Measuring hand washing behaviour in low income settings: methodological and validity issues

Abstract

Significant global health attention and promotion has been focused on hand washing with soap due to the
clear benefits observed in promoting and ensuring child health. However, the measurement and evaluation
of hand washing behaviours remains complex. The Sanitation, Hygiene Education and Water Supply in
Bangladesh Programme (SHEWA-B) is a large project being implemented by the Government of
Bangladesh and UNICEF.

This research assessed methodological issues of measuring hand washing behaviours through comparison
of structured observation and responses to cross-sectional survey measures (spot-check observation, selfreported
hand washing and a hand washing demonstration) and discusses the suitability of indicators. Focus
group discussions with fieldworkers were also conducted.

The results of this study indicate that hand washing behaviours were over-reported compared with
structured observation findings. This implies that current estimates of hand washing from large scale
surveys, for example, Demographic and Health Surveys (DHS) are also likely to be overestimates.

In about 1000 households, approximately 1% or less of female caregivers were observed to wash their
hands with soap or ash before preparing food, before eating, and 3% before feeding a child. Hand washing
with soap was higher for defecation related events with approximately 29% of female caregivers using soap
two thirds or more of the time after cleaning a child’s anus/disposing of a child’s stools and 38% used soap
two-thirds or more of the time after defecation. Soap was observed at the hand washing location in about
50% of the households but actual practice was much lower. Reported knowledge was high; approximately
90% identified the important times for hand washing as being before eating and after defecation and
approximately 50% identified before preparing food and after cleaning/changing a baby.

The measurement of hand washing is complex and there has been limited research into the validity of
different measurement methods. This research used an epidemiological style approach using the concepts of
screening/diagnostic testing and calculation of kappa statistics to assess validity.

In conclusion, this research demonstrates that self report hand washing measures are subject to over
reporting. Structured observation provides useful information on directly observed hand washing behaviours
and the frequency of behaviours. Spot check methods of soap and hand washing locations also provide more
optimistic data than observations and can be used as an alternative to structured observation. In addition, the
use of questions on the 24 hour recall of soap and other self report questions on knowledge and the
availability of spare soap demonstrate potential for use as potential indicators as an alternative to structured
observation. Further validation of measurement methods is required in different country settings.

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Identifiers

ORCID for Jane Falkingham: orcid.org/0000-0002-7135-5875

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