ABSTRACT.
Improvement in hand hygiene has been strongly associated with positive outcomes in maternal and child health. Although Bangladesh has a high level of awareness of key hygiene messages, the practice of handwashing, the most effective hygiene behavior, is low. Suchana, a multisectoral nutrition program, aims to increase knowledge and practices around various water, sanitation, and hygiene settings in Sylhet region, the northeast of rural Bangladesh. This study aimed to investigate the changes in indicators related to handwashing knowledge and practices among Suchana beneficiaries in final compared with baseline evaluations. Data were derived from the baseline and final cross-sectional evaluation survey. The following handwashing knowledge and practices were considered: handwashing before preparing food, before eating food and feeding children, before serving food, after defecation, and after touching animals. The descriptive findings indicate that Suchana intervention improved handwashing knowledge and practices in the intervention area compared with the control. The odds of having knowledge of hand washing before preparing food (adjusted odds ratio [aOR]: 1.60; 95% CI: 1.30–1.98), before eating food and feeding children (aOR: 1.68; 95% CI: 1.25–2.25), before serving food (aOR: 1.35; 95% CI: 1.04–1.76), after defecation (aOR: 1.74; 95% CI: 1.25–2.41), and after touching animals (aOR: 1.67; 95% CI: 1.29–2.16) were higher in intervention area than the control area. Similarly, the impact on maternal handwashing practices at final evaluation indicated successful effects of the intervention. These results suggest scaling-up of similar interventions for larger populations living in vulnerable areas of rural Bangladesh.
INTRODUCTION
Globally, a high incidence of hand hygiene–related diseases among children under age 5 still accounts for an inordinate number of deaths.1 According to the national hygiene baseline survey, sanitation is often poor and hygiene practices are suboptimal in Bangladesh, which may result in several hand hygiene–related diseases.2 Moreover, in rural Bangladeshi households (HH), domestication of cattle and poultry promotes increased human–animal contact, leading to high infectious disease transmission.3 Handwashing with soap could considerably decrease diarrhea and respiratory infections; however, handwashing is still not widely practiced in many countries, including Bangladesh.4–6 Despite its protective effect, handwashing remains infrequently practiced in low- and middle-income countries. It is estimated that only 3% to 34% of the adults worldwide wash their hands with soap at critical times. Using data from national surveys, Wolf et al. reported that 27% of the world population lacks a designated handwashing facility. Knowledge and practices of handwashing with soap has been proposed to be one of the most cost-effective interventions for prevention of infectious diseases.7,8 Nonetheless, there have been few evaluations of large-scale handwashing promotion programs in the community setting. Several studies highlighted the impact of a scaled-up program to increase knowledge and behavior change around different water, sanitation, and hygiene (WASH) settings. Earlier studies have not been conclusive in determining a specific intervention, which will be effective to increase such knowledge and practices across all geographic locations and scenarios because each study made use of different interventions and measured various outcomes.9–13
In many countries, mothers are the primary caregivers for their children, and mothers’ knowledge and practices play an important role in child health.14–17 Earlier studies have shown that mothers are not always aware of the importance of using soap with handwashing and the impact of hand hygiene on their children’s health.15–18 Certain behavioral aspects of mothers such as handling food and water or nurturing the children immediately after handling domestic animals increases the risk of hand-to-mouth contamination.19 Improvements in hand hygiene have the potential to decrease morbidity and mortality by reducing infections, transmitted through fecal–oral routes and person-to-person contact.20–22 A recent systematic review revealed that educating mothers about personal hygiene can reduce the risk of infectious disease by 27%.23 However, there is a lack of information on knowledge and practices of handwashing with soap or other handwashing agents, especially among the disadvantaged segments of the population in Bangladesh. It is well established that recurrent subclinical gastrointestinal infections can lead to chronic mucosal inflammatory conditions and disrupt the gut microbiome, resulting in “environmental enteric dysfunction,” which can further obstruct nutrient absorption.24 Indeed, the causes of undernutrition are multifaceted, and thus interventions are needed to address the factors underlying inadequate health and nutrition. Literature suggests that interventions focusing on hygiene promotion among vulnerable groups are relatively rare, which has created a gap in our understanding of their potential contribution to reducing child undernutrition and infectious disease burden. In addition, previous research that looked at the long-term effects of handwashing interventions found that they seldom resulted in long-term adoption of improved handwashing practices in resource-constrained settings.25,26
There is increasing recognition that many poor/very poor HH, especially in low- and middle-income countries, lack even the most basic WASH services, required to prevent and control infections. Adequate water supply and sufficient sanitation measures, as well as improved hygienic practices, should be promoted as integral components of any nutrition program in low- and middle-income countries such as Bangladesh. Current data suggest that there have been improvements in the water and sanitation situation nationwide: the estimated national prevalence of hygienic sanitation in Bangladesh was 45% in 2014 and increased to 65% in 2018. In contrast, Sylhet is one of the most vulnerable regions in northeastern Bangladesh; several important indicators of healthcare, maternal and child nutrition, and socioeconomic status (SES) remain low in this division, even though Bangladesh has achieved remarkable accomplishments in improving the health of the population.27,28 The situation in Sylhet will only worsen if adequate strategies are not implemented. The Suchana program is a 7-year intervention initiated in 2015 and is being implemented in 157 unions (clusters), the smallest administrative unit in Bangladesh, of Sylhet and Moulvibazar districts.29 WASH is one significant component of this large-scale nutrition program working with the poor and vulnerable population. The program advises the vulnerable beneficiaries on handwashing and waste management practices at five critical times: before preparing food, before eating food and feeding children, before serving food, after defecation, and after touching animals.
This article examines the hypothesis that the Suchana intervention achieved a significant improvement in handwashing knowledge and practices and aimed to address the knowledge gaps related to hand hygiene, with a particular emphasis on determining the factors associated with knowledge and practices of handwashing among women with at least one child aged < 24 months from systematically selected vulnerable HH in rural Bangladesh.
METHODS
Study design and population.
Suchana is a large-scale, multisector nutrition program that aimed to reduce the incidence of stunting among children under two years-of-age by breaking the intergenerational cycle of malnutrition in Sylhet and Moulvibazar districts, Sylhet division, Bangladesh. The study design, methodology, and inclusion and exclusion criteria have been previously described in detail.29–31 Briefly, the program is being implemented via a stepped-wedge model; however, the evaluation surveys used a cluster-randomized controlled pre–post design among the beneficiary women with at least one child aged < 24 months belonging to the selected vulnerable HHs.
Randomization was performed before the unions were allocated to one of the four phases. HHs were selected via a probability sampling approach using a systematic sampling method to ensure an equal beneficiary-to-control HH survey ratio. For evaluation purposes, the baseline and final surveys were carried out among Suchana beneficiaries from the first phase of 40 unions exposed to 3 years of the program (intervention group) and a fourth phase of 40 unions (control group) who will begin the intervention in the fourth year of the program.
Baseline data were collected between the end of November 2016 and February 2017 and final survey data, between November 2019 and February 2020. Data on 5,440 HHs from 80 unions consisting of 640 villages were collected in the baseline survey. To measure the changes in the surveyed HHs, data on 10,722 HHs was collected in the final survey after the first 3 years of the intervention.
The sampling procedure primarily entailed selection of 80 of 157 unions by lottery. Thereafter, through consultation with local leaders, government officials, and representatives, vulnerable communities in the selected unions were identified. A participatory rural appraisal approach involving the HH heads or representatives was used to identify the poor and very poor HH in each village. The terms “poor” and “very poor” were context-specific, reflecting villagers’ perceptions of each HH ’s level of poverty and vulnerability; hence, these criteria differed between villages. A list of vulnerable HH was made for each village, that were visited to validate their vulnerable status. A systematic questionnaire was used to assess the vulnerability of the HH based on the Suchana beneficiary inclusion criteria. The inclusion criteria for enrolled vulnerable HH are shown in Supplemental Table 1.
Suchana intervention and data collection.
Water and sanitation were major components of Suchana, and the program aimed to advise the beneficiaries on handwashing practices at critical events to reduce transmission of pathogens to the young children (Supplemental Table 2). Suchana considered two major events, fecal contact events (i.e., after defecation, after contact with animals) and food events (i.e., before preparing food, before eating food and feeding children, before serving food), at five critical times to assess the knowledge and practices of the vulnerable beneficiaries. Suchana also encouraged women to keep waste in a dedicated place and trained women on poultry and livestock (goat, sheep, etc.) rearing. One of the nutrition-specific interventions of the program was courtyard sessions with mother and child groups, with the messages sequentially addressing the importance of hand hygiene in health outcomes. Suchana also provided logistic support to install handwashing stations within the HHs. Moreover, Suchana developed linkages with the private sector to make hygiene sanitation equipment available to the Suchana beneficiary families.29,32 With the aim to measure the effects of intervention on handwashing, the program assessed maternal knowledge (cognitive domain) and practices (behavioral domain) after 3 years at final evaluation.
Separate standard operating procedures were followed for interviewing the study participants. The survey team planned 40 days of training, including field testing and adjustment of the data collection tools. The training included a brief program overview; general rules, norms, and guidance on survey implementation; the survey methodology, such as team composition, sampling and the HH selection process; a detailed discussion of the questionnaire form, interview techniques, administration of questionnaires, and handling of the Android PDA; role-play exercises aided by demonstrations to gain a better understanding of techniques for asking sensitive questions; and methods of ensuring the quality of the data.
Outcome variables.
The outcome variables were the handwashing knowledge and practices of mothers during five critical times: 1) before preparing food, 2) before eating food and feeding children, 3) before serving food, 4) cleaning children after defecation, and 5) after handling livestock. All outcomes were treated as dichotomous variables. Of note, the data were gathered from maternal responses, that is, the practices were self-reported practices.
Covariates.
A list of several covariates was generated through descriptive analysis and a literature review.
The conceptual framework of this work is provided in Figure 1. Information on religion, level of education and occupation of the head of the HH, and number of family members were used as HH demographic characteristics. Ownership of HH asset, floor material, main roof material, external wall material, number of dwelling rooms, type of latrine, and sources of drinking water were the key indicators of SES. Factor analysis was used to create asset index as SES using this information. Several maternal characteristics were used in this study as covariates to adjust the multiple models to assess the independent impact of intervention on handwashing practice and knowledge at five critical times. The indicators were current age, visit by NGO healthcare professionals, experience of any domestic violence, education level of women, antenatal care check-up, and attending courtyard Expanded Program on Immunization sessions in the community.31 Other covariates such as water and soap/ash/mud available within 30 feet of the toilet structure and membership in cooperative/savings committee were also analyzed.
Figure 1.
Conceptual framework. HH = household.
Statistical analysis.
Data management.
The Suchana data collection software contained built-in validation rules, including maximum validation rules to prevent errors during data entry, such as uniqueness, requirements, skipping rules, value ranges, conditional fields and the numbers of digits that could be entered. The software interface was developed by the icddr,b IT team as an Android based application and data were synchronized to the central server. Activities such as editing (after receiving feedback from field staff members), updating, range checks, duplication checks, consistency checks, frequency checks, and cross tabulation were regularly performed during data entry. If any unusual observations were reported, the issues were discussed and resolved. When data collection was complete, the data were transferred to Stata software (Release 14; StataCorp LP, College Station, TX), and the variable labels and values were coded as per the questionnaire.
Descriptive statistics.
Histograms, bar diagrams, pie charts and scatterplots were used for data visualization. Descriptive statistics were used to summarize the data, including frequencies and proportions for categorical variables, means and standard deviations for normally distributed quantitative variables, and medians and interquartile ranges for nonnormally distributed quantitative variables. The outcome variables and covariates were stratified by the baseline/final survey and by the intervention/control group.
Explorative statistics.
To test the hypothesis of interest, that Suchana achieved significant improvements in handwashing knowledge and practices at five critical times, a simple logit model was primarily used to explore the bivariate associations between each outcome variables and the intervention variables. For this analysis, the Suchana control group was used as the reference category. To estimate the independent effect of the Suchana intervention as an exposure, multiple binary logistic regression models were used after adjusting for union as a cluster and relevant covariates. The covariates were included in the multiple regression model using a stepwise forward selection method; some relevant variables were also adjusted, regardless of their P value. To compare pre–post and treatment–control group, we performed difference in differences (D-I-D) analyses. D-I-D values were calculated from post-estimation findings using multiple logistic regression analysis where interaction between Suchana intervention and time was adjusted in the model. P values < 0.05 were considered as statistically significant.
RESULTS
General characteristics.
A total of 16,158 women were interviewed: 5,440 (intervention: 2,720; control: 2,720) in the baseline study and 10,722 (intervention: 5,282; control: 5,440) in the final study. Table 1 describes the sociodemographic characteristics and general characteristics of the surveyed women. Figure 2 describes the handwashing knowledge and practices with soap at five critical times for the mothers with children aged under 2 years. There was no significant difference between the intervention and control unions in terms of maternal handwashing knowledge and practices with soap at five critical times at baseline.
Table 1.
Household and women’s general characteristics
| Indicator, % (n) | Baseline survey | Final survey | ||||
|---|---|---|---|---|---|---|
| Intervention | Control | P | Intervention | Control | P | |
| HH characteristics | ||||||
| HH head was male | 95.99 (2,611) | 96.80 (2,633) | 0.273 | 92.41 (4,880) | 92.48 (5,028) | 0.934 |
| Age of HH head | 39.3 ± 13.0 | 40.2 ± 13.2 | 0.103 | 38.5 ± 10.5 | 38.6 ± 12.1 | 0.811 |
| HH head had no formal schooling | 49.02 (1,333) | 48.86 (1,329) | 0.954 | 44.26 (2,337) | 40.68 (2,212) | 0.212 |
| HH size | 6.12 ± 2.31 | 6.48 ± 2.56 | 0.002 | 6.13 ± 2.11 | 5.94 ± 2.27 | 0.029 |
| Asset index | ||||||
| 1st quintile | 20.26 (551) | 19.74 (537) | 0.859 | 18.73 (989) | 21.24 (1,155) | 0.335 |
| 2nd quintile | 20.92 (569) | 19.08 (519) | 0.187 | 19.96 (1,054) | 20.08 (1,092) | 0.93 |
| 3rd quintile | 19.71 (536) | 20.29 (552) | 0.613 | 20.58 (1,087) | 19.39 (1,054) | 0.283 |
| 4th quintile | 20.77 (565) | 19.23 (523) | 0.32 | 20.98 (1,108) | 19.05 (1,036) | 0.18 |
| 5th quintile | 18.35 (499) | 21.65 (589) | 0.197 | 19.75 (1,043) | 20.23 (1,100) | 0.856 |
| Membership in cooperative/savings committee | 33.3 (905) | 32.0 (869) | 0.707 | 50.75 (2,680) | 33.92 (1,844) | < 0.001 |
| Women’s general characteristics | ||||||
| Current age | 26.87 ± 5.61 | 26.92 ± 5.67 | 0.838 | 29.15 ± 5.31 | 27.27 ± 5.71 | < 0.001 |
| Age at marriage | 18.14 ± 2.65 | 18.34 ± 2.77 | 0.209 | 18.68 ± 2.94 | 18.88 ± 3.08 | 0.298 |
| Age at first pregnancy | 19.24 ± 2.87 | 19.40 ± 2.94 | 0.279 | 19.73 ± 3.12 | 19.79 ± 3.21 | 0.738 |
| Education | ||||||
| No schooling | 22.32 (607) | 23.75 (646) | 0.665 | 17.91 (946) | 14.66 (797) | 0.18 |
| Primary incomplete | 22.72 (618) | 21.14 (575) | 0.285 | 23.37 (1,234) | 22.51 (1,224) | 0.664 |
| Primary complete | 54.96 (1,495) | 55.11 (1,499) | 0.969 | 58.72 (3,101) | 62.83 (3,416) | 0.281 |
| Did not get any support from HH members | 5.44 (148) | 5.77 (157) | 0.726 | 3.43 (181) | 4.10 (223) | 0.499 |
| Visits from NGO health professionals | 27.50 (748) | 17.1 (465) | 0.062 | 39.92 (2,108) | 20.05 (1,090) | < 0.001 |
| Domestic violence and abuse | ||||||
| Husband threatening divorce | 7.46 (203) | 6.80 (185) | 0.428 | 9.35 (494) | 11.44 (622) | 0.105 |
| Husband threatening to take another wife | 7.87 (214) | 6.99 (190) | 0.343 | 10.68 (564) | 12.31 (669) | 0.24 |
| Verbal abuse by husband/other family member(s) | 33.79 (919) | 31.32 (852) | 0.272 | 43.14 (2,278) | 41.92 (2,279) | 0.665 |
| Physical abuse by husband/other family member(s) | 13.75 (374) | 13.38 (364) | 0.794 | 17.97 (949) | 19.32 (1,050) | 0.519 |
| Experienced any domestic violence | 36.07 (981) | 33.27 (905) | 0.198 | 44.57 (2,354) | 43.65 (2,373) | 0.747 |
| At least four antenatal care checkups | 14.63 (398) | 12.21 (332) | 0.317 | 36.08 (1,905) | 16.16 (879) | < 0.001 |
| Water and soap/ash/mud available within 30 feet of the toilet structure | 25.55 (695) | 28.6 (778) | 0.244 | 51.02 (2,694) | 48.93 (2,662) | 0.620 |
| Whether attend courtyard sessions during EPI sessions in community | 19.3 (525) | 21.84 (594) | 0.434 | 23.53 (1,243) | 10.27 (559) | < 0.001 |
EPI = Expanded Program on Immunization; HH = household; NGO = nongovernmental organization.
Figure 2.
Mothers with at least one child aged < 24 months reported hand washing knowledge and practice with soap at five critical times.
In the final survey, 49.2% of mothers reported knowledge of the need for handwashing before preparing food (intervention: 55.8%, control: 42.5%), 55.1%, before eating and feeding children (intervention: 62.5%, control: 47.6%); 24.2%, before serving food (intervention: 27.8%, control: 20.6%); 40.7%, after defecation (intervention: 48.3%, control: 33.1%); and 22.3%, after touching animals (intervention: 27.7%, control: 17.5%). Again, at final evaluation, 55.5% of mothers reported practices of handwashing before preparing food (intervention: 63.9%, control: 47.1%); 48.9%, before eating and feeding children (intervention: 59.3%, control: 38.5%); 45.5%, before serving food (intervention: 53.9%, control: 37.0%); 84.1%, after defecation (intervention: 89.3%, control: 78.9%); and 71.0%, after touching animals (intervention: 78.6%, control: 63.3%; Figure 2).
The proportion of HH using tube-wells as a source of drinking water during all seasons was not significantly different between groups in either survey. Overall, at both baseline and final survey, there was no significant difference between groups in terms of the proportion of HH with a handwashing station equipped with both a water source and soap within 30 feet of the toilet structure. At final survey, the intervention significantly increased the proportion of HH receiving visits from NGO health professionals, mothers receiving the optimal number of antenatal care visits, and the mothers’ attendance at courtyard sessions regarding the Expanded Program on Immunization in the community (Table 1).
Factors associated with maternal handwashing practices.
We calculated the adjusted odds ratios (aORs) to assess the associations between the indicators of maternal knowledge and practice of handwashing with soap/ash at five critical times and other relevant variables/covariates using multiple binary logistic regression after adjusting for union as a cluster (Tables 2 and 3). Mothers receiving at least four antenatal care checkups, maternal experience of no domestic violence, maternal education (primary level complete), age of the HH head, women receiving support from HH members, HH membership in cooperative/savings committee, and the availability of water and soap/ash/mud within 30 feet of the toilet structure were significantly associated with maternal handwashing practices (Table 3).
Table 2.
Factors associated with maternal knowledge of handwashing with soap/ash at five critical times
| Indicator | Before preparing food Adjusted odds ratio (95% CI) | Before eating and feeding children Adjusted odds ratio (95% CI) | Before serving food Adjusted odds ratio (95% CI) | After defecation Adjusted odds ratio (95% CI) | After touching animals/birds Adjusted odds ratio (95% CI) |
|---|---|---|---|---|---|
| Antenatal care checkup during pregnancy | |||||
| Less than four | Reference | Reference | Reference | Reference | Reference |
| At least four | 1.37 (1.24–1.50) | 1.39 (1.26–1.54) | 1.28 (1.14–1.44) | 1.25 (1.11–1.41) | 1.29 (1.14–1.45) |
| Experience of domestic violence | |||||
| Yes | Reference | Reference | Reference | Reference | Reference |
| No | 0.94 (0.87–1.01)* | 1.02 (0.94–1.12)* | 1.07 (0.96–1.19)* | 1.1 (0.98–1.24)* | 1.00 (0.87–1.16)* |
| Maternal education | |||||
| No schooling | Reference | Reference | Reference | Reference | Reference |
| Primary incomplete | 1.20 (1.07–1.35) | 1.11 (0.99–1.24)* | 1.10 (0.97–1.26)* | 1.03 (0.92–1.15)* | 1.02 (0.90–1.16)* |
| Primary complete | 1.15 (1.03–1.28) | 1.22 (1.09–1.37) | 1.03 (0.90–1.17) | 1.05 (0.94–1.19) | 0.96 (0.85–1.07) |
| At least 1 year formal education of HH head | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.07 (0.99–1.15)* | 1.05 (0.97–1.13)* | 0.93 (0.85–1.02)* | 0.97 (0.91–1.04)* | 0.90 (0.83–0.97) |
| Age of HH head | 1.00 (1.00–1.00)* | 1.00 (1.00–1.00)* | 1.00 (0.99–1.00)* | 1.00 (0.99–1.00)* | 1.00 (0.99–1.00) |
| Attended courtyard EPI sessions in community | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.12 (0.98–1.29)* | 1.23 (1.06–1.44) | 1.14 (0.92–1.41)* | 1.21 (1.05–1.39) | 1.25 (1.05–1.48) |
| Women received support from HH members | |||||
| No support | Reference | Reference | Reference | Reference | Reference |
| Some support | 0.91 (0.77–1.08)* | 1.55 (1.27–1.9) | 1.04 (0.85–1.28)* | 1.73 (1.36–2.21) | 1.90 (1.4–2.56) |
| Membership in cooperative/savings committee | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.14 (1.04–1.24) | 1.12 (1.03–1.22) | 1.12 (1.01–1.25) | 0.99 (0.89–1.10)* | 1.08 (0.97–1.21)* |
| Water and soap/ash/mud available within 30 feet of the toilet structure | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.21 (1.08–1.36) | 1.23 (1.11–1.36) | 1.39 (1.22–1.58) | 1.30 (1.16–1.47) | 1.39 (1.22–1.58) |
| Asset index | |||||
| 1st quintile | Reference | Reference | Reference | Reference | Reference |
| 2nd quintile | 1.12 (1.01–1.24) | 1.12 (1.03–1.23) | 1.15 (1.00–1.32) | 1.27 (1.16–1.40) | 1.19 (1.03–1.37) |
| 3rd quintile | 1.08 (0.97–1.19)* | 1.31 (1.18–1.46) | 1.31 (1.13–1.50) | 1.30 (1.17–1.44) | 1.21 (1.04–1.42) |
| 4th quintile | 1.22 (1.06–1.39) | 1.51 (1.33–1.70) | 1.42 (1.23–1.64) | 1.47 (1.31–1.66) | 1.42 (1.22–1.66) |
| 5th quintile | 1.18 (1.03–1.35) | 1.46 (1.28–1.66) | 1.29 (1.11–1.51) | 1.29 (1.14–1.47) | 1.45 (1.24–1.69) |
EPI = Expanded Program on Immunization; HH = household.
Not statistically significant. Union was adjusted for as a cluster.
Table 3.
Factors associated with maternal practices of hand washing with soap/ash at five critical times
| Indicator | Before preparing food Adjusted odds ratio (95% CI) | Before eating food and feeding children Adjusted odds ratio (95% CI) | Before serving food Adjusted odds ratio (95% CI) | After defecation Adjusted odds ratio (95% CI) | After touching animals/birds Adjusted odds ratio (95% CI) |
|---|---|---|---|---|---|
| Antenatal care checkups | |||||
| Less than four | Reference | Reference | Reference | Reference | Reference |
| At least four | 1.58 (1.43–1.75) | 1.72 (1.54–1.93) | 1.62 (1.46–1.79) | 1.56 (1.36–1.78) | 1.59 (1.44–1.75) |
| Experience of domestic violence | |||||
| Yes | Reference | Reference | Reference | Reference | Reference |
| No | 1.19 (1.07–1.33) | 1.19 (1.07–1.31) | 1.22 (1.11–1.35) | 1.45 (1.29–1.62) | 1.25 (1.14–1.38) |
| Maternal education | |||||
| No schooling | Reference | Reference | Reference | Reference | Reference |
| Primary incomplete | 1.15 (1.02–1.30) | 1.1 (0.97–1.23)* | 1.08 (0.98–1.20)* | 1.21 (1.07–1.37) | 1.16 (1.05–1.28) |
| Primary complete | 1.19 (1.06–1.35) | 1.18 (1.03–1.34) | 1.15 (1.03–1.29) | 1.46 (1.29–1.65) | 1.21 (1.09–1.36) |
| At least 1 year formal education of HH head | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.19 (1.09–1.30) | 1.24 (1.14–1.35) | 1.19 (1.10–1.30) | 1.28 (1.17–1.4) | 1.12 (1.03–1.21) |
| HH head age | 1.00 (1.00–1.01) | 1 (1–1.01) | 1.01 (1.00–1.01) | 1.00 (1.00–1.01)* | 1.00 (1.00–1.01) |
| Attended courtyard EPI sessions in community | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.38 (1.16–1.65) | 1.36 (1.17–1.59) | 1.33 (1.13–1.56) | 1.19 (1.01–1.4) | 1.33 (1.17–1.52) |
| Women received support from HH members | |||||
| No support | Reference | Reference | Reference | Reference | Reference |
| Some support | 0.8 (0.68–0.96) | 0.86 (0.71–1.03)* | 0.66 (0.54–0.80) | 1.14 (0.93–1.4)* | 1.12 (0.96–1.3)* |
| Membership in cooperative/savings committee | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.31 (1.17–1.47) | 1.32 (1.18–1.47) | 1.26 (1.13–1.41) | 1.29 (1.14–1.45) | 1.25 (1.14–1.37) |
| Water and soap/ash/mud available within 30 feet of the toilet structure | |||||
| No | Reference | Reference | Reference | Reference | Reference |
| Yes | 1.61 (1.45–1.79) | 1.51 (1.35–1.7) | 1.49 (1.34–1.66) | 1.78 (1.54–2.06) | 1.56 (1.38–1.77) |
| Asset index | |||||
| 1st quintile | Reference | Reference | Reference | Reference | Reference |
| 2nd quintile | 0.98 (0.87–1.10)* | 1.06 (0.94–1.20)* | 1.09 (0.97–1.23)* | 1.22 (1.09–1.37) | 1.11 (1.00–1.23)* |
| 3rd quintile | 0.94 (0.83–1.07)* | 1.00 (0.89–1.13)* | 1.04 (0.92–1.18)* | 1.31 (1.15–1.48) | 1.17 (1.04–1.30) |
| 4th quintile | 0.97 (0.85–1.09)* | 0.99 (0.87–1.12)* | 1.01 (0.89–1.15)* | 1.43 (1.20–1.72) | 1.15 (1.03–1.28) |
| 5th quintile | 1.07 (0.94–1.23)* | 1.09 (0.94–1.26)* | 1.05 (0.89–1.24)* | 1.57 (1.29–1.90) | 1.36 (1.18–1.57) |
EPI = Expanded Program on Immunization; HH = household.
Not statistically significant. Union was adjusted for as a cluster.
Explorative findings.
If significant differences were detected in the baseline survey, our aim was to perform “difference in differences” analyses to compare the pre–post and intervention–control groups. We did not undertake “difference in differences” analyses because there were no significant differences between the intervention and control groups at the baseline survey. As a result, the inferential statements were made based on analysis of final survey. The aORs were computed by multiple binary logistic regression to assess the strength of the associations between maternal handwashing knowledge and practices and exposure to the Suchana intervention (Table 4). The model was adjusted for several significant variables to identify the determinants of each outcome (Tables 2 and 3). Highly significant associations were observed between the Suchana intervention as exposure and outcome variables at final survey, whereas at baseline, there was no significant association.
Table 4.
Impact of the Suchana intervention on maternal handwashing knowledge and practices
| Baseline survey | Final survey | D-I-D (P value)* | |||
|---|---|---|---|---|---|
| aOR (95% CI) | P value | aOR (95% CI) | P value | ||
| Handwashing knowledge with soap/ash | |||||
| Before preparing food | 0.93 (0.79–1.10) | 0.409 | 1.60 (1.30–1.98) | 0.000 | 0.14 (0.000) |
| Before eating and feeding children | 1.06 (0.86–1.29) | 0.591 | 1.68 (1.25–2.25) | 0.001 | 0.12 (0.005) |
| Before serving food | 0.99 (0.77–1.26) | 0.911 | 1.35 (1.04–1.76) | 0.025 | 0.06 (0.102) |
| After defecation | 0.93 (0.73–1.17) | 0.518 | 1.74 (1.25–2.41) | 0.001 | 0.16 (0.000) |
| After touching animals/birds | 0.92 (0.72–1.17) | 0.485 | 1.67 (1.29–2.16) | 0.000 | 0.11 (0.002) |
| Hand washing practice with soap/ash | |||||
| Before preparing food | 0.83 (0.58–1.18) | 0.293 | 1.74 (1.35–2.24) | 0.000 | 0.19 (0.001) |
| Before eating and feeding children | 0.89 (0.62–1.26) | 0.502 | 2.08 (1.59–2.72) | 0.000 | 0.20 (0.000) |
| Before serving food | 0.87 (0.60–1.27) | 0.470 | 1.81 (1.43–2.30) | 0.000 | 0.17 (0.001) |
| After defecation | 0.84 (0.67–1.04) | 0.114 | 2.02 (1.52–2.68) | 0.000 | 0.12 (0.000) |
| After touching animals/birds | 0.91 (0.70–1.18) | 0.463 | 1.83 (1.44–2.33) | 0.000 | 0.16 (0.000) |
aOR = adjusted odds ratio; D-I-D = difference in differences. Adjusted for antenatal care checkup, experience of domestic violence, maternal education, at least 1-year formal education of household head, household head education, women receiving support from household members, membership in cooperative/savings committee, water and soap/ash/mud available within 30 feet from the toilet structure, and asset index. Union was adjusted as cluster. Corresponding knowledge was adjusted in the model on handwashing practices.
D-I-D values were calculated from post-estimation findings using multiple logistic regression analysis where interaction between Suchana intervention and time was adjusted in the model.
As shown in Table 4, the odds of mothers having knowledge of handwashing before preparing food (aOR: 1.60; 95% CI: 1.30–1.98; P < 0.001), before eating food and feeding children (aOR: 1.68; 95% CI: 1.25–2.25; P < 0.001), before serving food (aOR: 1.35; 95% CI: 1.04–1.76; P = 0.025), after defecation (aOR: 1.74; 95% CI: 1.25–2.41; P < 0.001), and after touching animals (aOR: 1.67; 95% CI: 1.29–2.16; P < 0.001) were significantly higher in the intervention group compared with the control group at final survey.
In terms of handwashing practices at final evaluation, the odds of mothers in the intervention group reporting handwashing before preparing food (aOR: 1.74; 95% CI: 1.35–2.24; P < 0.001), before eating and feeding children (aOR: 2.08; 95% CI: 1.59–2.72); P < 0.001), before serving food (aOR: 1.81; 95% CI: 1.43–2.30; P < 0.001), after defecation (aOR: 2.02; 95% CI: 1.52–2.68); P < 0.001), and after touching animals (aOR: 1.83; 95% CI: 1.44–2.33); P < 0.001) were also significantly higher than those of the control group. After performing the D-I-D analyses, we found that all indicators were significantly associated with Suchana intervention except handwashing knowledge with soap/ash before serving food.
DISCUSSION
This article explored the potential contribution of a large-scale intervention on handwashing knowledge and practices with soap at five critical times among mothers in the most vulnerable HH in rural Bangladesh. The results suggest that structural factors—namely, antenatal care checkup, experience of domestic violence, maternal education, at least 1 year of formal education of HH head, women getting support from HH members, membership in a cooperative/savings committee, water and soap/ash/mud available within 30 feet from the toilet structure, and asset index are associated with greater handwashing knowledge and practices with soap. After controlling these indicators, the Suchana intervention improved maternal handwashing knowledge and practice, which will eventually reduce the risk of disease transmission.33,34
Despite good hand hygiene practice being crucial preventative measures to reduce the burden of infectious diseases, the findings of this study indicate that many mothers in this rural setting do not have adequate knowledge of the need to wash their hands properly. For instance, approximately only one-third of mothers reported handwashing with soap after defecation at baseline survey. Similarly, study conducted by Scott et al. in Kerala, India, revealed that only 34% and 35% respondents used soap and water to wash their hands after using a toilet and after cleaning up a child, respectively.35 In this study, ∼15% of the mothers reported to have knowledge of handwashing with soap after touching animals at the baseline survey. Applying the intervention, it was found that ∼80% of mothers reported the practice of handwashing after such an event. Indeed, after exposure to the intervention, the proportion of mothers having knowledge of handwashing overall and at key event times increased. Similar improvements in maternal handwashing practices were observed, indicating that the Suchana approach successfully improved maternal handwashing knowledge and practices at all critical times. These findings are in line with other studies that have demonstrated increased knowledge and practice of handwashing after various interactive strategies.36,37 Previous hygiene interventions often used health messages that were apparently ineffective in terms of achieving sustained changes in handwashing practices.37,38 According to the Bangladesh National Hygiene Baseline Survey among nationally representative population, a location near the toilet for handwashing after defecation was detected in > 75% of the HH. In contrast, only 40% of the HH had both water and soap available for the purpose of handwashing.2 Notably, the Suchana intervention includes logistic support to install handwashing stations (water and soap/ash/mud available within 30 feet of the toilet structure) in the HH. Our findings are consistent with findings of earlier studies that provided handwashing agent (sanitizers, soap, or both), as part of the intervention strategy.12,13 Thus, the implication of this study is that a carefully designed, scalable intervention that meets the needs and aspirations of the vulnerable population has the potential to reduce the gap of knowledge and practice of handwashing with water and soap. Essentially, these needs will vary, and specific programs should be designed to improve hand hygiene practices and prevent both the spread of infectious diseases and undernutrition globally.
Our analysis revealed that several factors are associated with maternal handwashing knowledge and practices. For example, the availability of water and soap/ash/mud within 30 feet from the toilet structure is a major factor that influences handwashing behavior. Schmidt et al. showed that the frequency of handwashing was higher in HH with access to water and sanitation facilities.39 Luby and Halder reported that the availability of a handwashing station is associated with greater prevalence of handwashing practices.40 In agreement with previous studies, we found that educational level was positively associated with all maternal outcomes related to handwashing knowledge and practices.39,41 Importantly, SES is an important factor in context of optimal hand hygiene. Also, several studies have reported associations between handwashing behavior and HH socioeconomic characteristics.42,43 Moreover, our findings indicate that optimal antenatal care, reduced domestic violence, women receiving support from HH members, and membership in a cooperative/savings committee may help to enhance maternal hand hygiene practices. The aORs were computed to assess the strength of the associations between maternal handwashing knowledge and practices and exposure to the Suchana intervention. After controlling for relatively large number of significant covariates, our results depict significant positive associations between the intervention and any outcome at final evaluation indicating successful effect of the Suchana intervention. It is well established that mothers’ handwashing knowledge and practices are related to the cultural background of the HH as well as the community.44 Similar to earlier findings, our data suggest that promotion of social behavior-change activities using effective approaches coupled with supporting materials may offer a more concrete solution to ensure handwashing practices in poor and very poor HH of our society.45 Therefore, it is clear that, compared with the control group, the Suchana interventions, such as the courtyard sessions that included mother and child group discussions to describe the significance of handwashing, connections with the private sector for easy access to hygiene sanitation to the beneficiaries, as well as having a handwashing station in suitable place, increased the prevalence of handwashing at key events in the intervention group at the final evaluation. This indicates that improved handwashing habits are more likely to be adopted in the long run among the Suchana beneficiaries. Nevertheless, whether the detected increase in handwashing with soap is sufficient to control infection requires further investigation. It is worth mentioning that when collecting data on the hand hygiene–specific status of the surveyed HH, we had to depend solely on the respondents’ reports at baseline and at the final evaluation. Thus, we cannot conclude that an equivalent degree of changes was achieved throughout the survey period. Further follow-up research studies using the logical framework approach are needed to address these issues efficiently.
Our analysis also demonstrated that exposure to the program increased the proportion of mothers receiving antenatal care. Mothers receiving antenatal care visits by skilled service providers is a major contributing factor for better nutritional status among children.46 The size of the HH, as well as mothers’ attendance at courtyard sessions regarding the Expanded Program on Immunization in the community also increased in the intervention areas. The Expanded Program on Immunization is an important indicator of child health, which has improved since the program’s inception in Bangladesh through several multisectoral strategies.47 These findings further support the implementation of large-scale interventions within the existing health system in rural Bangladesh.
Strengths and limitations.
The Suchana program, one of the largest nutrition interventions ever implemented globally, successfully led to positive changes in most critical study indicators. The cluster randomized pre–post design, large sample size, and appropriate sampling techniques provide strong evidence of the effect of the program on the outcome indicators are strengths of this study. Nevertheless, the possibility of recall bias exists because the data were gathered from maternal responses. However, the large sample size and adjustment for relevant covariates in the regression model help to diminish bias. Further, literature suggests that a valid method of measuring adoption of handwashing is indirect observation, which is focused on the existence of a particular place for handwashing in HH as well as the presence of soap and water at the time of observation.48,49 The Suchana program only targets marginalized HH, thus the inferences derived from this study are applicable to this marginalized subgroup and may not necessarily represent the determinant factors among the general population of Bangladesh.
CONCLUSION
The goal of this study was to see whether a scalable intervention, Suchana, might enhance the level of handwashing knowledge and practices among women with at least one child aged < 24 months from randomly selected underprivileged HH in rural Bangladesh. The evaluation data shows the Suchana intervention had a positive effect on handwashing knowledge and practices among study participants. Our analysis revealed significant positive associations between the intervention and maternal knowledge and practices on handwashing with soap/ash at five critical times at final evaluation. In light of the present global COVID-19 pandemic, interventions that disseminate good handwashing practices and, ideally, provision of soap in areas in need are urgently required. Moreover, such a message may also have a crossover effect; that is, we may observe reductions in other diseases linked to poor handwashing practices. Ultimately, the findings of this evaluation provide further support for implementation of future large-scale interventions in rural Bangladesh.
Supplemental Materials
ACKNOWLEDGMENTS
The study analyzed baseline and endline survey data from the Suchana intervention, which is being implemented by a consortium led by Save the Children, with support from the UK Foreign, Commonwealth, and Development Office (FCDO) and the European Union (EU). icddr,b acknowledges with gratitude the commitment of Save the Children, FCDO, and EU to its research efforts. We also acknowledge with gratitude the commitment of the Government of the People’s Republic of Bangladesh to icddr,b’s research activities. We sincerely acknowledge the following donors for providing unrestricted support to icddr,b’s efforts and advancement of its strategic plan: Global Affairs Canada, Sweden (SIDA), and FCDO. We acknowledge the invaluable contributions of Save the Children as the lead agency; our technical partners Helen Keller International and the World Fish and International Development Enterprises; and the implementing partners Friends In Village Development Bangladesh (FIVDB), Rangpur Dinajpur Rural Services (RDRS), and Center for Natural Resource Studies (CNRS), who played critical roles in generating and refining the Suchana data-collection tools. The American Society of Tropical Medicine and Hygiene (ASTMH) assisted with publication expenses.
Note: Supplemental material appears at www.ajtmh.org.
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