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Handwashing: Part and parcel of CLTS?!

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Recently we have had a very lively debate about a number of key issues, so rather than keeping those discussions limited to emails flying back and forth between a few people, I am going to share them here.

A very lively discussion started around the subject of handwashing after someone raised the concern that handwashing does not form part of CLTS, saying that the CLTS handbook does not make (sufficient) reference to it and interpreting the manual’s passage “DO NOT LECTURE or try to educate the community about the diseases caused by open defecation, flies as agents of contamination, or the need for hand-washing at this stage” as meaning that handwashing should not be included in triggering. The person then went on to conclude that PHAST or similar tools were needed to add a hygiene component to CLTS.

Below is the e-discussion that ensued- do add your own voice, questions and examples either by hitting the Add a comment button below or by emailing me

Petra Bongartz, IDS
From my own experience of triggering and from many conversations about this with practitioners, handwashing always comes up at triggering and is an integral part of it. If the community (and the facilitator) understands CLTS and its true meaning of cutting all faecal-oral contamination routes, there is no way handwashing will be left out. And this comes up when discussing how the shit gets back to the households, when doing the water and shit exercise and also when conversations about how to stop eating shit happen and natural leaders start sketching latrine models…. more often than not, this will include a tippy tap or the like… and if it does not naturally arise out of discussions, a good facilitator, without being didactic, will steer the conversation in that direction, through pointed questions…

I really am surprised that time and again, people ask this question and assume that handwashing is not included in CLTS. For me, if you really understand the thinking behind the CLTS process, there is no way it is not a part of it.

Robert Chambers, IDS
Handwashing is widely included in triggering or comes soon after. There are ways in which this is facilitated which are not didactic (and so not like PHAST). I am separately forwarding this correspondence to Kamal Kar, Sammy Musyoki, and others to trawl for the methods that are used. The main
one is likely to be – (if you don’t wash) – the realisation that they are eating their own shit. Sammy also has something about shaking hands.

Handwashing station at a school in Awassa, Ethiopia We all agree that handwashing is very important. And incidentally recent ICDDRB research has found that the key times are after defecation, and before preparing food. Other times not found to be significant.

It is wrong to say that the only reference to handwashing in the handbook is “DO NOT LECTURE or try to educate the community about the diseases caused by open defecation, flies as agents of contamination, or the need for hand-washing at this stage”

The point is at this stage. That is absolutely vital. This is one of the DO’s and DON’TS for triggering. If the facilitator gets into a teaching mode about the need for handwashing, relationships change and successful triggering immediately becomes less likely. And in follow up too, it is important to avoid the deferential relationships that go with a teaching mode.

If you read the handbook thoroughly, you will find references to hygienic behaviour and hand washing, for example:

  • Indirectly handwashing is implied on page 34: Then ask how shit then gets into the mouth. For example: Hands, fingernails…
  • Page 49: In South Sumatra, Indonesia, issues related to stopping open defecation and washing hands with soap after defecation and before food were regularly discussed in weekly Quran reading competition in CLTS triggered villages.These discussions expedited the process of achieving ODF status.
  • Page 50 …Schools also teach and reinforce hygienic behaviour
  • Page 52 …hygiene behaviour…
  • Page 54: Verification activities can or have included:… Asking how a community itself monitors hygiene behaviour change? Distinct and visible marks indicating hygiene behaviour change, e.g. soap for washing hands, water containers near latrines etc
  • Page 67 ODF is an excellent basis for progress up the sanitation ladder,
    hygiene and behaviour change,….
  • And page 69 has a photograph of handwashing, and a subtitle A community in Chencha Woreda in Ethiopia innovated this simple handwashing device. Plastic cans with perforation were used as water taps to wash hands with soap after defecation.

There is a general point for us to ponder, whether handwashing should have more prominence, and whether there should be a supplement to the Handbook. Though I am reluctant, and Kamal may be too, we have to consider this. Part of the problem is that the Handbook is now in at least 8 languages, and exists in probably over 20k copies.

Sammy Musyoki, Plan Kenya
I think the bigger challenge here is practitioners who pick a manual off the shelf or the internet and decide to apply it like a blue print without undergoing a thorough hands-on-training. It is indicated clearly that CLTS handbook is not a blue print.

In practice there is no way you can do CLTS triggering effectively and not have aspects of hand washing. In our experience and in particular in Urban CLTS, at the end of triggering people WASH their hands with soap. This practice has been incorporated because during the exercise itself people touch the ground and from the transect walk they interact with shit. The need for hand washing comes naturally and in our facilitation toolkit a Water and Soap have become essential tools. The activity at the end of the exercise naturally provides an opportunity to discuss hand washing and get people to demonstrate how to do it well. Verification is not complete without including hand washing facilities and practice of hand washing in the checklist.

The quality of participation is important, hence the need for hands-on training and not relying on manuals, and facilitators need to go beyond mechanistic application of tools or the hand book.

Philip Otieno, Plan Kenya
Handwashing facility in Kilifi, KenyaThe practitioner would wish to share his views and experience on how hand washing can be incorporated during triggering without getting into a didactic mode.

One of the tools applied during a CLTS triggering session is the flow diagram. This tool provides an environment for the community to collectively analyse the fecal-oral contamination routes. It is during this time that the CLTS facilitator will get an opportunity to create sensitization on the importance of hand washing without explicitly teaching/lecturing the community.

An astute facilitator will conduct the session by asking questions, which will enable the community to reflect on the undesirable practices and hopefully trigger the community to take the appropriate action. The session comes after transect walk and the shit calculation have been done, and the community has also openly accepted/acknowledged their practice of open defecation.

The session normally goes like this:-
Facilitator: What do you commonly use to wipe your anus after defecation?
Community: (They provide different answers such as stones, leaves, maize cobs, sticks, papers, grass etc)
Facilitator: When wiping your anus, is there a possibility that your hands could come into contact with shit?
Community: Yes
Facilitator: When you are walking back home or to other commitments that you have, after defecation, do you meet people on the way?
Community: Yes
Facilitator: What is the first thing you do once you meet them?
Community: WE shake hands!
Facilitator: When you shake hands with someone who has come from defecation but did not wash his hands, what do you think you most likely pick from his hands?
Community: Shit (At this point some people may be reluctant to answer the question out of shame and disgust, as it is a common practice where open defecation is rampant for people not to wash hands immediately after defecation).
Facilitator: When you meet a friend eating (use suitable examples that the community can relate with. (Common examples in rural villages include maize, groundnuts, sugar cane, oranges, boiled potatoes, etc) and he shares that food with you, do you accept?
Community: Yes
Facilitator: Would you know whether this friend went for defecation but did not wash his hands?
Community: No
Facilitator: When you eat the food he has given you with “unclean” hands, what else do you eat?
Community: Shit (at this moment some people may be reluctant to answer the question due to shame and disgust).
Facilitator: What do you eat, when you eat food with unclean hands?
Community: Shit

This kind of facilitation has two effects. The first is that it creates shame and disgust about walking around with unclean hands, and secondly it sensitizes the community on the risk they expose themselves to when they don’t wash their hands. In effect this directly implies the importance of hand washing after defecation and before eating.

However, it will be noticed that the facilitation is done in a manner that does not directly teach or ask the audience to practice hand washing. The audience is left to discern on their own, from the questions posed, that they are at risk of ingesting their own or other people’s shit if they do not practice hand washing.

Jolly Ann Maulit, EWB Malawi
This is indeed an important topic and something that we have also discussed in Malawi.

One of the things that was contentious when writing our ODF Malawi 2015 strategy (to scale up CLTS and other approaches) was whether to include handwashing as part of our ODF criteria. Some districts included it while others did not. Some thought that it is too difficult for communities to stay motivated and achieve ODF if handwashing was included in the verification process, whereas others thought that not including it was detrimental to a community being truly ODF (completely eliminating fecal-oral transmission).

This is to say that the handbook and the CLTS process in itself can be open to various interpretations based on what people believe is more important to consider, eliminating fecal-oral route completely in one go, or slowly moving people up the sanitation ladder.

In Malawi, we decided to strike a compromise and declare 2 levels of ODF: ODF status is simply focused on stopping OD, whereas ODF++ involves not only stopping OD but including hygienic components like drop hole covers and handwashing facilities in the verification process. This aims to address the concern that people might be de-motivated if handwashing is pushed immediately for ODF, but still encourages and supports eventual movement up the sanitation ladder, the pace of which depends on each individual community.

In any case I believe handwashing is an important part of CLTS and our facilitators certainly include reflections on this issue during both the triggering and the follow-up process. I would say that they do a better job of drawing out these insights through questions posed to the community during triggering. After the triggering moment where communities realize they eat their own shit and are ignited to stop OD, the facilitators usually pose questions about their current behaviours when defecating and draw out the fecal-oral route through the dialogue.

At the triggering, we find that it’s often not hard to trigger communities into including handwashing into the behaviours they want to change, however it’s getting them to commit to it post-triggering that’s the challenge. This is why during follow-ups (before reaching ODF and even after being declared ODF), it’s important to facilitate continuous reflection and commitment to handwashing to reinforce its importance in truly becoming ODF. There doesn’t seem to be too many methods available right now to make this process happen during follow-ups which are participatory. This was realized by one of our interns, Karina Redick, last summer. To try to solve this challenge, she created a demonstration called the Shit and Shake which can be used by extension staff during follow-ups to trigger shame, fear and disgust in relation to not washing hands after using a latrine.

Do let me know if you have further questions about how we approach handwashing in Malawi or the “Shit and Shake” tool.

Handwashing station in ZambiaPhilip Otieno, Plan Kenya
As an additional point, I would wish to add that many countries include hand washing as critical factor to be included during ODF verification. The point here is that the community, the NLs and all other stakeholders become sensitive about the importance of hand washing at very early stage during CLTS process. The communities practice HW by either using soap or ash. I am still touched by how people become amazed to learn that ash is an effective alternative to soap, can also be used as disinfectant for maintaining the latrines. At one time during an ODF celebration, I was interviewed by a journalist who was pleasantly surprised, to learn that ash was a good alternative to soap. He said that this message needed to reach as many people as possible especially in the rural areas, who could not afford soap. He indeed ensured that this message was aired on three separate occasions during prime time news! This is how my own dad also learnt about using ash to maintain his pit latrine at home. He immediately called me to confirm the news! It soon dawned on me, how is easy it is for us to spread good news to far away places and totally forget our own homes. I am probably digressing. But my point is that, hand washing is critical to successful CLTS process, and it is included in the checklist for ODF verification by many countries, Kenya included, and that some communities are using locally available resources such as ash to wash their hands

Jolly Ann Maulit
Just one quick thing to note regard Philip’s latest comment on soap vs. ash
for handwashing. In Malawi we actually find that many rural households have
soap and can therefore use them for handwashing, however they prefer use
them for washing dishes or taking a bath instead. Although we still encourage the use of ash for households which really do not have access to soap, our main push with our Handwashing Campaign this year is to get the large percentage of households who already have soap to actually use them for handwashing at critical times (before preparing food, before eating,
after using a toilet, and after changing a baby’s nappies).

Date: 2 February 2012