Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH)

Abstract

BackgroundIn Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. 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.MethodsWe conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs.ResultsFactors 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. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials.ConclusionsA number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.

Sustained Uptake of a Hospital-Based Handwashing with Soap and Water Treatment Intervention (Cholera-Hospital-Based Intervention for 7 Days [CHoBI7]): A Randomized Controlled Trial

“…This hardware was selected because of previous formative research that showed high user acceptance in our study site of urban Dhaka, Bangladesh. 46 Consistent with high user acceptance, we observed that more than 80% of intervention households continued to use the hardware provided by the CHoBI7 intervention 6 to 12 months post-intervention. Furthermore, when intervention hardware failed, it was repaired by the majority of households and usage continued, suggesting high perceived value of the hardware provided in the CHoBI7 intervention.…”

Observed Practices and Perceived Advantages of Different Hand Cleansing Agents in Rural Bangladesh: Ash, Soil, and Soap

“…Soapy water is just as microbiologically effective as bar soap at reducing fecal indicator organisms from hands, 35 and it is acceptable elsewhere in Bangladesh. 36 A trial of individual and combined water, sanitation, hygiene, and nutrition interventions (WASH Benefits; www.washbenefits.org) will likely provide insights on the health benefit of washing hands with soapy water. To address the physical barriers of convenient handwashing agent location, encouraging placement of low-cost options such as soapy water at handwashing locations may be more successful compared with bar soap.…”

Disgust, Shame, and Soapy Water: Tests of Novel Interventions to Promote Safe Water and Hygiene

“…We demonstrated how to mix water and detergent in the soapy water bottle and how to use discarded plastic bottles to create additional or replacement units (Hulland et al 2013). We resupplied detergent periodically during the free trial period.…”

“…We randomized the promotional message, allocating half of compounds to a standard health message and half to a message targeting disgust and shame, both emphasizing water treatment. We orthogonally randomized two-thirds of treatment compounds to receive additional messaging on handwashing, and provided a simple, inexpensive "soapy water bottle" to facilitate washing hands with soap (Hulland et al 2013). Finally, compounds were randomized between a group auction, in which we asked the compound for its collective willingness to pay, and a "weakest link" auction intended to uncover household-level willingness to pay.…”