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


METHODS
We 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.


RESULTS
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. 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.


CONCLUSIONS
A 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.
Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. rdreibel@jhsph.edu.
Kristyna R S
KR
Hulland
Elli
E
Leontsini
Robert
R
Dreibelbis
Leanne
L
Unicomb
Aasma
A
Afroz
Notan Chandra
NC
Dutta
Fosiul Alam
FA
Nizame
Stephen P
SP
Luby
Pavani K
PK
Ram
Peter J
PJ
Winch
D000328:Adult; D001459:Bangladesh; D003967:Diarrhea / Q000453:epidemiology / Q000517:prevention & control; D004867:Equipment Design; D005260:Female; D006235:Hand Disinfection; D015438:Health Behavior; D006801:Humans; D008297:Male; D008875:Middle Aged; D011634:Public Health / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D012141:Respiratory Tract Infections / Q000453:epidemiology / Q000517:prevention & control; D012499:Sanitation / Q000295:instrumentation*; D012915:Soaps; D011795:Surveys and Questionnaires; D014881:Water Supply
D012915:Soaps