with faucet to pedal-operated devices and traditional sinks connected tap water. These facilities included some very basic devices made from jerricans with a small hole that is closed by a nail.

There wasn’t much message on the handwashing stations except some stickers about the sponsors or advertisements. In some places, faded lines painted on the ground guided physical distancing while queuing to wash hands. At malls and banks, guards asked patrons to either wash or sanitize their hands upon entry. At a church, there were young volunteers spraying sanitizer on hands of people entering the compound.

As much as there was availability, we noticed some broken and empty handwashing stations that seemed abandoned. In general, it looks like access to handwashing stations in the observed areas had increased noticeably while the practice seemed low.  The awareness creation campaigns seem to have trailed off as time went on.

For more focused observations on practice, we staked out an outdoor traditional coffee shop with hand washing station at the gate to see how many people washed their hand before sitting down to drink their coffee. A coffee shop might not be a place where people wash their hands regularly like restaurants, but WHO advises washing hands regularly and thoroughly after touching any frequently touched objects or surface coins and banknotes. The result was frustrating as only four customers out of a total of 187 customers washed their hands in the coffee shop in the four hours of the monitoring period.  

The Experiment

Using the opportunity presented by COVID-19 on the availability of handwashing facilities, we wanted to look at how to create a lasting behavioural change on handwashing practices that will serve us beyond the pandemic.  The lab's experiment tested the following hypothesis.

If we promote a well-designed and user-centred hand washing stations, then people are more likely to wash their hands.

·      If we post a message about handwashing on handwashing stations, then people are more likely to wash their hands.

·      If we post messaging that elicit an emotional response, then people are more likely to wash their hands.

The team tested two different types of handwashing stations and three messages with each device. We used the same traditional coffee shop from our observation to experiment, in consultation with the owners. We placed the handwashing facility at the entrance of the coffee shop where it was visible and accessible to clientele. The experiment was based on observation at peak hours of the coffee shop from 10 am –1:30 pm for ten days to capture the experience of hand washing.  

Key observations

· In general, there was a low level of handwashing practice regardless of the type of handwashing stations and messages used, with only 83 of the total 2,003 customers observed washing their hands.

· Text-only messages got the greatest number of handwashing compared to those with only pictorial messages.

· People responded better to the commanding message than the emotional or informational messages. 

· The number of customers who washed their hands increased with the new pedal-operated handwashing station. 

· We didn’t see a consistent pattern on the effects of our messages between the two devices. While messages used on the regular hand washing station increased the number of hand washes, the pedal-operated handwashing stations didn’t show as much improvement. (see numbers below)

· People follow and wash their hands when they see other customers washing their hands.

· 74% of the customers who washed their hands followed the WHO recommendations of washing hands.

What Is Next?

We need to build on the opportunity the pandemic presents on making hand washing facilities accessible and continue the legacy of COVID-19 on improved handwashing practice. Moreover, we have seen that availing handwashing facilities alone is not sufficient to improve handwashing practices. People who wash their hands showed that they had the awareness and determinations to do so because they followed the guidelines. It had to do more with what they wanted to do (wash their hands) rather than what was available for them. Therefore, while access is important, awareness and knowledge are much more powerful drivers for people to wash their hands. Once we get people wanting to wash their hands, they will find the facilities to do so. Therefore, continuing the awareness creation activities on handwashing will create sustainable markets for the entrepreneurs manufacturing and selling hand washing devices. 

Finally, we have learned that appropriately designed handwashing devices can contribute to improving handwashing practice, but it needs to be supported by behavioural change communication and messaging. In other words, design and implementation of behavioral change initiatives on a continuing basis is key. From our experiment, we saw that messaging on the devices helped increase the number of people who washed their hands, and it is a low-cost way communication method. We recommend co-designing behaviour change communication and awareness creation tools with the community to not only improve buy-in but also build a sense of community ownership. 

The lab will leverage the partnership between UNDP and Dalberg Catalyst on the Safe Hands Ethiopia coalition on COVID-19 to scale up the learnings from our experiment. The coalition brings together the private sector, government and civil society to provide information for vulnerable communities and provide sanitary materials by aligning the private sector’s production of sanitary products with the distribution capacity of the government. The lab will leverage this partnership to share learnings with all relevant stakeholders, including local innovators benefitted from our challenge grant.