We conducted a baseline evaluation for a large intervention project that has a primary objective of promoting handwashing with soap or ash at key times--before preparing food, before eating or feeding a child, after defecating and after cleaning an infant who has defecated. In 100 randomly selected communities in 34 districts of Bangladesh, field workers observed the proportion of persons who washed their hands and 2 months later returned to the same communities and interviewed residents about their handwashing behavior. Among the 20,546 key times observed, study subjects washed their hands 11,800 (55%) of the time, though in only 350 episodes (1.7%) did they wash both hands with soap or ash. Efforts to improve handwashing in Bangladesh need to focus on transforming people’s hand rinsing practice into thorough handwashing with soap.
In small studies targeting hundreds or a few thousand households, interventions that promoted handwashing with soap consistently reduced diarrhea and respiratory disease (1,2). It is challenging, however, to implement handwashing promotion on a large scale.
The Government of Bangladesh, Department of Public Health Engineering in collaboration with UNICEF and with support from the Department for International Development (DFID) of the British Government has launched a programme, `SHEWA-B’ (Sanitation, Hygiene Education and Water supply-Bangladesh) that is among the largest intensive handwashing, hygiene/sanitation and water quality improvement programmes ever attempted in a developing country. The intervention is targeting 30 million underserved people in Bangladesh. A primary objective of the intervention is to increase the proportion of persons who wash their hands with soap or ash at key times, i.e. before preparing food, before eating, before feeding a child, after defecating and after cleaning a child’s anus. There are some data from Bangladesh that suggest that washing hands with ash reduces the concentration of fecal organisms on hands (3).
ICDDR,B was contracted to perform the health impact evaluation for this intervention. We report a summary of the baseline findings on handwashing practices. We used population proportional to size sampling to select 50 villages from SHEWA-B intervention communities and another 50 comparison villages from nearby upazilas that were judged to be similar (Figure 1). Beginning from the center of the village, field workers identified households with children under the age of 5 years. The trained field workers then performed 5-hour structured observations of handwashing behavior between 9:00 AM and 2:00 PM in 1,000 sampled households. They noted handwashing behaviour at key times.
Two months later, field workers conducted a survey that included questions on handwashing behaviour and other variables in these same 1,000 households, and an additional 700 neighboring households. The combined results from intervention and control area are presented to provide a description of a large area of rural Bangladesh.
We measured handwashing practices in several different ways. When field workers asked subjects open-ended questions “When and how do you wash your hands with soap or ash?”, the proportion who mentioned washing hands at key times was different than when specific questions were asked about whether or not the subject washed their hands with soap or ash at each key time (figure 2). However, study subjects consistently reported washing their hands with soap much more frequently than they were observed to.
During the observations about half of the study subjects made some effort to wash their hands at most of the key times. Usually, this was just rinsing with water (Figure 3). Indeed, washing both hands with soap or ash, was quite uncommon, ranging from <1% of people before eating to 23% of people who cleaned a child’s anus after defecation. Overall, among the 20,546 key times observed, study subjects washed their hands 11,800 (55%) of the time, though in only 350 episodes (1.7%) did they wash both hands with soap or ash (figure 4).
At the end of the interview, data collectors asked the subjects to wash their hands as they usually did following defecation. Fifty-five percent of mothers and 42% of children age 3-5 years washed both hands with water and used soap and/or ash. Among the subjects who used soap, the median rubbing time with soap was 14 seconds.
Reported by:Programme on Infectious Diseases and Vaccine Sciences, ICDDR,B and UNICEF
Supported by: UNICEF, Dhaka, Bangladesh
Comments
In a broad cross section of households in rural Bangladesh respondents consistently reported washing hands with soap at key times, and when asked to wash their hands over half did so thoroughly. However, on observations conducted 2 months previously, while over half of subjects did make effort to wash their hands at key times, they generally only rinsed their hands with water.
The research studies that have demonstrated marked reductions in diarrhoeal disease with handwashing all promoted handwashing with soap (1,2). The good news is that the residents of these communities had good knowledge of when handwashing with soap was recommended, and a little over half of them had a habit of at least rinsing their hands at those key times. The challenge for handwashing promotion programmes is to further develop these behaviours so that people habitually use soap when they wash their hands.
The study subjects reported washing their hands more frequently than they were observed to. This pattern has been noted in prior studies in Bangladesh and other countries (4,5). This finding demonstrates that asking people about their handwashing behavior does not provide a valid assessment.
This study population was not representative of all Bangladesh. The upazilas (sub-districts) selected for the SHEWA-B intervention were chosen because they were of high need. However, they are a large population drawn from across Bangladesh and the behaviours in the control communities was similar to the intervention communities (data not shown) which suggests that their behaviours are not exceptional.
Behaviour change in public health is difficult, but the Government of Bangladesh and UNICEF are focusing on an important behaviour. We will provide follow-up on this ambitious intervention in subsequent issues of the HSB.
Reference
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Stanton BF, Clemens JD, Aziz KM, Rahman M. Twenty-four-hour recall, knowledge-attitude-practice questionnaires, and direct observations of sanitary practices: a comparative study. Bull World Health Organ 1987;65:217-22.
Cousens S, Kanki B, Toure S, Diallo I, Curtis V. Reactivity and repeatability of hygiene behaviour: structured observations from Burkina Faso. Soc Sci Med 1996;43:1299-308.
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