Determinants of Handwashing Practices in Kenya : The Role of Media Exposure, Poverty and Infrastructure

BACKGROUND To explore how structural constraints such as lack of reliable water supply, sanitation, educational and other socio-economic factors limit the adoption of better hygiene. METHODS In preparation for the Kenya National Handwashing Campaign, we conducted a nationwide cross sectional survey in 800 households with two components: (i) direct structured observation of hygiene practices at key junctures (food handling, cleaning a child after defaecation, toilet use), followed by (ii) a structured interview addressing potential socio-economic, water access and behavioural determinants of handwashing. RESULTS We observed a total of 5182 critical opportunities for handwashing, and handwashing with soap at 25% of these. Handwashing with soap was more often practised after faecal contact (32%) than in connection with food handling (15%). In univariate and multivariate analysis, water access, level of education, media exposure and media ownership were associated with handwashing with soap. Only households with very poor access to water and sanitation, and with the lowest levels of education and media exposure, washed their hands markedly less than the majority of the households. CONCLUSION The results underscore that structural constraints can limit hygiene practices in the very disadvantaged sections of a population, thus jeopardizing the potential success of hygiene promotion campaigns in those most at risk of disease. Nevertheless, the strong association of handwashing with media ownership and exposure supports the view that mass media can play a role in hygiene promotion.

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Three Kinds of Psychological Determinants for Hand-Washing Behaviour in Kenya
(2010) Aunger, R.; Schmidt, W. P.; Ranpura, A.; Coombes, Y.; Maina, P. M.; Matiko, C. N.; Curtis, V.
Washing hands with soap at the right times - primarily after contact with faeces, but also before handling food or feeding an infant - can significantly reduce the incidence of childhood infectious disease. Here, we present empirical results which substantiate a recent claim that washing hands can be the consequence of different kinds of psychological causes. Such causes can be divided into three kinds of control over behaviour: automatic or habitual responses, motivated or goal-driven behaviour to satisfy needs, and cognitive causes which reflect conscious concerns. Empirical results are based on 3-h-long structured observations of hand-washing behaviour in 802 nationally representative Kenyan households with children under five, and structured interviews with the primary female caretaker in these households, collected in March 2007. Factor analysis of questionnaire responses identified three psychological factors which are also significant predictors of observed hand-washing behaviour: having the habit of hand-washing at particular junctures during the day, the motivated need for personal or household cleanliness, and a lack of cognitive concern about the cost of soap use. These factors each represent a different kind of psychological cause. A perceived link between clean hands and sexual attractiveness also appeared in the factor analysis, but was not a determinant of actual behaviour. We also report evidence that those who express concern about the cost of soap use are those with relatively few economic resources. We suggest that those developing hygiene promotion programmes should consider the possible existence of multiple types of strategies for increasing hand-washing behaviour. (C) 2009 Elsevier Ltd. All rights reserved.
Comparing the Performance of Indicators of Hand-Washing Practices in Rural Indian Households
(2008) Biran, A.; Rabie, T.; Schmidt, W.; Juvekar, S.; Hirve, S.; Curtis, V.
OBJECTIVE To compare the results obtained from 26 proxy indicators of domestic hand-washing practices with those obtained from direct, 'structured' observation of hand-washing in a sample of 387 households and to assess the potential of these indicators for use in the evaluation of hygiene promotion campaigns. METHODS Fieldwork in rural India between February 2005 and April 2006. Household-level data on hand-washing practices and the availability of soap and water were collected by structured observation, questionnaire survey, pocket voting, hand-wash demonstration and environmental check. Between them these techniques produced 27 binary indicators of hand-washing practices, each of which was used to classify households as 'hand-washing' or 'non-hand-washing. To assess the extent to which household classification based on each of 26 proxy indicators concurred with classification based on observation, we used the kappa statistic. The prevalence of households defined as 'hand-washing' according to each indicator was compared statistically with the prevalence according to structured observations by testing for a significant difference between two proportions. RESULTS Agreement between all the proxy indicators and the observation data was poor and all but two of the indicators produced estimates of hand-washing prevalence that were significantly different from that resulting from observation. CONCLUSION Although some interventions may be able to use proxy indicators as a guide to the magnitude and direction of their impact, these indicators do not provide an accurate guide to the actual practice or prevalence of hand-washing. Structured observation remains the best indicator of those tested.
Can Intense Exposure to Hand-Washing and Hygiene Information Campaigns Affect Children's Socio-Emotional Skills?
(World Bank, Washington, DC, 2015-11) Briceno, Bertha; Borja-Vega, Christian; Garcia, Vicente
Hygiene information and practices play a critical role in preventing diseases, particularly among children. Hygiene behaviors practiced in the household have been linked to development outcomes such as socio-emotional skills. This paper exploits data from impact evaluation surveys of a hygiene information campaign conducted in Senegal, where the randomized design suffered from contamination between comparison groups. The variations in exposure and intensity to hygiene information campaigns captured in the surveys were used to understand contamination biases. Such variations were interacted with the presence of household communication assets to explore potential effects on children’s socio-emotional scores. In the presence of contamination biases, the study exploited the longitudinal sample of children in the surveys to reduce time-dependent biases. For robustness, statistical matching was applied between the impact evaluation surveys and Demographic and Health Surveys conducted in 2008 and 2011. Socio-emotional outcomes were the imputed into Demographic and Health surveys to expand sample sizes. By applying matching techniques and imputing outcomes into a larger sample, impacts were non-negligible. Double-difference estimates showed that children’s socio-emotional scores were higher when intervention status was interacted with the presence of communication assets within households. Without the presence of communication assets in the households the impacts were close to zero. Evaluating the effect of hygiene campaigns on children’s socio-emotional skills is challenging because of the biases from contamination that exist when information flows between comparison groups. Targeted hygiene information to the poorest households is relevant for reducing risks of recurrent infections and enables better conditions for socio-emotional development of children.
Promoting Handwashing Behavior in Peru : The Effect of Large-Scale Mass-Media and Community Level Interventions
(World Bank, Washington, DC, 2012-11) Galiani, Sebastian; Gertler, Paul; Orsola-Vidal, Alexandra
This paper analyzes a randomized experiment that uses novel strategies to promote handwashing with soap at critical times in Peru. It evaluates a large-scale intervention that includes a mass media provincial campaign and a district-level community component. The analysis finds that the mass media intervention alone had no significant effect on exposure to the handwashing promotion campaign messages, and therefore no effect on handwashing knowledge or handwashing behavior. In contrast, the community-level intervention, a more comprehensive intervention that included several community and school activities in addition to the communications campaign, was successful in reaching the target audience with handwashing promotion messages and in improving the knowledge of the treated population on appropriate handwashing behavior. Those improvements translated into higher self-reported and observed handwashing with soap at critical junctures. However, no significant improvements in the health of children under the age of five were observed. The results are consistent with earlier literature, which indicates that substantively changing behavior to improve health is a complex task requiring intensive and more personalized interventions.
Does Openness Imply Greater Exposure?
(World Bank, Washington, DC, 2005-10) Calderón, César; Loayza, Norman; Schmidt-Hebbel, Klaus
External exposure can be measured by the sensitivity of first and second moments of economic growth to openness and foreign shocks. This paper provides an empirical evaluation of external exposure using panel data methods for a worldwide sample of countries. Controlling for domestic conditions, the paper examines the growth and volatility effects of outcome measures of trade and financial integration, as well as four types of foreign shocks: terms of trade changes, trading partners' growth rates, international real interest rate changes, and net regional capital inflows. The paper analyzes the possibility of nonlinearities by allowing the growth and volatility effects of openness to vary with the general level of economic development and by letting the effects of foreign shocks depend on the degree of trade and financial integration. The findings point toward strong non-monotonic effects of openness and external shocks on growth and volatility. Moreover, all in all, the results contradict the view that international integration increases external vulnerability by hurting growth and increasing volatility or by amplifying the adverse effect of external shocks.

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