An Annotated Bibliography of 2013 Handwashing Studies
This annotated bibliography was compiled by WASHplus and contains citations and abstracts to 20 peer-review handwashing studies that were published from January through September 2013. Links are also provided to the abstract or full-text for each article. Please email WASHplus if you have additional studies to inlcude. 
JOURNAL ARTICLES, BY PUBLICATION DATE
SEPTEMBER 2013
1 — Handwashing before Food Preparation and Child Feeding: A Missed Opportunity for Hygiene Promotion. Am J Trop Med Hyg, Sep 2013. F Nizame. (Abstract)
From 50 randomly selected villages in Bangladesh, we collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program. Most participants cited the unavailability of soap and water near the cooking place as a barrier to handwashing before food preparation. Most caregivers ranked nurturing messages as the best motivator to encourage handwashing with soap.
2–Designing a Handwashing Station for Infrastructure-Restricted Communities in Bangladesh Using the Integrated Behavioural Model for Water, Sanitation and Hygiene Interventions (IBM-WASH). BMC Public Health, Sep 2013. K Hulland. (Full text)
Handwashing stations — a dedicated, convenient location where both soap and water are available for handwashing — are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal.
3–A Qualitative Evaluation of Hand Drying Practices among Kenyans. PLoS One, Sept 2013. B Person. (Full text)
Recommended disease prevention behaviors of hand washing, hygienic hand drying, and covering one’s mouth and nose in a hygienic manner when coughing and sneezing appear to be simple behaviors but continue to be a challenge to successfully promote and sustain worldwide. We conducted a qualitative inquiry to better understand current hand drying behaviors associated with activities of daily living, and mouth and nose covering practices, among Kenyans. We conducted 7 focus group discussions; 30 in-depth interviews; 10 structured household observations; and 75 structured observations in public venues in the urban area of Kisumu; rural communities surrounding Kisumu; and a peri-urban area outside Nairobi, Kenya. Using a grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes. Hand drying, specifically on a clean towel, was not a common practice among our participants. Most women dried their hands on their waist cloth, called a leso, or their clothes whether they were cooking, eating or cleaning the nose of a young child. If men dried their hands, they used their trousers or a handkerchief.
4–The Context and Practice of Handwashing Among New Mothers in Serang, Indonesia: A Formative Research Study. BMC Public Health, Sep 2013. K Greenland. (Full text)
This article reports on formative research into the context and practice of handwashing with soap by new mothers, which can substantially impact child morbidity and mortality. New mothers are an important target group for handwashing interventions: they are considered particularly susceptible to behaviour change and their actions can directly affect a child’s health. Twenty-seven mothers of infants (including neonates) from urban and rural sub-districts of Serang were recruited and filmed over a period of eight hours. Video footage was used to identify handwashing occasions and to understand the context in which behaviour took place. Each woman was subsequently interviewed. Handwashing with soap was found to be infrequent, typically occurring after eating, cooking and household chores or after cleaning a child’s bottom. Handwashing before preparing food or eating was rare. Pre-pregnancy routines were reported to have been disrupted. Advice on child care comes from many sources, particularly the midwife and new child’s grandmother.
5–Formative Research on Hygiene Behaviors and Geophagy among Infants and Young Children and Implications of Exposure to Fecal Bacteria. Am J Trop Med Hyg, Sep 2013. F Ngure. (Abstract)
We conducted direct observation of 23 caregiver-infant pairs for 130 hours and recorded wash-related behaviors to identify pathways of fecal-oral transmission of bacteria among infants. In addition to testing fingers, food, and drinking water of infants, three infants actively ingested 11.3 ± 9.2 (mean ± SD) handfuls of soil and two ingested chicken feces 2 ± 1.4 times in 6 hours. Hand washing with soap was not common and drinking water was contaminated with Escherichia coli in half (12 of 22) of the households. A one-year-old infant ingesting 1 gram of chicken feces in a day and 20 grams of soil from a laundry area of the kitchen yard would consume 4,700,000-23,000,000 and 440-4,240 E. coli, respectively, from these sources. Besides standard wash and nutrition interventions, infants in low-income communities should be protected from exploratory ingestion of chicken feces, soil, and geophagia for optimal child health and growth..
6–Access to Waterless Hand Sanitizer Improves Student Hand Hygiene Behavior in Primary Schools in Nairobi, Kenya. Am J Trop Med Hyg, Sep 2013. A Pickering. (Abstract)
Handwashing is difficult in settings with limited resources and water access. In primary schools within urban Kibera, Kenya, we investigated the impact of providing waterless hand sanitizer on student hand hygiene behavior. Two schools received a waterless hand sanitizer intervention, two schools received a handwashing with soap intervention, and two schools received no intervention. Hand cleaning behavior after toilet use was monitored for 2 months using structured observation. Hand cleaning after toileting was 82% at sanitizer schools (N = 2,507 toileting events), 38% at soap schools (N = 3,429), and 37% at control schools (N = 2,797). Students at sanitizer schools were 23% less likely to have observed rhinorrhea than control students (P = 0.02); reductions in student-reported gastrointestinal and respiratory illness symptoms were not statistically significant. Providing waterless hand sanitizer markedly increased student hand cleaning after toilet use, whereas the soap intervention did not. Waterless hand sanitizer may be a promising option to improve student hand cleansing behavior, particularly in schools with limited water access.
7–Improving Service Delivery of Water, Sanitation, and Hygiene in Primary Schools: A Cluster-randomized Trial in Western Kenya. J Water Health, Sep 2013. K Alexander. (Abstract)
Water, sanitation, and hygiene (WASH) programs in schools have been shown to improve health and reduce absence. In resource-poor settings, barriers such as inadequate budgets, lack of oversight, and competing priorities limit effective and sustained WASH service delivery in schools. We employed a cluster-randomized trial to examine if schools could improve WASH conditions within existing administrative structures. Seventy schools were divided into a control group and three intervention groups. All intervention schools received a budget for purchasing WASH-related items. One group received no further intervention. A second group received additional funding for hiring a WASH attendant and making repairs to WASH infrastructure, and a third group was given guides for student and community monitoring of conditions. Intervention schools made significant improvements in provision of soap and handwashing water, treated drinking water, and clean latrines compared with controls.
AUGUST 2013
8–Cluster-Randomised Controlled Trials of Individual and Combined Water, Sanitation, Hygiene and Uutritional Interventions in Rural Bangladesh and Kenya: The WASH Benefits Study Design and Rationale. BMJ Open, Aug 2013. B Arnold. (Full text)
Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap. WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation,handwashing and child nutrition-alone and in combination-to rural households with pregnant women in Kenya and Bangladesh.
9–Implementation of an Educational Intervention to Improve Hand Washing in Primary Schools: Process Evaluation within a Randomised Controlled Trial. BMC Public Health, Aug 2013. C Chittleborough. (Full text)
CONCLUSIONS: The hand washing intervention was acceptable to schools, but its reach outside of a randomised trial, evidenced in the low proportion of schools in the control arm who received it after the trial had ended, suggests that the model of delivery may not be sustainable.
10–Impact of Regular Soap Provision to Primary Schools on Hand Washing and E. coli Hand Contamination among Pupils in Nyanza Province, Kenya: A Cluster-Randomized Trial. Am J Trop Med Hyg, Aug 2013. S Saboori. (Abstract)
We assessed whether supplying soap to primary schools on a regular basis increased pupil hand washing and decreased Escherichia coli handcontamination. Multiple rounds of structured observations of hand washing events after latrine use were conducted in 60 Kenyan schools, andhand rinse samples were collected one time in a subset of schools. The proportion of pupils observed practicing hand washing with soap (HWWS) events was significantly higher in schools that received a soap provision intervention (32%) and schools that received soap and latrine cleaning materials (38%) compared with controls (3%). Girls and boys had similar hand washing rates. There were non-significant reductions in E. coli contamination among intervention school pupils compared with controls. Removing the barrier of soap procurement can significantly increase availability of soap and hand washing among pupils; however, we discuss limitations in the enabling policy and institutional environment that may have prevented reaching desired levels of HWWS.
11–Impact of Duration of Structured Observations on Measurement of Handwashing Behavior at Critical Times.BMC Public Health, Aug 2013. A Halder, (Full text)
CONCLUSIONS: Decreasing the duration of handwashing significantly reduced the observation of critical events of interest to evaluators ofhandwashing programs. Researchers seeking to measure observed handwashing behavior should continue with prolonged duration of structured observation. Future research should develop and evaluate novel models to reduce reactivity to observation and improve the measurement ofhandwashing behavior.
12–Interventions to Improve Water Quality and Supply, Sanitation and Hygiene Practices, and Their Effects on the Nutritional Status of Children. Cochrane Database Syst Rev, Aug 2013. A Dangour. (Abstract)
AUTHORS’ CONCLUSIONS: The available evidence from meta-analysis of data from cluster-randomised controlled trials with an intervention period of 9-12 months is suggestive of a small benefit of WASH interventions (specifically solar disinfection of water, provision of soap, and improvement of water quality) on length growth in children under five years of age. The duration of the intervention studies was relatively short and none of the included studies is of high methodological quality. Very few studies provided information on intervention adherence, attrition and costs. There are several ongoing trials in low-income country settings that may provide robust evidence to inform these findings.
JANUARY – JULY 2013
13–Household Environmental Conditions are Associated with Enteropathy and Impaired Growth in Rural Bangladesh. Am J Trop Med Hyg, Jul 2013. L Lin. (Full text)
We assessed the relationship of fecal environmental contamination and environmental enteropathy. We compared markers of environmental enteropathy, parasite burden, and growth in 119 Bangladeshi children (≤ 48 months of age) across rural Bangladesh living in different levels of household environmental cleanliness defined by objective indicators of water quality and sanitary and hand-washing infrastructure. Adjusted for potential confounding characteristics, children from clean households had 0.54 SDs (95% confidence interval [CI] = 0.06, 1.01) higher height-for-age z scores (HAZs), 0.32 SDs (95% CI = -0.72, 0.08) lower lactulose:mannitol (L:M) ratios in urine, and 0.24 SDs (95% CI = -0.63, 0.16) lower immunoglobulin G endotoxin core antibody (IgG EndoCAb) titers than children from contaminated households. After adjusting for age and sex, a 1-unit increase in the ln L:M was associated with a 0.33 SDs decrease in HAZ (95% CI = -0.62, -0.05). These results are consistent with the hypothesis that environmental contamination causes growth faltering mediated through environmental enteropathy.
14–Teaching Handwashing with Soap for Schoolchildren in a Multi-ethnic Population in Northern Rural Vietnam. Global Health Action, Apr 2013. T Xuan. (Full text)
CONCLUSIONS: This study demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of HWWS in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures. However, in those areas there was limited transfer of practice from school promotion to home. Continuous access to soaps at schools needs to be invested.
15–Knowledge, Awareness and Practice of the Importance of Hand-Washing Amongst Children Attending State Run Primary Schools in Rural Malawi. Int J Environ Health Res, Apr 2013. A Grimason. (Abstract)
A study was undertaken to determine the efficacy of hygiene practices in 2 primary schools in Malawi. The study determined: (1) presence of Escherichia coli on the hands of 126 primary school pupils, (2) knowledge, awareness and hygiene practices amongst pupils and teachers and (3) the school environment through observation. Pupil appreciation of hygiene issues was reasonable; however, the high percentage presence of E. coli on hands (71%) and the evidence of large-scale open defaecation in school grounds revealed that apparent knowledge was not put into practice. The standard of facilities for sanitation and hygiene did not significantly impact on the level of knowledge or percentage of school children’s hands harbouring faecal bacteria. Evidence from pupils and teachers indicated a poor understanding of principles of disease transmission. Latrines and hand-washing facilities constructed were not child friendly. This study identifies a multidisciplinary approach to improve sanitation and hygiene practices within schools.
16–Editorial: Can We Afford to Overlook Hand Hygiene Again? Trop Med Int Health, Mar 2013. K Greenland. (Full text)
Handwashing with soap (HWWS) is one of the most cost-effective of all public health interventions (Jamieson et al. 2006). Alongside sanitation, HWWS after defecation acts as a primary barrier to faecal–oral spread of diarrhoea by preventing fecal matter from entering the environment, while HWWS before eating reduces transmission from faecal pathogens in the environment
17–Sustained Improvements in Handwashing Indicators More than 5 years after a Cluster-Randomised, Community-Based Trial of Handwashing Promotion in Karachi, Pakistan. Trop Med Int Health, Mar 2013. A Bowen. (Abstract)
CONCLUSIONS: Five years after receiving handwashing promotion, intervention households were more likely to have soap at the householdhandwashing station, know key times to wash hands and report purchasing more soap than controls, suggesting habituation of improvedhandwashing practices in this population. Intensive handwashing promotion may be an effective strategy for habituating hygiene behaviours and improving health.
18–Effect of Recent Diarrhoeal Episodes on Risk of Pneumonia in Children Under the Age of 5 Years in Karachi, Pakistan. Int J Epidemiol, Feb 2013. S Ashraf. (Full text)
CONCLUSION: Children <5 years of age are at an increased risk of pneumonia following recent diarrhoeal illness. Public health programmes that prevent diarrhoea may also reduce the burden of respiratory illnesses.
19-Exploring the Gap Between Hand Washing Knowledge and Practices in Bangladesh: A Cross-Sectional Comparative Study. BMC Public Health, Jan 2013. S Rabbi. (Full text)
RESULTS: A gap between perception and practice of proper hand washing practices with soap was identified in the study areas. Hand washingpractice with soap before eating was much lower than after defecation. In baseline data, 8% reported to wash their hands with soap which significantly increased to 22% in end line. Hand washing knowledge and practices before cooking food, before serving food and while handling babies is considerably limited than other critical times. A multivariate analysis shows that socio-economic factors including education of household head and respondent, water availability and access to media have strong positive association with hand washing with soap.
20–Hands and Water as Vectors of Diarrheal Pathogens in Bagamoyo, Tanzania.Environ Sci Technol, Jan 2013. M Mattioli. (Abstract)
Using molecular methods, this study examines the relative importance of different exposure routes by measuring enteric bacteria (pathogenic Escherichia coli) and viruses (rotavirus, enterovirus, adenovirus) in hand rinses, stored water, and source waters in Bagamoyo, Tanzania. Viruses were most frequently found on hands, suggesting that hands are important vectors for viral illness. The occurrence of E. coli virulence genes (ECVG) was equivalent across all sample types, indicating that both water and hands are important for bacterial pathogen transmission. Fecal indicator bacteria and turbidity were good predictors of ECVG, whereas turbidity and human-specific Bacteroidales were good predictors of viruses.
Filed under: Hygiene Promotion Tagged: handwashing 
