COVID-19 has generated high levels of contribution and collaboration in the fields of clinical medicine, scientific research, and engineering. The authors argue an effective public handwashing station they have designed is an example of such contribution.
Hand hygiene is one of the most cost-effective public health interventions, with the potential to save millions of lives and billions of dollars annually. Yet handwashing remains a challenging practice to ingrain in both community settings and professional healthcare environments. Handwashing in low-resource settings is particularly difficult. One reason for this is that it requires infrastructure that enables people with different needs to wash their hands effectively despite environmental constraints, such as lack of clean, running water. This is exactly the kind of problem that is well suited to a design-driven solution.
WHY SHOULD WE CARE ABOUT HAND HYGIENE?
Effective hand hygiene is key to reducing the spread of infectious diseases. According to UNICEF, diarrhoea is a leading cause of death of children under the age of five. In 2017, diarrhoea accounted for eight per cent of these deaths globally while ten per cent of the deaths of Nigerian children under the age of five could be attributed to diarrhoea. Hospital-Acquired Infections (HAIs), those that occur during a hospital stay or procedure, also pose significant risks. HAIs are the cause of five to ten per cent of complications in high-income countries, claiming the lives of at least 80,000 patients each year in the United States, for instance. In low-income countries, although the data is sparser, the WHO estimates that every day, 4,000 children die due to an HAI and hospital-wide infection rates are usually higher than 15 per cent.
Hand hygiene can be performed in two ways—handwashing with soap and clean, running water or by using an alcohol-based hand sanitizer (ABHS) consisting of at least 60 per cent alcohol content. While the use of ABHS is effective, its widespread use and prominence can be hindered by the high cost of hand sanitizer, with its effectiveness reduced when the hands are visibly soiled. In low-resource settings, it is more common to see handwashing as the preferred method of hand hygiene.
Studies show that handwashing with soap can prevent 30-47 per cent of child diarrhoea and 23 per cent of respiratory infections. In terms of value for money, handwashing with soap costs approximately $3.35 per disability-adjusted life-year saved. The potential economic impact of handwashing is demonstrated by a 2017 study, which concluded that the annual net costs to India for not handwashing were approximately $23 billion. On the other hand, the authors estimate net returns on a successful national handwashing campaign would be $5.6 billion.
Despite the clear benefits of handwashing, the WHO estimates that global hand hygiene compliance is as low as 40 per cent. Several factors determine whether a person engages in handwashing activities, including: motivation (disgust, nurture, comfort, status, affiliation, attraction, fear of disease), planning (good health, religious practice, socializing children) and environmental (physical infrastructure, social, biological).
Only 38 per cent of Nigerian households have access to soap and 63 per cent of households to water for use in handwashing. In addition, Nigeria has a shortage of public handwashing facilities. The 2018 Nigeria National Outcome Routine Mapping of Water, Sanitation and Hygiene Services reports that 95 per cent of markets and motor parks do not have access to basic hygiene services. The situation in hospitals is also dire—during interviews we conducted last year, healthcare workers at several healthcare facilities cited the lack of an uninterrupted supply of clean running water as a significant barrier to performing effective handwashing. Only 40 per cent of hospitals in Nigeria have access to basic hygiene services, 46 per cent of hospitals have access to basic supply of water and 32 per cent of hospitals have water supply that is accessible to people living with disabilities.
COVID-19 AND THE LACK OF BASIC INFRASTRUCTURE IN NIGERIA
The first case of COVID-19 in Nigeria was confirmed on 27 February 2020. The pandemic had been spreading across China, Europe, and the United States and it became clear that this virus was causing widespread disruption to healthcare infrastructure and global supply chains. The response to the pandemic was chaotic in some cases and best practices evolved rapidly as scientists and clinicians raced to understand more about the SARS-CoV-2 virus, how it spread and how the disease could be treated.
In low-resource environments where healthcare can be severely underfunded, the pandemic was expected to have a devastating impact. If Nigeria’s response to the pandemic was going to be modelled on the Chinese, European and American playbook, it was clear that Nigeria and other African countries would need significant investments to rapidly shore up its infrastructure for prevention, testing and treatment of the disease. Various private and public sector groups immediately developed initiatives to prepare the required infrastructure. Prevention strategies focused on respiratory and hand hygiene, which involved improving capacity for local manufacturing of masks and other personal protective equipment, hand sanitizers and public handwashing facilities. Capacity for polymerase chain reaction (PCR) testing (which is currently the best way to detect a current infection) was ramped up across Nigeria through the Nigerian Centre for Disease Control and private sector partnerships. For the treatment of COVID-19, the focus was on building isolation centres and expanding ICU capacity.
COVID-19 is the latest instance of a widespread disease outbreak that has exposed the inadequate investment in basic but potentially impactful public health infrastructure, across the world. During this time, hand hygiene awareness campaigns in Nigeria were reminding people to wash or sanitize their hands frequently and teaching them the proper techniques to do so. Much like during the 2014 Ebola virus outbreak, hand hygiene was a matter of urgency for the general public in ways we are not accustomed to seeing with other infectious diseases such as diarrhoea. The public was becoming more motivated (whether internally to protect themselves and others around them or externally by government mandates for public spaces) to wash their hands. With the increased awareness and demand for handwashing infrastructure, the lack of these facilities in hospitals and public spaces became more obvious.
TACKLING LARGE, INTRACTABLE PROBLEMS WITH DESIGN
The COVID-19 pandemic has generated high levels of contribution and collaboration in the fields of clinical medicine, scientific research, and engineering globally. In the context of all the discussions around local preparedness for the pandemic, we at Haralago and nmbello Studio found ourselves asking, ‘What is the role of the design discipline in an effective pandemic response in Nigeria?’ We believe that since design is a creative process, design is uniquely suited to solve complex problems in an environment that is dynamic and uncertain. Design is particularly important in situations where the success of a public health intervention depends not only on providing infrastructure but also on how people interact with that infrastructure.
Our goal is to create a handwashing station for use in a Nigerian healthcare facility. We are particularly interested in the area of prevention because this is where we feel that we could have greater long-term impact not only for COVID-19 but for other infectious diseases as well. We also believe that it is important for us to collaborate closely with users and artisans, to ensure that the solution will ultimately be practical and valued. We chose to design for a healthcare setting because we consider this to be an extreme use case—by solving for these users, we can generate a solution that could be extended to other situations, such as a community or corporate setting.
Design has many sub-disciplines, each bringing a specific skill set and viewpoint. For this project, we incorporated human-centred design, accessibility design, universal design, inclusive design and industrial design.
Human-centred design is a structured approach to problem-solving that is anchored by using ethnographic methods to develop insights about a person, their needs and their environment. This allows the design of a product, service or experience that resonates with the user. The iterative nature of the process means that solutions can be updated on the fly as more information is obtained.
Empathy is at the core of the human-centred design process and it was critical for us to gain clarity on the users’ needs and experiences to allow for better design. Therefore, our first step was to conduct in-depth interviews with various stakeholders in the healthcare environment, including nurses, doctors, infection prevention and control specialists, hospital administrators, users living with physical disabilities and users with visual impairment. Due to Nigeria being under lockdown restrictions at the time of our research, these conversations were conducted remotely. Therefore, we supported these conversations with photographs of handwashing infrastructure from several hospitals as well as the first-hand experiences from Haralago’s work in hospital cleaning and infection control. Once we had produced a physical prototype, we continued to gain feedback and further insights from these stakeholders.
For a product to be considered accessible, it must make the user experience available to all, including people living with disabilities. Accessibility design focuses on the outcome of the design process, meaning that accessibility regulations and guidelines that are published by various governmental and industry groups must be met. We consulted the Discrimination Against People with Disabilities (Prohibition) Act of 2018 to ensure that our design would meet the requirements under Nigerian law.
Universal design is the design of a product, service or environment that is accessible and functional in the widest possible range of situations without the need for adaptation. With every design decision, we considered which feature would provide value and functionality to the most users in a way that does not require additional modification.
Inclusive design involves including and learning from people with a range of perspectives and/or who are typically not considered in the design process. Throughout our design process, we considered the perspectives of all stakeholders who would potentially interact with the handwashing station, including users (healthcare workers and patients), decision-makers (hospital administrators) and maintenance personnel (cleaning staff, plumbers, welders, mechanical or maintenance staff).
Industrial design is the strategic design of physical products and systems with a focus on functionality, aesthetics and manufacturability in a way that improves the lives of the users and provides value to society. Our design strategy was to create a solution around locally available and accessible production techniques and materials, with the goal of achieving a design that carefully considered production costs. We embraced each constraint and reframed them as challenges that could be solved with the skills and craftsmanship of the makers and the designers in Nigeria.
It is important to emphasize the critical role of constraints. Rather than being regarded as negative, as designers, we reframe problems and limitations as opportunities. Constraints become essential in driving the design process and help lead to more creative solutions. Some of the constraints which drove several significant design decisions for us are described below.
Global best practice
We wanted to demonstrate that it is possible to design a solution that is locally appropriate while still meeting global technical standards for infection prevention and control. We referenced guidelines for handwashing stations published by UNICEF as well as the Alberta Health Services for detailed specifications with respect to features including material selection and dimensions. For example, the sink must be made of a non-porous, scratch-resistant material and should be seamless, with an inside contour that allows for easy cleaning and maintenance. For prototyping, we used fibreglass as it is cheaper to fabricate in small batches. However, for production at scale, we plan to use a material such as ABS plastic which is more suitable due to its low cost, durability, chemical resistance, and ease of manufacture.
During our interviews with potential users, individuals with physical disabilities described the shame and trauma of being unable to independently and conveniently access hygiene facilities due to the physical infrastructure being a barrier. A step that was too high or a door that was too narrow often made the difference between accessing indoor facilities and having to go outside. For those with visual impairments or blindness, they described the fear induced by needing to rely on their sense of touch to navigate their environment during a pandemic that requires clean hands to avoid being infected. In order to address these two issues, we decided to use a tap activated by a proximity sensor rather than a foot or hand-controlled water and soap dispensing mechanism. In addition, the dimensions of the handwashing station are suitable for users who might be wheelchair-bound.
Total cost of ownership and ease of maintenance
The business of healthcare in Nigeria is tough, with hospital administrators under constant pressure to manage financial resources and often having to choose between investing in multiple competing yet critical needs for patient care. The total cost of ownership includes the acquisition, maintenance, and repair costs. We are keeping production costs low by implementing a very simple design using locally available tubular steel for the frame. Tubular steel is commonly used in the local manufacture of hospital beds. In this way, we also reduce maintenance cost because welders are used to working with this material, so no additional manufacturing capability needs to be developed. In addition, we decided to employ modular components, so that all major parts can be repaired or replaced independently without having to dispose of the whole handwashing station.
Responsiveness to individual and institutional needs
Healthcare workers are busy—for every 30 patient interactions, they may spend up to 30 minutes each day just on handwashing. Nurses and doctors expressed a need to be able to wash their hands when and where they needed to. Many healthcare facilities in Nigeria are not purpose-built, so space is at a premium and handwashing infrastructure might be inconveniently located relative to where patient care is actually being delivered. This drove our decision for a compact, mobile handwashing station that can be moved to where it is needed the most. The station has an independent water supply that can accommodate standard containers that are widely available in the Nigerian market, such as water dispenser bottles or 25-litre jerry cans. The grey wastewater goes directly into a jerry can, which minimizes contamination due to splashing. Water is also precious, so the proximity sensor activates the tap for 30 seconds at a low flow rate in order to minimize waste. Healthcare workers also told us that hand drying often posed difficulties during this process, so the handwashing station also includes a holder for any standard disposable paper towel roll, as well as a waste bin. The touch-free soap dispenser and tap activation is also key to preventing cross-contamination.
Aesthetics and ergonomics
We believe that design for low-resource settings should be aesthetically pleasing. This drove our decision to cover the frame with a durable, easy to clean cover while allowing easy access to the front for replacing water bottles. In terms of ergonomics, the height of the push bar allows the handwashing station to be pushed from location to location in a comfortable posture. In addition, we decided to place the water bottles at the bottom of the hand wash station, to avoid the frequent heavy lifting that would be necessary for a water storage system that is placed at a higher level.
TOWARDS ACHIEVING BETTER OUTCOMES
We still have some work ahead of us but have demonstrated so far that the principles of design can indeed be used to contribute to a locally relevant response to health crises such as the COVID-19 pandemic.
For the community
We translated global best practice into a design for a handwashing station that is appropriate within our local context, with a large focus on functionality, cost and accessibility. In addition to the product itself, we were able to integrate these aspects in the manufacturing process.
By the community
nmbello Studio led the design in collaboration with Haralago who led the research. We designed based on meaningful insights and contributions from users in the Nigerian healthcare context, leveraging local design and manufacturing capabilities and using locally available materials. This outcome would not have been possible in the absence of collaboration with healthcare workers, users and artisans⎈
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