Efforts to improve handwashing do not always include basic access to soap and water
The lack of hand hygiene causes 740,000 deaths annually from diarrhea or respiratory infections
But, despite global recognition of its importance, governments are slow to act on hand hygiene
The lack of soap is the most frequently reported barrier to effective hand hygiene — fundamental to curbing the spread of infections — in shared community spaces, such as households, schools, and public places, according to a systematic review of available research published in the open-access journal BMJ Global Health.
The review found that the barriers most frequently reported related to physical opportunity, such as the availability of soap, and to a lack of motivation — hand hygiene not prioritized or routinely practiced, for example. On the other hand, the most frequently reported facilitators aligned with motivation in the form of habitual practice and perceived health risk.
Another analysis found that most of the efforts reported to improve handwashing did not always address the barriers or facilitators identified to ensure behavioral sustainability, nor did they fully consider the fundamental resources required for hand hygiene, such as soap, water and handwashing facilities.
“If environments still lack these critical components for hand hygiene, interventions aiming to improve hand hygiene purely through motivation, social pressure or increased knowledge should be reconsidered,” the authors say.
The reviews are part of a set of five, published in a special supplement of the journal, which served as the basis for the World Health Organization (WHO) and UNICEF guidelines on hand hygiene in community settings, to be published on 15 October, World Handwashing Day.
The guidelines were driven by the many inconsistencies and the lack of solid evidence to support some of the practices recommended in the current global handwashing guidelines.
The systematic reviews focus on the effectiveness of methods to remove pathogens from hands; minimum material requirements; behavioral factors; strategies to improve handwashing; and the effectiveness of government measures.
The review that analyzed what works best to remove and inactivate pathogenic agents found that most of the evidence evaluated the capacity to reduce bacteria; only 4% of the studies addressed enveloped viruses, such as influenza, HIV, respiratory syncytial virus (RSV), and human coronaviruses, and even fewer focused on other pathogens such as fungi and protozoa.
Other knowledge gaps included soap alternatives commonly used worldwide, such as sand and ash; optimal drying methods; and the impact of water contaminated with microbes.
“To formulate solid recommendations for handwashing methods, especially considering viral pandemic diseases and constraints on community resources, it is essential to conduct more research that describes the efficacy and efficiency of a wider range of methods,” the authors emphasize.
In a related commentary, Joanna Esteves Mills, of the WHO’s Water, Sanitation, Hygiene and Health Unit, notes that hand hygiene not only protects health and reinforces community resilience but also reduces pressure on health systems, saving resources needed for other health priorities.
It can also reduce the need for antibiotic treatment, thereby decreasing the spread of antimicrobial resistance and the deaths and health costs associated with it, she adds.
However, “despite international recognition of its importance, global progress on hand hygiene has consistently failed to meet commitments and policy promises,” she writes.
“There have been gains — between 2015 and 2024, 1.6 billion people gained access to basic handwashing facilities — but in 2024, 1.7 billion people still did not have handwashing facilities with water and soap at home and 611 million did not have any handwashing facilities at all,” she adds, citing the latest figures from the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene.
“Achieving universal access by 2030 [a Sustainable Development Goal] would require doubling the current rates of progress, increasing by 11 times in the least developed countries and 8 times in fragile contexts. Meanwhile, each year, 740,000 people die from diarrhea or acute respiratory infections that could have been prevented with hand hygiene,” she notes.
According to the official, the evidence from all five systematic reviews points to three fundamental principles:
- Access to water and soap and/or alcohol-based sanitizers are minimum material needs that should be the first priority of any government
- People need to know why, when, and how to wash their hands
- A physical and social environment conducive to encouraging and sustaining practice. In other words, an environment that is convenient, attractive, with easy-to-use facilities that meet social norms
Although governments and international institutions often mobilize rapidly during disease outbreaks, afterward budgets are cut, preparedness plans become dormant, and political attention shifts to other issues, she says, creating a “cycle of panic and neglect.”
To break this cycle, governments need to strengthen systems that can incorporate hand hygiene into broader health initiatives. But strong leadership will be required, she insists.
“More importantly, political leadership requires sufficient investment to promote change. Although they are economical and relatively simple, hand hygiene interventions are not always low-cost. In particular, water supply infrastructure requires investment. Governments should not rely on emergency budgets, incorporating hand hygiene funding into annual health budgets,” she concludes.
