Besides awareness of known needs for cultural embeddedness, future behavioural change approaches for promoting frequent hand washing may benefit from adopting business strategies, including partnering with existing institutions and leveraging shared ambitions to deliver corporate social responsibility.
Hand hygiene is critical for reducing transmission of communicable diseases, as we are so acutely aware during the COVID-19 pandemic. UNICEF has identified behaviour change and knowledge promotion as top strategies for increasing hand washing during this crisis, while acknowledging that millions of people lack the water necessary for handwashing.
An estimated 40% of households globally lack access to basic hand washing facilities. A recent cross-cultural study of household water insecurity experiences found that nearly one in four of 6,637 randomly sampled households across 23 sites in 20 low- and middle-income countries (LMICs) were unable to wash their hands in the previous month. These challenges are not unique to LMICs. Indeed, many poorer families in high-income nations experience similar water, sanitation and hygiene (WASH) problems.
In the spotlight of the current COVID-19 pandemic, this Comment explores the challenge of hand hygiene in a changing water world and reflects on the importance of making rapid progress to “ensure availability and sustainable management of water and sanitation for all” (United Nations Sustainable Development Goal (SDG) 6). We contest that solutions to combat the spread of infectious disease, including COVID-19, must consider household water insecurity as a function of water availability, quality and accessibility. Drawing on the latest evidence, we provide recommendations on how to improve human health and well-being during a pandemic by reducing household water insecurity.
Although the blue planet is 70% covered by water, only 3% is freshwater (of which 70% is snow or ice, or otherwise unavailable for human use). Furthermore, available freshwater is unequally distributed geographically in space and time, such that an estimated four billion people experience ‘severe water scarcity’ for the duration of at least one month every year, causing difficulties for hand washing and sanitation. Challenges with availability are projected to become more widespread and acute due to climate change and associated increases in hydrological extremes (such as floods and drought), as well as changed water demand due to population growth, displacement, intensification of agriculture and infrastructure degradation7.
While it is more obvious how droughts reduce water availability, there is increasing recognition that flooding can reduce the availability of clean water due to, for instance, storm-induced contamination from combined sewerage overflows polluting rivers and groundwater resources. As a result, water may be unsuitable for consumption or hygiene due to contamination by multiple chemical or biological pollutants (for example, pathogens, viruses, bacteria and protozoa) that present immediate risks to health. For example, hand washing with polluted water may increase the risk of contracting enteric infections that can cause diarrhoea, which is a proximate driver of under nutrition that can exacerbate a range of morbidities. The majority of the annual 1.7 billion cases of childhood diarrhoeal disease, the second largest cause of death for children under five, are related to poor water quality, highlighting the severity of water insecurity consequences. Furthermore, intensive hand washing, especially with contaminated water, can cause skin lesions that serve as conduits for waterborne infectious agents such as bacteria or viruses, as well as chemicals and allergens, to enter the bloodstream. Thus, poor water quality can undermine an individual’s ability to resist or recover from infectious disease through numerous pathways.
The anticipated inability of many households to follow World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) guidelines during the COVID-19 pandemic reveals that major investments in both water infrastructure and water governance are critically needed to manage and provision water to ensure safe hand washing.
A Guest Editorial