SA's hand hygiene strategy: The COVID-19 curve ball

In South Africa, the government’s earliest response to COVID-19 prioritised the protection of specific population groups and spaces. Children and young people in educational institutions were the first groups to have their main activity, school and tertiary learning, disrupted by the pandemic. One of the key interventions to curb the spread of the virus is the handwashing campaign, which is based on the Department of Health’s National Hand Hygiene Behaviour Change Strategy 2016-2020. Dr Mokhantšo Makoae, Tsidiso Tolla, Prof Charles Hongoro and Dr Emmanuel O. Sekyere analyse the strategy and argue that it may have some challenges.

Photo: Gelani Banks/Unsplash

The South African government’s national COVID-19 response is guided by the Constitution, which describes certain groups as vulnerable, including children. This is despite some emerging evidence that children may not be particularly susceptible to the coronavirus infection, related morbidity and mortality. Additionally, the government relied on international and national policy frameworks, which require collaboration across the health, human settlements, education, sanitation, water and hygiene sectors, as well as collaboration from business and families.

The World Health Organization (WHO), as provided for by the 2005 International Health Regulations, has the responsibility “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks”. Drastic steps by the South African government have, accordingly, involved promulgating population-wide and inter-state legal instruments that target large-scale individual behavioural changes, including restriction of economic activities and mobility across spaces, maintaining social distancing, self-isolation at home; and trans-border inbound travel. To date, the decisive government response was an initial 21-day national lockdown from 27 March, later extended, which has been complemented by information-education-communication and campaigns for infection prevention, including handwashing.

The SA hand hygiene strategy
The Department of Health’s National Hand Hygiene Behaviour Change Strategy 2016-2020 was developed within the UNICEF WASH framework and supports the hand hygiene campaign as core to the COVID-19 response. Of the key actions included in the COVID-19 health-education messages, frequent handwashing with soap and avoiding touching one’s face are relevant to children. The majority of children are at home during the lockdown, some without parental supervision. Successful implementation of the 2016-2020 hand hygiene strategy is based on specific assumptions that may not be consistent with what is required from children to contain COVID-19.

The COVID-19 crisis and the emphasis on handwashing to prevent the spread of the virus could be an opportunity for society to effect immediate and sustainable behavioural changes in children. It supports Sustainable Development Goals (SDG 3) to “Ensure healthy lives and promote wellbeing for all at all ages”, which includes the target to end communicable diseases by 2030. However, as part of the national policy framework for the COVID-19 response, the hand hygiene strategy has glaring challenges that require an institutional rethink.

Touching faces
Firstly, in terms of public-health problems, the strategy seems to principally frame hand hygiene as an intervention to prevent childhood diarrhoeal diseases, which are rated the third largest cause of under-five mortality in South Africa. Although it recognises evidence that supports the effectiveness of handwashing with soap in the prevention of respiratory infections among children, its goal explicitly states: “To prevent and reduce the prevalence of diarrhoea and other diseases related to poor water, sanitation and hygiene, particularly in children under-5 years”.

The strategy relies on “critical moments” that should induce handwashing with soap, namely, before handling food or eating and after using a toilet (including after changing babies’ nappies and before feeding a child or others). Overall, it does not anticipate mechanisms of infection transmission in the case of respiratory diseases, including the risk of exposing the mucous membrane in their eyes, nostrils and mouth by children touching their own faces. The notion that people should avoid touching their faces to prevent the spread of COVID-19 is new to the public’s repertoire of maintaining health, even though it is well-documented in respiratory disease prevention literature.

Schools and mothers
Secondly, as most children of school-going age are at home during the lockdown, it is important to analyse the implementation framework of the 2016–2020 hand hygiene strategy, which identifies children and primary caregivers as the target population to develop the habit of handwashing with soap. At the household level, it emphasises mothers’ and fathers’ traditional gender roles as carers and providers, respectively. They are expected to be the change agents who introduce and support hand hygiene. Schools and early-childhood-development centres are also key in the implementation framework.

In practice, the locus of implementation is educational institutions and evidence of community-level implementation is lacking. Mothers are explicitly targeted for preventing diarrhoeal infection among children under five, while schools and the health-care system are identified as settings for implementing behaviour change for older children.

South Africa is a water-scarce country and access to water and related services is uneven, despite government prioritising service delivery. However, the national response to COVID-19 suggests possibilities. The structural constraints to the implementation of the hand hygiene strategy such as poor access to water and inadequate sanitation in some educational institutions and households mean that many impoverished communities continue to grapple with the contradictions relating to their quest to save and preserve water, and the expectation to practise frequent handwashing. The implementation of the 2016-2020 hand hygiene strategy should consider that, while most households have water and soap, its priority uses may be washing dishes, bathing and laundry.

The predisposition not to wash hands with soap at critical moments suggests an internalised ranking of the uses of soap and water. Frequent handwashing with soap might be incongruent with socioeconomic realities of poor households and it may be considered a wasteful practice in resource-scarce households. Because of their developmental stage, children are closely monitored during periods of scarcity to ensure they do not waste resources, and parental vigilance is likely to intensify due to the lockdown and prevailing uncertainties.

It can be difficult for communities to redefine their relationship with water during the pandemic, and effective motivation is required to increase children’s participation in reducing the spread of COVID-19. The interventions by the Department of Human Settlements, Water and Sanitation, and distribution of bars of soap in Gauteng province demonstrate the government’s appreciation of the challenges that are faced with the implementation of the strategy and should not be withdrawn after the COVID-19 crisis has ended.

COVID-19 as catalyst
COVID-19 is catalysing institutionalisation of the UNICEF WASH programme and providing a key moment for leveraging the hand hygiene strategy. It is the final year of this strategy’s implementation in South Africa and some of the limitations and potential issues are being exposed by the COVID-19 pandemic. The temporary exodus of children from schools means that teachers cannot reach millions of children with nuanced hand hygiene education.

Many children and their caregivers will learn that touching one’s face is a possible factor in spreading respiratory infections and other nuances in the hand hygiene campaign through mass media. Longitudinal research is needed to assess the adoption of hand hygiene and its sustainability as a health-protecting habit among parents and children. COVID-19 could entrench individual and household hygiene habits, thus complementing the role of schools in this regard.

Authors: Acting research directors, Drs Mokhantšo Makoae and Emmanuel Owusu-Sekyere, and Prof Charles Hongoro (strategic lead), at the Peace and Sustainable Security unit in the HSRC’s Democracy, Capable and Ethical State research division, and Tsidiso Tolla, researcher at the HSRC’s Human and Social Capabilities research division.