Strategy of Making Hand Washing a Routine Habit: Principles of 5Es and 3Rs

  • Nirmal Kandel Public Health Specialist, Geneva, Switzerland
  • Jaya Lamichhane Monitoring and Evaluation Specialist, Geneva, Switzerland
Keywords: hand washing, routine habit, principles of 5HEs and 3Rs, educationa intervention, school


Regular hand washing habit has potential to reduce morbidity and mortality due to diseases and improves child development and reduces absenteeism of children, teachers and workforce. Improving hand washing behavior is more cost effective than improving clean water and sanitation infrastructure. There are numbers of initiatives and interventions in place, which have gained momentum with key messages of a call to action with increasing investment in schools, engaging policy makers and demonstration them with evidence. However, change in behavior as a routine habit has not reached to an optimum level and requires institutionalizing hand washing practices in schools, from schools and by schools and develop it as a curriculum. Therefore, we are purposing principles of 5Es and 3Rs – a strategy to make hand washing a routine habit. These 5E principles are: i) Embedding in a system, ii) Enabling Environment, iii) Eliminating Friction, iv) Encouraging all, and v) Establishing intervention and 3Rs are practicing them Religiously, Routinely and Repeatedly.Numbers of interventions have well demonstrated that hand hygiene educational interventionscan help maintaining good practices. Finally, if schools and community start doing today, we canobserve behavioral change practices for hand washing as a routine habit by at least 10 years after.
Keywords: Hand washing, Routine Habit, Principles of 5Es and 3Rs, Educational Interventions, School. | PubMed


1. Biran A, Schimidt WP, Varadharjan et. al. Effect of a behavior-change intervention on hand washing with soap in India (SuperAmma): a cluster –randomized trial. Lancet Glob Health 2014; Vol 2: 2145-154
2. Zwane A and Michael K. What Works in Fighting Diarrheal Diseases in Developing Countries? A Critical Review. The World Bank Economic Review. 2007: 2-27
3. Aiello, Allison E. et al. Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis. American Journal of Public Health. 2008. 98(8):1-10
4. Fewtrell, Lorna et al. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. The Lancet Infectious Disease. 2005. 5:42–52.
5. Bowen A, Ma H, Ou J, et al. A cluster-randomized controlled trial evaluating the eff ect of a hand washing promotion program in Chinese primary schools. Am J Trop Med Hyg 2007; 76: 1166–73
6. O Reilly CE, Freeman MC, Ravani M, et al. The impact of a school based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, Western Kenya. Epidemiol Infect 2008; 136: 80–91
7. Laxminarayan R, Chow J, Shahid-Salles SA. Intervention cost-effectiveness: overview of main messages. In: Jamison DT, Breman JG, Measham AR, eds. Disease control priorities in developing countries, 2nd edn. New York: Oxford University Press and The World Bank, 2006: 35–58.
8. Department for Children, Schools and Families. School Workforce in England. January 2009 (Revised). London: Department for Children, Schools and Families, 2009. Available at: Accessed: 27 Dec 2014)
9. Chittleborough CR, Nicholson AL, Basker SB et. al. Factors influencing hand washing behavior in primary schools: process evaluation within a randomized control trial. Heal Educ Resea. Oxford University Press. Vol.27 no.6 2012 page 1055-1068
10. Curtis, Valerie et al. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization. 2001. 79 (6): 518-27.
11. Caincross, Sandy et al. What causes sustainable changes in hygiene behaviour? Social Science & Medicine. 2005. 61: 2212–2220.
12. Luby, Stephen et al. Effect of hand washing on child health: a randomised controlled trial. The Lancet. 2005. 366: 225–33.
13. Rosen L et al. The effect of a handwashing intervention on educator beliefs, attitudes, knowledge and self-efficacy. Health Education Research. 2009. 24(4):686–698.
14. George CM, Perin J, Neiswender de Calani KJ et al. Risk Factors for Diarrhea in Children Under Five Years of Age Residing in Peri-urban Communities in Cochabamba, Bolivia. Am J Trop Med Hyg 2014 Dec 3;91(6):1190-6
15. Grimason AM, Masangwi SJ, Morse TD, et al. Knowledge, awareness and practice of the importance of hand-washing amongst children attending state run primary schools in rural Malawi. Int J Environ Health Res 2014;24(1):31-43.)
16. UNICEF. Health In Hand – Global Hand Washing Day. 2009. Planners Guides, Second Edition
17. Biran A, Schmidt W-P, Wright R et al. The effect of a soap promotion and hygiene education campaign on handwashing behavior in rural India: a cluster randomized trial. Tropical Medicine and International Health. 2009;14:1303-1314.)
18. Scott BE, Lawson DW, Curtis V. Hard to handle: understanding mothers’ hand washing behaviour in Ghana. Health Policy Plan 2007; 22: 216–24
19. Curtis V, Danquah L, Aunger R. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res 2009; 24: 655–73
20. Luby SP, Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB. Household characteristics associated with handwashing with soap in rural Bangladesh. Am J Trop Med Hyg 2009; 81: 882–87
21. Aunger R, Schmidt WP, Ranpura A, et al. Three kinds of psychological determinants for hand-washing behaviour in Kenya. Soc Sci Med 2010; 70: 383–91
22. Curtis V, Biran A, Deverell K, et al. Hygiene in the home: relating bugs and behaviour. Soc Sci Med 2003; 57: 657–72
23. Judah G, Aunger R, Schmidt WP, et al. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health 2009; 99 (suppl 2): S405–11
24. UNICEF. Global Hand Washing Day. Fast Facts and Figures. 2013. Accessed from on 27th December 2014
25. Galiani S, Gertler P, Orsola-Vidal A. Promoting Handwashign Behavior In Peru. The World Bank Group, 2012, Impact Evaluation Series no. 74; 30-31
26. Freeman M, Stocks M, Cumming O, et al. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine and International Health. 2014b
27. Field Guide. The three star approach for WASH in schools. UNICEF. Program Division/WASH. New York, 2013 p4 -7
28. Seimetz, Elisabeth and Mosler, Hans-Joachim (2013): Monitoring and Evaluation of a Large-Scale Handwashing Campaign in India: Preliminary Results of the Evaluation Study of “The Great WASH Yatra”. Working Papers in Environmental Social Sciences 2013-03, Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland.
29. Welch J, Welch S. Winning. 2005. Harper Collings Books. New York. First Edition
30. IRC (2007).Towards Effective Programming for WASH in Schools: A manual on scaling up programmes for water, sanitation and hygiene in schools. Delft, The Netherlands, IRC International Water and Sanitation Centre. (TP series; no. 48). 93 p
31. Le Thi Thanh X, Luu Ngoc H. Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam. Glob Health Action 2013, 6: 18869
32. Zhang C, Mosa AJ, Hayward AS et al. Promoting clean hands among children in Uganda: a school based intervention using ‘tippy-taps’. Public Health. 2013 June ; 127(6): 586–589
33. Early E, Battle K, Cantwell E, English J, Lavin JE, Larson E. Effect of several interventions on the frequency of handwashing among elementary public school children. Am J Infect Control 1998; 26: 263–9., 24
34. Rosen L, Zucker D, Brody D et al. Enabling hygienic behavior among preschoolers: Improving environmental conditions through a multi-faceted intervention. Am J Health Promot 2011; 25: 248–56., 25
35. Curtis V. Talking dirty: how to save a million lives. Int J Environ Health Res 2003; 13: S73–9
36. Neal D, Vujcic J, Hernandez O et al. Hand washing and the Science. Catalyst Behavioral Sciences. Water and Health, UNC, Oct 13, 2014
37. Giddens A. The Constitution of Society: Outline of the Theory of Structuration. Cambridge: Polity Press, 1984.
38. School Network for Absenteeism Prevention. Healthy Schools, Healthy People: A Cross-Curricular, School wide education program for Middle Schools. USA. 2013 (accessed on 27 December, 2014 at )
How to Cite
Kandel, N., & Lamichhane, J. (2016). Strategy of Making Hand Washing a Routine Habit: Principles of 5Es and 3Rs. Journal of Nepal Medical Association, 55(203), 40-44.