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      Acceptability and Feasibility of Sharing a Soapy Water System for Handwashing in a Low-Income Urban Community in Dhaka, Bangladesh: A Qualitative Study

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          Abstract.

          Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and stored in a 1.5-L reclaimed mineral water bottle. Community health promoters encouraged sharing of the recurrent detergent cost among compound members. Of 152 participating compounds, fieldworkers randomly selected 60 for qualitative assessment. Fieldworkers conducted 30 in-depth interviews and five focus group discussions among purposively selected compound members. The reclaimed bottles served as an easily accessible dispenser for the soapy water, which could feasibly be retained next to the toilet and kitchen areas for communal use. Bottles functioned as a positive reminder for handwashing at recommended key times. Most compounds (45/60, 75%) shared a common soapy water system and its associated costs. There was reluctance to prepare soapy water for shared use in the remaining 25%. Soapy water was an acceptable hand cleaning agent, with the bottle as a feasible dispenser. It was simple in design, cost-effective, replicable, popular with intervention recipient, and neighboring nonrecipients, and commonly shared among nonrelated households. The need to share expenses and product preparation served as a barrier. Developing a sustainable maintenance system, therefore, is critical to ensuring the public health benefits of handwashing with soap.

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          Effect of handwashing on child health: a randomised controlled trial.

          More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea. In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat. Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap. Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.
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            The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings

            Background Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance. Methods We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH). Results We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual). Conclusions A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.
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              Beyond frequency: habit as mental construct.

              Progress in habit theory can be made by distinguishing habit from frequency of occurrence, and using independent measures for these constructs. This proposition was investigated in three studies using a longitudinal, cross-sectional and experimental design on eating, mental habits and word processing, respectively. In Study 1, snacking habit and past snacking frequency independently predicted later snacking behaviour, while controlling for the theory of planned behaviour variables. Habit fully mediated the effect of past on later behaviour. In Study 2, habitual negative self-thinking and past frequency of negative self-thoughts independently predicted self-esteem and the presence of depressive and anxiety symptoms. In Study 3, habit varied as a function of experimentally manipulated task complexity, while behavioural frequency was held constant. Taken together, while repetition is necessary for habits to develop, these studies demonstrate that habit should not be equated with frequency of occurrence, but rather should be considered as a mental construct involving features of automaticity, such as lack of awareness, difficulty to control and mental efficiency.
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                Author and article information

                Journal
                Am J Trop Med Hyg
                Am. J. Trop. Med. Hyg
                tpmd
                tropmed
                The American Journal of Tropical Medicine and Hygiene
                The American Society of Tropical Medicine and Hygiene
                0002-9637
                1476-1645
                August 2018
                11 June 2018
                11 June 2018
                : 99
                : 2
                : 502-512
                Affiliations
                [1 ]International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
                [2 ]University at Buffalo, Buffalo, New York;
                [3 ]Stanford University, Stanford, California;
                [4 ]Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
                Author notes
                [* ]Address correspondence to Farhana Sultana, Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh. E-mails: farhana.sultana@ 123456icddrb.org or farhana_ju@ 123456yahoo.com

                Authors’ addresses: Farhana Sultana, Leanne E. Unicomb, Fosiul A. Nizame, and Notan Chandra Dutta, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh, E-mails: farhana.sultana@ 123456icddrb.org , Leanne@ 123456icddrb.org , fosiul@ 123456icddrb.org , and duttanota@ 123456gmail.com . Pavani K. Ram, University at Buffalo, Buffalo, NY, E-mail: pkram@ 123456buffalo.edu . Stephen P. Luby, Stanford University, Stanford, CA, E-mail: sluby@ 123456stanford.edu . Peter J. Winch, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: pwinch@ 123456jhu.edu .

                Article
                tpmd170672
                10.4269/ajtmh.17-0672
                6090367
                29893204
                46c35117-ce7d-4f77-be53-7908c62c5916
                © The American Society of Tropical Medicine and Hygiene

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 August 2017
                : 20 April 2018
                Page count
                Pages: 11
                Categories
                Articles

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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