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

Significant global health attention and promotion has been focused on hand washing with soap due to the<br/>clear benefits observed in promoting and ensuring child health. However, the measurement and evaluation<br/>of hand washing behaviours remains complex. The Sanitation, Hygiene Education and Water Supply in<br/>Bangladesh Programme (SHEWA-B) is a large project being implemented by the Government of<br/>Bangladesh and UNICEF.<br/><br/>This research assessed methodological issues of measuring hand washing behaviours through comparison<br/>of structured observation and responses to cross-sectional survey measures (spot-check observation, selfreported<br/>hand washing and a hand washing demonstration) and discusses the suitability of indicators. Focus<br/>group discussions with fieldworkers were also conducted.<br/><br/>The results of this study indicate that hand washing behaviours were over-reported compared with<br/>structured observation findings. This implies that current estimates of hand washing from large scale<br/>surveys, for example, Demographic and Health Surveys (DHS) are also likely to be overestimates.<br/><br/>In about 1000 households, approximately 1% or less of female caregivers were observed to wash their<br/>hands with soap or ash before preparing food, before eating, and 3% before feeding a child. Hand washing<br/>with soap was higher for defecation related events with approximately 29% of female caregivers using soap<br/>two thirds or more of the time after cleaning a child’s anus/disposing of a child’s stools and 38% used soap<br/>two-thirds or more of the time after defecation. Soap was observed at the hand washing location in about<br/>50% of the households but actual practice was much lower. Reported knowledge was high; approximately<br/>90% identified the important times for hand washing as being before eating and after defecation and<br/>approximately 50% identified before preparing food and after cleaning/changing a baby.<br/><br/>The measurement of hand washing is complex and there has been limited research into the validity of<br/>different measurement methods. This research used an epidemiological style approach using the concepts of<br/>screening/diagnostic testing and calculation of kappa statistics to assess validity.<br/><br/>In conclusion, this research demonstrates that self report hand washing measures are subject to over<br/>reporting. Structured observation provides useful information on directly observed hand washing behaviours<br/>and the frequency of behaviours. Spot check methods of soap and hand washing locations also provide more<br/>optimistic data than observations and can be used as an alternative to structured observation. In addition, the<br/>use of questions on the 24 hour recall of soap and other self report questions on knowledge and the<br/>availability of spare soap demonstrate potential for use as potential indicators as an alternative to structured<br/>observation. Further validation of measurement methods is required in different country settings.

Name dc:type.qualificationname

Ph.D.

Level dc:type.qualificationlevel

doctoral

Grantor dc:publisher.institution

University of Southampton

Year dc:date.issued

2010

Author dc:creator

• Danquah, Lisa Odoso

Advisor dc:contributor.advisor

• Falkingham, Jane