Measuring hand washing behaviour: methodological and validity issues : paper presented at the South Asia Hygiene Practitioners Workshop, Dhaka, Bangladesh, 1 to 4 February 2010

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 assesses methodological issues of measuring hand washing behaviours through comparison of structured observation and responses to cross-sectional survey measures (spot-check observation, self-reported hand washing and a hand washing demonstration) and discusses the suitability of indicators. Focus group discussions with fieldworkers also shed light on measurement issues and appropriateness of indicators. 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 likely to also be overestimates. This research also has important implications for the methods used for measuring hand hygiene practices in the clinical setting. 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; however, actual practice was much lower. Reported knowledge was high; approximately 90% identified before eating and after defecation as important times for hand washing and approximately 50% before preparing food and after cleaning/changing a baby. 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.