LRH: LUBY AND OTHERS
RRH: HANDWASHING WITH SOAP IN RURAL BANGLADESH
Household Characteristics Associated with Handwashing with Soap in Rural Bangladesh
Stephen P. Luby, Amal K. Halder, Carole Tronchet, Shamima Akhter, Abbas Bhuiya, and
Richard Johnston
International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
Centers for Disease Control and Prevention, Atlanta, Georgia
Water and Environmental Sanitation Section, UNICEF Bangladesh, Dhaka, Bangladesh
ABSTRACT
Handwashing with soap prevents diarrhea and respiratory disease, but it is rarely practiced in
high need settings. Among 100 randomly selected villages in rural Bangladesh, field workers
enrolled 10 households per village and observed and recorded household activities for five hours.
Field workers observed 761 handwashing opportunities among household members in 527
households who had just defecated or who cleaned a child’s anus who had defecated. In the final
multivariate analysis, having water available at the place to wash hands after toileting (odds ratio
= 2.2, 95% confidence interval 1.3, 4.0) and having soap available at the place to wash hands
after toileting (odds ratio = 2.1, 95% confidence interval 1.3, 3.4) were associated with washing
both hands with soap after fecal contact. Interventions that improve the presence of water and
soap at the designated place to wash hands would be expected to improve handwashing behavior
and health.
2
INTRODUCTION
An estimated 1.9 million children under the age of 5 years die annually from diarrheal disease1
and an additional 2 million die from pneumonia.2 Small scale studies (fewer than 4,000
households) in settings where diarrhea and respiratory disease are leading causes of death
demonstrate that households that receive intensive handwashing promotion report less diarrhea3,
4, 5, 6
and respiratory disease7 compared to control households. However, in settings where
diarrhea is an important cause of child mortality, the prevalence of handwashing with soap after
contact with feces as assessed by structured observation is typically <30%.8, 9, 10, 11
In 2007 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 launched a program, SHEWA-B (Sanitation,
Hygiene Education and Water supply-Bangladesh) that is among the largest intensive
handwashing, hygiene/sanitation and water quality improvement programs ever attempted in a
low income country. In the first stage the intervention is targeting 19.6 million people in rural
Bangladesh. A primary objective of the intervention is to increase the proportion of persons who
wash their hands at key times, that is before preparing food, before eating, before feeding a child,
after defecating and after cleaning a child’s anus.
Earlier work from urban Dhaka, Bangladesh noted that children living in households that field
workers confirmed had water at the most convenient place to wash hands, had 5% less
respiratory symptoms compared to households without water available at the place to wash
3
hands after correcting for differences in socioeconomic status.12 We analyzed data collected from
100 villages for the baseline assessment before initiation of the SHEWA-B program. The
objective of this analysis was to explore characteristics associated with handwashing, and
specifically to explore if elements of handwashing infrastructure, that is having a designated
place to wash hands, and having water and soap present at the place, was associated with
handwashing with soap independent of socioeconomic status.
METHODS
Study population.
During the first two years the SHEWA-B program targeted 68 sub districts (upazilas) with a
population of 19.6 million people (Figure 1). The government and UNICEF selected the specific
sub-districts because of the perceived need in these communities and the absence of other active
programs addressing water, sanitation and hygiene in these sub-districts. Upazilas are further
subdivided into unions. We listed all of the unions in the 68 targeted sub-districts and randomly
selected 50 unions with the probability of selection proportional to the size of the union. The
only exception to strict proportionality by population was an intentional oversample of the subdistricts in the Chittagong Hill Tracts. These sub-districts are among the most impoverished in
the country, and because an important objective of the program is to reach the poorest groups,
10% of the evaluation sample was reserved for Chittagong Hill Tract communities to assure
sufficient observations to permit separate analysis.
4
Within each selected union we listed all village names, and using a random number generator
selected the evaluation village. UNICEF and the Department of Public Health Engineering
selected one non-intervention control sub-district that had no major hygiene promotion
intervention, but had similar infrastructure, agricultural productivity, household construction and
hydrogeology for each randomly selected intervention sub-district. Unions and villages within
the control sub-districts were enrolled as controls using the same methods used for enrolling
intervention villages.
Field workers asked residents of the selected village to identify the village center. Field workers
identified the household closest to the village center that had a child <5 years of age and sought
consent for participation in the evaluation. As part of the consent process, field workers
explained that the objective of the evaluation was to understand water, sanitation, and hand
hygiene practices. To enroll the next household, fieldworkers skipped the next two closest
households, and then looked for the next household with a child <5 years of age. Field workers
repeated the process for enrolling additional households until 10 households in each selected
village were enrolled. Since intervention activities had not been initiated and we were interested
in associations between characteristics and handwashing behavior throughout rural Bangladesh
we included both the intervention and control households in this analysis.
Data collection.
Structured observation.
Trained field workers conducted 5-hour structured observations of handwashing behavior of all
persons in selected households between 9:00 AM and 2:00 PM, a culturally acceptable hour for
5
visitors and the typical time for a range of personal hygiene and food preparation behaviors.
Using a pre-tested instrument field workers noted handwashing behavior at key times -- before
preparing food, before eating or feeding a child, after defecating and after cleaning a child’s anus
who had defecated.
Cross sectional survey.
Two months after the structured observation field workers returned to the households and
administered a pre-tested cross sectional survey and spot check. Questions included on the cross
sectional survey included demographic information as well as household construction and
possessions to permit a measurement of acquired household wealth. Field workers asked
respondents to, “Show me where you usually wash your hands after you use the toilet.” The field
worker coded whether this was inside or near the toilet facility, inside or near the kitchen,
elsewhere in the yard, outside the yard, or no specific place. The field worker also observed
whether there was water available and whether there was soap available at the identified
location.
We classified latrines as improved according to the WHO definitions, that is a pit latrine with a
slab, a ventilated improved pit latrine, a composting toilet or a flush toilet connecting to a piped
sewer system, septic tank or pit latrine.13
Outcomes.
We linked data from the household structured observation with the household cross sectional
survey. The primary outcome variable was whether or not a person under observation in the
6
household who had defecated or had cleaned the anus of a child who had defecated, subsequently
washed both hands with soap. The objective for handwashing within rural Bangladesh culture
differs from the germ theory conceptualization used by public health practitioners 14. After
defecation most adults in rural Bangladesh clean their anus by using water and their left hand.
The left hand is most commonly subsequently rinsed with water. Because of its impurity, the left
hand should not touch the right.14 We focused on handwashing after fecal contact because this is
a situation where handwashing with soap would be expected to interrupt gastrointestinal
pathogen transmission. We focused on handwashing with soap because of the strength of
evidence that this improves health. We evaluated washing both hands because earlier studies
noted that both the right and left hands were contaminated with fecal coliforms.15
Data analysis.
We calculated odds ratios to evaluate the association between individual and household
characteristics with washing both hands with soap. To account for the repeated observations in
single households and the clustering of observations in villages we used general estimated
equations to calculate these odds ratios and 95% confidence intervals.16 To construct a
multivariate model we began with the characteristic that had the greatest effect on the goodness
of fit of the general estimated equation model. We sequentially tested additional variables that
were associated with handwashing in the bivariate analysis with a p-value < 0.10 into the
multivariate model. For the final multivariate model we retained all variables that were
significantly associated with handwashing with soap (p<0.05) and significantly improved fit
(p<0.05). We used a nested correlation structure for all general estimated equations analyses to
account for the clustering of observations within households, and the clustering of measures
7
within the same villages. We tested for interaction by combining characteristics of hypothesized
interactions and evaluating if they made an independent contribution to the model. We used SAS
for Windows, Version 9.1 (SAS Institute, Cary, NC, USA) for the general estimated equations
modeling.
We used principal component analysis to evaluate household wealth.17 We excluded hygiene and
sanitary infrastructure from the wealth index, because we wanted to analyze the impact of wealth
independent of the specific facilities and supplies that might contribute to handwashing. We
analyzed variables in the wealth index by means, frequencies and standard deviations and
calculated score coefficients. We used the correlation matrix of the 24 variables to calculate
sample weights.18 The coefficients were calculated by rounding the expression
(Loading/standard deviation) x 100 to the nearest integer. We used the first principal component
as the wealth score.19
Ethics.
All households provided informed consent. Because this was an evaluation of a public health
program rather than a primary research project, the program evaluation was not reviewed by a
human subjects research panel.
RESULTS
The field team completed structured observations of 1000 households. In 529 households (53%),
field workers observed a household member who had just defecated or who cleaned a child’s
8
anus who had defecated. Two to four months later field workers interviewed the mother of the
youngest child in 527 of these households (99%) with the cross sectional survey. This analysis is
based on the handwashing behavior following the 761 episodes of fecal contact observed in these
527 households.
Approximately one third of mothers and fathers within the observation group did not have any
formal education. Only 15% of fathers and 8% of mothers completed secondary school. Most
used a tubewell for drinking water and owned a latrine (Table 1). The most common type of
latrine (56%) was a pit latrine with a slab, but without a lid or water seal. Respondents in 95% of
households identified a place to wash hands after toileting, though only 38% of these were inside
or near the toilet. Field workers observed water present at 72% of the designated handwashing
locations and soap at 52% (Table 1).
In the wealth analysis, the first principle component retained 29% of the total data variability.
The first principle component was highly correlated with 16 variables.
The majority of fecal contacts were observed among females (79%) and among adult caregivers
(58%) (Table 2).
After contact with feces 134 persons (18%) washed both hands with soap. Adults and females
were significantly more likely to wash both hands with soap following fecal contact than
children and males in bivariate analysis. Household characteristics that were significantly
associated with washing both hands with soap after fecal contact on bivariate analysis included
9
the mother of the youngest child having education above the primary level; wealth in the top two
quintiles, and having soap, water, or water plus soap available at the place of handwashing after
toileting (Table 3). The presence of water at the place to wash hands doubled the probability of
washing both hands with soap. Similarly the presence of soap at the place to wash hands doubled
the probability of washing both hands with soap. The location where household members
specified that they usually washed their hands after toileting was not significantly associated
with handwashing with soap after fecal contact.
In the multivariate analysis, the characteristics that were independently significantly associated
with handwashing were being an adult caregiver, mother’s education above primary level,
having water available at the place to wash hands after toileting and having soap available at the
place to wash hands after toileting (Table 4). The odds ratios in the multivariate analysis were
little changed from the bivariate analysis. We tested the possible contribution of a place to wash
hands after toileting that included both water and soap by adding this as a combined variable to
the model in Table 4 that coded the presence of water and the presence of soap separately. The
combined variable, neither improved fit nor was it significantly associated with observed
handwashing with soap. We also constructed a model with the combined water plus soap at the
place to wash hands, being an adult caregiver and mother’s education level. The model in Table
4 that included the presence of water separately from the presence of soap fit the data
significantly better (p=0.01) than the model with only the combined variables.
DISCUSSION
10
Rural Bangladeshi residents living in households with either water or soap at the place they
usually wash their hands were twice as likely to wash both hands with soap after contact with
feces than those whose handwashing location lacked soap or water. These findings are consistent
with studies of handwashing in hospitals that concluded that hand hygiene was improved when
equipment and supplies were present that made it easier to wash hands.20, 21, 22 It is possible that
having a designated place to wash hands that included soap and water was purely an external
manifestation of household residents’ intent to wash hands, and so was only a marker of
handwashing intent, and not an independent facilitator. But this extreme interpretation ignores
the broad scholarship on ecological models of behavior change which stress the contribution of
an appropriate environment to facilitate healthy behavior.23
The relationship of handwashing infrastructure and supplies with improved handwashing
behavior suggests that encouraging households to equip a place to wash hands with water and
soap would be expected to increase the rate of handwashing. Ninety-five percent of households
identified a place to wash hands after toileting. The proximity of the handwashing location to the
toilet did not predict handwashing behavior. Thus, environmental interventions are most likely to
change handwashing behavior if they focus on adding water and/or soap to the household’s
designated handwashing site.
Measuring handwashing behavior has proved difficult. Careful studies have repeatedly
confirmed that reported handwashing behavior is not a valid measure of observed behavior.9, 24,
25, 26
Structured observation is time consuming, expensive, and risks altering behavior in the
presence of an observer. Microbiological measures of hand contamination are expensive and
11
only weakly associated with health outcomes.27, 28, 29 Earlier work suggested that the presence of
a place to wash hands with water in urban Bangladesh was associated with a slight decrease in
respiratory disease symptoms.12 The findings from the presented analysis are new evidence that a
spot check to identify a convenient place to wash hands that has soap and water present, is a
rapid, inexpensive, objective proxy measure associated with handwashing. If studies in other
settings confirm the associations between a place for handwashing that has soap and water, and
handwashing behavior and handwashing associated diseases, then this may become a useful
indicator for assessing progress in handwashing promotion efforts in high need communities
globally.
An important limitation to this evaluation is that the handwashing behavior that was observed
during the structured observation session may not be typical behavior of the household’s
residents after fecal contact. The presence of the observer and the disclosure of our interest in
hand hygiene may have changed the behavior so the associations between handwashing with
soap and the specific characteristics may be spurious. However, educated persons would be the
most likely group to recognize that the observers were interested in a public health
conceptualization of handwashing behavior, and so be the most likely to change their behavior.
The association of water and soap at the place to wash hands with handwashing was independent
of education, suggesting that such bias is an unlikely explanation of the association. Indeed, the
consistency of these results with experience in hospitals and ecological behavior change theory
suggests that the association is not a result of bias.
12
A second limitation is that this program evaluation was not specifically designed to test the
hypothesis that the presence of soap and water at the designated place to wash hands was
associated with washing hands with soap. Thus, these results could have arisen by chance
association and should not be considered as final confirmation of the hypothesis. However, these
results did not come from mining the data for significant associations. Indeed, this analysis was
outlined before the data were collected. Moreover, the associations were not borderline. The
probability that either association would occur by chance is one in a thousand. Thus, while no
single study is ever definitive, these data strongly support the hypothesis that having water and
soap available at the place to wash hands improves the probability that both hands will be
washed with soap following contact with feces.
A third limitation is that the study population was restricted to 100 communities in rural
Bangladesh. It was not a statistically representative sample of rural Bangladesh. No urban
households were included, and outside of Bangladesh determinants of handwashing may be
different. However, the study population is a large diverse sample from high need communities
across rural Bangladesh, precisely the type of communities that would be expected to benefit
most from improved handwashing behavior.
Important barriers to realizing broader public health benefits from handwashing include the
difficulty of changing handwashing habits and the difficulty in measuring handwashing behavior.
These results suggest that interventions that improve the presence of water and soap at the
designated place to wash hands would be expected to improve handwashing behavior and health.
13
Important next steps include active promotion of such interventions and careful evaluation of
their impact on handwashing behavior and health.
ACKNOWLEDGMENT
This program evaluation was funded by the United Kingdom Department for International Development
(DFID) through UNICEF Bangladesh. ICDDR,B acknowledges with gratitude the commitment of DFID
and UNICEF to the Centre’s research efforts.
Stephen P. Luby, Infectious Diseases and Vaccine Sciences, ICDDR,B, GPO Box 128
Dhaka-1000, Bangladesh, p : 88 02 988 1761 f: 8802 882 3963, sluby@icddrb.org
Amal K. Halder, World Vision, Darfur, Sudan, Amal_Halder@wvi.org
Carole Tronchet , UNICEF Bangladesh, BSL Office Complex, 1 Minto Road, Dhaka 1000,
Bangladesh, Tel:(880-2) 9336701, Fax:(880-2) 9335641, Email: ctronchet@unicef.org
Shamima Akhter, Department of Epidemiology, School of Public Health, University of Alabama
Birmingham, shamima@uab.edu
Abbas Bhuiya, ICDDR,B, GPO Box 128, Dhaka-1000, Bangladesh, abbas@icddrb.org
Richard Johnston, Water and Environmental Sanitation Section, UNICEF Bangladesh
BSL Office Complex, 1 Minto Road, Dhaka 1000, Bangladesh, Tel:(880-2) 9336701 ext. 486
14
Mobile: (880) 1713-030-536, Fax:(880-2) 9335641, Email: rjohnston@unicef.org
15
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19
Table 1. Characteristics of participating households, rural Bangladesh 2007, (N=527)
n
Percent/mean
Number household residents
3042
5.8
Father of the youngest child lacks formal education
184
35
Mother of the youngest child lacks formal education
171
32
Drinking water source is a tubewell
505
96
Owns source of drinking water
170
32
Owns latrine
433
82
Uses improved latrine
416
79
Inside or near the toilet
198
38
Inside or near kitchen
47
9
Elsewhere in the yard
121
23
Outside the yard
136
26
No specific place
25
5
Water is available
378
72
Soap is available
276
52
Water and soap are available
225
42
Characteristic
General
Where the household usually washes hands after toileting
At place of handwashing after toileting
20
Characteristics used in constructing wealth index
Proportion who own
House
493
93
Bicycle
132
25
Television (B/W)
109
21
Television (Color)
56
11
Refrigerator
15
3
Motor cycle
10
2
Sewing machine
42
8
Mobile phone
169
32
Wardrobe
155
29
Tables
527
1.1
Chairs
527
2.3
Watches/clocks
527
1.5
Beds
527
0.9
Inexpensive sleeping cots
527
1.4
Cement floor
55
10
Brick walls
52
10
Tin roof
479
91
Mean number of rooms
527
2.2
Mean number of items owned
House construction
21
Electrical connection
236
45
Wood
133
25
Crop residue /grass / Dung
390
74
4
1
Median amount of homestead land (acre)
527
.08
Median amount of other land (acre)
527
.17
Cooking fuel
Liquid gas/ gas
22
Table 2. The number and percentage of fecal contact events by age and sex (N=761)
Age in years
No (%)
<3
9 (1)
3- <5
54 (7)
5- 12
90 (12)
> 12
608 (80)
Female
601 (79)
Male
160 (21)
Adult caregivers
438 (58)
Adult (> 12 years) old non-caregivers
170 (22)
Children (< 12)
153 (20)
23
Table 3. Household characteristics associated with washing both hands with soap after fecal contact (N=761 observed fecal contact
events)
Characteristic
Number and
proportion of
persons with this
characteristic who
washed both
hands with soap
n (%)
Number and
proportion of
persons without
this characteristic
who washed both
hands with soap n
(%)
Adjusted odds
ratio* (95%
confidence limit)
P-value
Adult caregiver
102 (23)
9 (6)
4.3 (2.4, 7.3)
<0.001
Adult non-caregiver
23 (14)
9 (6)
2.1 (1.0, 4.4)
0.05
Female sex
119 (20)
15 (9)
2.2 (1.3, 3.8)
0.004
Some primary education
40 (17)
25 (10)
1.8 (1.0, 3.1)
0.04
Above primary education
69 (26)
25 (10)
3.0 (1.8, 5.1)
<0.001
Age (compared to child <12 years)
Mother’s education (compared to uneducated)
Father’s education (compared to uneducated)
24
Some primary education
37 (16)
37 (14)
1.2 (0.67, 2.0)
0.58
Above primary education
60 (23)
37 (14)
1.9 (1.1, 3.2)
0.03
2nd quintile
21 (14)
17 (11)
1.3 (0.64, 2.6)
0.47
3rd quintile
23 (16)
17 (11)
1.4 (0.72, 2.9)
0.30
4th quintile
32 (20)
17 (11)
2.0 (1.1, 3.9)
0.03
5th quintile
41 (26)
17 (11)
2.8 (1.4, 5.2)
0.02
Inside or near the toilet facility
56 (19)
30 (16)
1.3 (0.74, 2.3)
0.37
Inside or near kitchen
14 (21)
30 (16)
1.4 (0.60, 3.2)
0.44
Elsewhere in the yard
32 (18)
30 (16)
1.2 (0.64, 2.1)
0.63
2 (6)
30 (16)
0.33 (0.06, 1.7)
0.19
Wealth index (compared to poorest quintile)
Where the household usually washes hands after
toileting (compared to outside the yard)
No specific place
25
At place of handwashing after toileting
Water is available
116 (21)
18 (9)
2.7 (1.5, 4.7)
<0.001
Soap is available
93 (24)
41 (11)
2.5 (1.3, 1.6)
<0.001
Water plus soap is available
79 (24)
55 (13)
2.1 (1.4, 3.1)
<0.001
Has separate soap for handwashing
39 (21)
95 (16)
1.2 (0.89, 2.1)
0.15
Has spare soap available in the household
55 (21)
79 (16)
1.5 (0.95, 2.3)
0.09
Buys soap weekly
47 (19)
87 (17)
1.2 (0.75, 1.8)
0.48
Drinking water source is shallow tube well
113 (18)
21 (15)
1.2 (0.64, 2.2)
0.59
Has other container to wash hands in
28 (21)
106 (17)
1.4 (0.81, 2.3)
0.25
Water observed in other container to wash hands in
16 (16)
118 (18)
1.0 (0.53, 1.9)
0.97
Has a household water tap
2 (40)
132 (18)
3.3 (0.47, 23.6)
0.23
111 (19)
23 (14)
1.3 (0.78, 2.2)
0.29
Has access to improved sanitation facilities
*Odds ratio was calculated using a general estimated equations model that adjusted for neighborhood clustering and repeated
sampling from the same household with a nested correlation structure.
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Table 4. Multivariable analysis* of characteristics associated with handwashing
Characteristic
Adjusted Odds
P-value
ratio* (95%
Confidence Limit)
Age group compared to child <12 years of age
Adult caregiver
4.2 (2.3, 7.6)
<0.001
Adult non-caregiver
1.8 (0.78, 4.0)
0.17
Some primary education
1.6 (0.89, 2.7)
0.12
Above primary education
2.4 (1.4, 4.1)
0.002
Water is available
2.2 (1.3, 4.0)
0.006
Soap is available
2.1 (1.3, 3.4)
0.002
Mother’s education compared to uneducated
At place of handwashing after toileting
*Odds ratio was calculated using a general estimated equations model that accounted for
neighborhood clustering and repeated household sampling using a nested correlation structure.
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Figure 1. Sub-districts included in the SHEWA-B Health Impact Evaluation
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