BackgroundTo design a maternal handwashing intervention for the newborn period, this qualitative study explored drivers of handwashing among mothers and other caregivers of neonates and infants in two rural areas of Bangladesh.MethodsWe conducted 40 semi-structured observation sessions to observe handwashing behaviors of primiparous and multiparous mothers of neonates, and to understand the contextual factors that facilitated or hampered those behaviors. We then conducted 64 interviews with mothers of neonates and mothers of infants and 6 group discussions with mothers of infants, other female caregivers and fathers to explore perceptions, beliefs, and practices related to handwashing in the neonatal period. Based on a conceptual model and the Theory of Reasoned Action/Theory of Planned Behavior, we developed a conceptual model a priori, we performed thematic analysis to explain determinants of maternal handwashing behaviors.ResultsWe conducted 200 h of observation among mothers of neonates. The age range of participating mothers varied between 17 and 25 years and their maximum education was up to 10th grade of schooling. Mothers, other female caregivers and fathers perceived a need to wash hands with or without soap before eating or before feeding a child by hand to prevent diarrhea. Mothers expressed the importance of washing their hands before holding a baby but were rarely observed doing so. All respondents prioritized using soap for visible dirt or feces; otherwise, water alone was considered sufficient. Lack of family support, social norms of infrequent handwashing, perceptions of frequent contact with water as a health threat and mothers’ restricted movement during first 40 days of neonate’s life, and childcare and household responsibilities adversely impacted handwashing behavior.ConclusionsAddressing emotive drivers of handwashing within existing social norms by engaging family members, ensuring handwashing facilities and clarifying neonatal health threats may improve maternal handwashing behavior in the neonatal period.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5365-1) contains supplementary material, which is available to authorized users.

One-quarter of neonatal deaths are attributed to infections. Maternal handwashing with soap may prevent neonatal sepsis. We examined impact of intensive handwashing promotion on handwashing behavior of mothers of neonates. In Matlab, Bangladesh, we randomly allocated pregnant women at 28–32 weeks' gestation to intensive handwashing promotion or control. Behavior change communicators used a participatory approach to motivate maternal handwashing with soap and provided soap and handwashing stations. In the neonatal period, we observed soap and water at handwashing places and, at the end of the neonatal period, we estimated impact on maternal handwashing by structured observation. Among 253 women enrolled, intervention households were between 5.7 and 15.2 times as likely as control households to have soap and water present at the handwashing station in the baby's sleeping area. Intervention mothers washed hands with soap 4.1 times as frequently as controls (95% CI 2.55–6.59); handwashing with soap at recommended times was infrequent in both intervention (9%) and control (2%) groups. Intensively promoting handwashing with soap resulted in increased availability of soap and water at handwashing places, but only a modest increase in maternal handwashing with soap. Novel approaches to motivating handwashing behavior to protect newborns should be developed and evaluated.

BackgroundDiarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings.MethodsWe conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing.ResultsAt the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as “maintaining a good image” and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene.ConclusionsHygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp’s existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.

The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, for whom, why and at what cost. We believe that better and policy-relevant evidence will help make development more effective and improve people's lives. 3ie systematic reviews 3ie systematic reviews appraise and synthesise the available high-quality evidence on the effectiveness of social and economic development interventions in low-and middleincome countries. These reviews follow scientifically recognised review methods, and are peer-reviewed and quality assured according to internationally accepted standards. 3ie is providing leadership in demonstrating rigorous and innovative review methodologies, such as using theory-based approaches suited to inform policy and programming in the dynamic contexts and challenges of low-and middle-income countries.

. We would also like to thank Karin Gallandat for assistance in processing the French evaluations and Karen Vagts, a Tufts University librarian, for helping with the search strategy. Finally, we would like to thank the organizations and individuals who contributed grey literature documents that were critical to this review. Action Contre la Faim and Oxfam, in particular, made significant contributions to advance this review. Series editorsThe report forms part of a series of humanitarian evidence syntheses and systematic reviews covering child protection, market support, mental health, nutrition, pastoralist livelihoods, shelter, urban contexts and water, sanitation and hygiene.The reports and corresponding protocols (methodology) can be found at: https://www.gov.uk/dfid-research-outputs  http://fic.tufts.edu/research-item/the-humanitarian-evidence-program/  http://policy-practice.oxfam.org.uk/our-work/humanitarian/humanitarian-evidenceprogrammeThe series editors are: Roxanne Krystalli, Eleanor Ott and Lisa Walmsley. Photo creditAs part of Oxfam's cholera response in Juba, South Sudan, teams of public health volunteers have been teaching affected communities about the importance of keeping themselves and their environment clean. May 2014. Kieran Doherty/Oxfam. © Copyright Oxfam GB 2017This publication is subject to copyright but the text may be used free of charge for the purposes of advocacy, campaigning, education and research, provided that the source is acknowledged in full. The copyright holder requests that all such use be registered with them for impact assessment purposes. For copying in any other circumstances, or for reuse in other publications, or for translation or adaptation, permission must be secured and a fee may be charged. WASH interventions are commonly implemented as part of emergency response activities (i.e. in response to disease outbreaks) in LMICs. WASH interventions are provided to large populations to reduce the risk of disease transmission in a variety of settings. This synthesis focuses on WASH interventions targeted at populations affected by cholera, Ebola virus disease (hereafter 'Ebola'), hepatitis E, hepatitis A, typhoid, acute watery diarrhoea and bacillary shigellosis (dysentery).The review focuses on the following 10 WASH interventions:  the occurrence of disease in excess of the normal baseline (two times the baseline) or a sudden spike in cases (two times the incidence of new cases) a single case of a communicable disease long absent from a population, or caused by a pathogen not previously recognized in that community or area  emergence of a previously unknown disease  a single case of particular diseases of interest (cholera, Ebola and hepatitis E).The evidence synthesis aims to: verify the quality of existing evidence relating to WASH interventions in humanitarian settings  help researchers identify the strengths and weaknesses of this evidence, and thus to recognize potential improvements and opportunities for future research  assist practitioners and policy m...