Abstract
Hygiene is critical for controlling infectious disease and delivering well-being. During the pandemic phase of COVID-19, there was widespread awareness of the importance of hygiene for disease control, and demand was high for action to improve access to hygiene materials. However, those efforts have faltered, and, in general, interventions to improve hygiene at scale have shown limited success in delivering sustained behaviour change and health impact. We convened experts in hygiene across sectors (for example, health, education and agriculture) and disciplines (for example, academia, policy and practice) in Dakar, Senegal, to discuss the critical barriers and opportunities for researching, developing and implementing systems-level hygiene interventions and promote learning across sectors, with a focus on systems approaches. We report what is needed to achieve catalytic improvements in hygiene in low-income settings and the Global South, with an emphasis on ‘hygienic systems’ that target all relevant hygiene moments—a set of associated behaviours at a given time and place with high pathogen exposure risk—and their enabling conditions and pre-conditions. This focus beyond individual behaviours will require removing silos across sectors and ministries, the generation of relevant evidence for policymakers and the localization of guidance.
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References
Sumpter, C. & Torondel, B. A systematic review of the health and social effects of menstrual hygiene management. PLoS ONE 8, e62004 (2013).
Stocks, M. E. et al. Effect of water, sanitation and hygiene on the prevention of trachoma: a systematic review and meta-analysis. PLoS Med. 11, e1001605 (2014).
Ross, I. et al. Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 401, 1681–1690 (2023).
Srigley, J. A., Furness, C. D. & Gardam, M. Interventions to improve patient hand hygiene: a systematic review. J. Hosp. Infect. 94, 23–29 (2016).
Curtis, V. et al. Hygiene: new hopes, new horizons. Lancet Infect. Dis. 11, 312–321 (2011).
Taylor, D. L., Kahawita, T. M., Cairncross, S. & Ensink, J. H. J. The impact of water, sanitation and hygiene interventions to control cholera: a systematic review. PLoS ONE 10, e0135676 (2015).
Strunz, E. C. et al. Water, sanitation, hygiene and soil-transmitted helminth infection: a systematic review and meta-analysis. PLoS Med. 11, e1001620 (2014).
Disease Control Priorities in Developing Countries (Oxford Univ. Press and The World Bank, 1993).
Sijbesma, C. & Christoffers, T. The value of hygiene promotion: cost-effectiveness analysis of interventions in developing countries. Health Policy Plan. 24, 418–427 (2009).
Wolf, J. et al. Burden of disease attributable to unsafe drinking water, sanitation and hygiene in domestic settings: a global analysis for selected adverse health outcomes. Lancet 401, 2060–2071 (2023).
Gautam, O. P., Schmidt, W.-P., Cairncross, S., Cavill, S. & Curtis, V. Trial of a novel intervention to improve multiple food hygiene behaviors in Nepal. Am. Soc. Trop. Med. Hyg. 96, 1415–1426 (2017).
Penakalapati, G. et al. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ. Sci. Technol. 51, 11537–11552 (2017).
Plesons, M. et al. Research priorities for improving menstrual health across the life-course in low- and middle-income countries. Glob. Health Action 16, 2279396 (2023).
Sweetman, C. & Medland, L. Introduction: gender and water, sanitation and hygiene. Gend. Dev. 25, 153–166 (2017).
Cumming, O. et al. The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement. BMC Med. 17, 173 (2019).
Curtis, V. A. A natural history of hygiene. Can. J. Infect. Dis. Med. Microbiol. 18, 11–14 (2007).
WHO. Recommendation to the Member States to Improve Hand Hygiene Practices Widely to Help Prevent the Transmission of the COVID-19 Virus (World Health Organization, 2020); https://www.who.int/publications/m/item/interim-recommendations-on-obligatory-hand-hygiene-against-transmission-of-covid-19
Brauer, M., Zhao, J. T., Bennitt, F. B. & Stanaway, J. D. Global access to handwashing: implications for COVID-19 control in low-income countries. Environ. Health Perspect. 128, 057005 (2020).
Freeman, M. C. & Caruso, B. A. Comment on ‘Global access to handwashing: implications for COVID-19 control in low-income countries’. Environ. Health Perspect. 128, 098001 (2020).
Kurowski, C., Kumar, A., Mieses Ramirez, J. C., Schmidt, M. & Silfverberg, D. V. Health Financing in a Time of Global Shocks: Strong Advance, Early Retreat (World Bank, 2023); https://doi.org/10.1596/39864
Joint Monitoring Program (JMP) (WHO, UNICEF); https://washdata.org/data
Freeman, M. C. et al. Systematic review: Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop. Med. Int. Health 19, 906–916 (2014).
Allegranzi, B. et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet 377, 228–241 (2011).
Erasmus, V. et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect. Control Hosp. Epidemiol. 31, 283–294 (2010).
Ali, A. S., Yohannes, M. W. & Tesfahun, T. Hygiene behavior and COVID-19 pandemic: opportunities of COVID-19-imposed changes in hygiene behavior. Inq. J. Med. Care Organ. Provis. Financ. 60, 00469580231218421 (2023).
Wilkinson, J., Goff, M., Rusoja, E., Hanson, C. & Swanson, R. C. The application of systems thinking concepts, methods and tools to global health practices: an analysis of case studies. J. Eval. Clin. Pract. 24, 607–618 (2018).
Peters, D. H. The application of systems thinking in health: why use systems thinking? Health Res. Policy Syst. 12, 51 (2014).
de Savigny, D. & Adam, T. (eds) Systems Thinking for Health Systems Strengthening (WHO, 2009); https://iris.who.int/handle/10665/44204
Sherr, K. et al. Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial. Implement. Sci. 9, 55 (2014).
McAlister, M. M. et al. Systems thinking for effective interventions in global environmental health. Environ. Sci. Technol. 56, 732–738 (2022).
Huston, A. & Moriarty, P. Understanding the WASH System and its Building Blocks (IRC-WASH, 2018).
IRC, SIWI, UNICEF. Principles for Water, Sanitation and Hygiene Systems Strengthening (UNICEF, 2024).
Crocker, J. et al. Hygiene system modeling for toileting in schools. SSRN https://doi.org/10.2139/ssrn.5056224 (2025).
Valcourt, N., Javernick-will, A., Walters, J. P. & Linden, K. System approaches to water, sanitation and hygiene: a systematic literature review. Int. J. Environ. Res. Public. Health 17, 702 (2020).
WASH BAT Map; https://www.washbat.org/map/list.html
Rosenweig, F. Synthesis of Four Country Enabling Environment Assessments for Scaling Up Handwashing Programs. Water and Sanitation Program report (World Bank, 2008); http://documents.worldbank.org/curated/en/567221468325172546
Kateule, E. et al. Multisectoral approach for the control of cholera outbreak—lessons and challenges from Lusaka district—Zambia, October 2023 - February 2024. Pan. Afr. Med. J. 48, 19 (2024).
Kapata, N. et al. A multisectoral emergency response approach to a cholera outbreak in Zambia: October 2017–February 2018. J. Infect. Dis. 218, S181–S183 (2018).
CDC Clean Hands: About Handwashing (CDC, 2024); https://www.cdc.gov/clean-hands/about/index.html
Crocker, J. et al. Hygiene system modeling for toileting in schools. Rev. Int. J. Hyg. Environ. Health https://doi.org/10.2139/ssrn.5056224 (2025).
Principles for Water, Sanitation, and Hygiene Systems Strengthening (RC, SIWI, UNICEF, 2024); https://clearinghouse.unicef.org/sites/ch/files/ch/sites-PD-WASH-WASH%20Knowledge%20unicef-2024%20Principles%20Paper-4.0.pdf
Five Building Blocks (Sanitation and Water for All); https://www.sanitationandwaterforall.org/about/our-work/priority-areas/building-blocks
Environmental Cleaning and Infection Prevention and Control in Health Care Facilities in Low- and Middle-Income Countries Trainer’s Guide (World Health Organization, 2023).
Henson, S., Jaffee, S. & Wang, S. New Directions for Tackling Food Safety Risks in the Informal Sector of Developing Countries (CGIAR, 2023); https://hdl.handle.net/10568/130652
Hygiene (Merriam-Webster.com Dictionary, 2024); https://www.merriam-webster.com/dictionary/hygiene
Strategy for Water, Sanitation and Hygiene 2016–2030 (UNICEF, 2016).
Haque, S. S. & Freeman, M. C. The applications of implementation science in water, sanitation, and hygiene (WASH) research and practice. Environ. Health Perspect. 129, 65002 (2021).
WHO & UNICEF. Drinking Water, Sanitation and Hygiene in Schools: Global Baseline Report 2018 (World Health Organization, 2018).
Macleod, C. et al. Recommendations for hand hygiene in community settings: a scoping review of current international guidelines. BMJ Open 13, e068887 (2023).
WHO. Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level (World Health Organization, 2016).
Acknowledgements
The Dakar Hygiene Roundtable was supported by the Reckitt Global Hygiene Institute (RGHI), including time and travel for all authors. RGHI was involved in the planning of the Dakar Roundtable Meeting, but not in the final publication or decision to publish this commentary.
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Freeman, M.C., Crocker, J., Chipungu, J. et al. Systems thinking for hygiene in settings with high risk of infectious disease transmission. Nat Water 3, 518–524 (2025). https://doi.org/10.1038/s44221-025-00424-9
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DOI: https://doi.org/10.1038/s44221-025-00424-9
