Improving measures of handwashing behavior : global scaling up handwashing project

As handwashing (HW) promotion is scaled up and adopted by organizations of varying research capacity, evaluation techniques that are more field-friendly, inexpensive, and readily adaptable are required. Based on the understanding of the available literature on measures of HW behavior, we posed the following questions: how reactive is a subject, with respect to HW behavior, when observed during an extended structured observation? Does the collection of hand rinse samples for quantifi cation of hand contamination result in handwashing reactivity? What is the optimum duration of a structured observation for the purposes of measuring HW behavior? What is the change in soap-use behavior during repeated structured observations within the same household? Does hand contamination measured at random times predict hand contamination at times critical to pathogen transmission? What is the rate of recontamination among the target population at two to three hours following a thorough handwashing? A cross-sectional survey was conducted in six randomly selected rural areas in Bangladesh to address these questions. In 100 households, handwashing behavior was assessed using sensor soaps, which consist of motion sensors embedded in soaps, structured observations of 90 minutes or five hours duration, spot checks, hand microbiology, and questionnaire administration. [authors abstract]