|Year : 2010 | Volume
| Issue : 3 | Page : 126-130
Hand washing practices in two communities of two states of Eastern India: An intervention study
Sandip Kumar Ray1, Forhad Akhtar Zaman2, Nasrin Banu Laskar3
1 Professor, Department of Community Medicine, KPC Medical College, Kolkata, India
2 Asst. Professor, Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Tadong, Gangtok, India
3 Assistant Professor, Department of Community Medicine, KPC Medical College, Kolkata, India
|Date of Web Publication||18-Jan-2011|
Sandip Kumar Ray
Department of Community Medicine, KPC Medical College, Kolkata
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background : Public health importance of hand washing as well as its importance in reduction of communicable diseases such as diarrhea and acute respiratory infections have been highlighted in many studies worldwide. Objective: This study was designed to study the hand washing practices followed in two urban slums as well as to assess and compare the status of different components of hand washing at the pre- and post-intervention phases. Materials and Methods: A community-based cross-sectional intervention study on hand washing practices was carried out at two urban slums situated in two states of Eastern India with similar sociocultural and linguistic background. The study was carried out by using an interview technique as well as observation of hand washing practices. Interpersonal communication for behavioural change was chosen as a method of intervention. Results: The majority (>90%) practiced hand washing after defecation in both the study areas. However, hand washing following all six steps and for stipulated time period was seen to be poor before intervention. Significant improvement was observed in all the aspects of hand washing after intervention in both the areas. The poor practice of hand washing was observed in some situations and needed attention. Use of soap and clean material for drying hands after hand washing was poor initially followed by improvement after intervention. Conclusion: Based on the findings of the study, it could be suggested that Behaviour Change Communication program should be further planned with emphasis on different components of hand washing with a final objective to bring down the incidence of target diseases.
Keywords: Hand washing, Intervention study, Steps of hand washing
|How to cite this article:|
Ray SK, Zaman FA, Laskar NB. Hand washing practices in two communities of two states of Eastern India: An intervention study. Indian J Public Health 2010;54:126-30
|How to cite this URL:|
Ray SK, Zaman FA, Laskar NB. Hand washing practices in two communities of two states of Eastern India: An intervention study. Indian J Public Health [serial online] 2010 [cited 2019 Feb 18];54:126-30. Available from: http://www.ijph.in/text.asp?2010/54/3/126/75734
| Introduction|| |
The Millennium Development Goals have firmly established the issues of "water, sanitation, and hygiene" on the global agenda. Neglect of hygiene goes a long way in explaining why water and sanitation programmes have often not brought the expected benefits. Public health importance of hand washing as well as its importance in reduction of communicable diseases such as diarrhea and acute respiratory infections (ARI) was highlighted in many studies. ,,,,,, Ray et al. in his earlier study in Kolkata and suburbs had also observed poor hand washing practices at community setting where the people considered other activities such as boiling and purification of water and cleanliness could have prevented diarrhea more efficiently than hand washing alone. It was also seen that the people had very little knowledge regarding the other diseases that could have been prevented by hand washing. 
A study in Dhaka,  capital city of Bangladesh, revealed 2.6-fold reduction in diarrheal episodes in the intervention area following the practice of regular hand washing with soap and water.
Under these circumstances, this study had been conducted with the objectives to study the hand washing practices followed in two communities having similar sociocultural and linguistic background situated in two states of Eastern India and to assess and compare the status of different components of hand washing at the pre- and postintervention phases.
| Materials and Methods|| |
The study was a community-based interventional pilot study conducted, in one area each in, two states of Eastern India, namely West Bengal and Tripura, which have close similarity in linguistic and sociocultural aspects, although situated nearly 1000 km apart. From West Bengal, an urban slum of Sibpur area (Howrah district) was selected as the study area where source of water supply was intermittent tap water. In Tripura, the study area was an urban slum of South Chandrapur area (Agartala Township) where water was used from pond, tube wells, and wells.
A baseline study regarding hand washing practices was carried out followed by concurrent intervention at the last week of September 2007 at Howrah and during the last week of November to first week of December 2007 at South Chandrapur area of Tripura. Due to operational problems, the study in both the places could not be conducted simultaneously. The evaluation was done in January 2008 in both the places. As the evaluation was not done with a uniform time gap after intervention in both the places, a second intervention followed by evaluation was done with a gap of 1 month at Sibpur to maintain uniformity with south Chandrapur. Thus in the study area of Sibpur, second evaluation was carried out in February 2008. Although some bias still remained, but could not be avoided due to operational constraints.
Sample size was purposively taken as 100 households due to constraints of funding and operational feasibility. However, the first household was selected by simple random sampling and then selecting 100 households consecutively till the final sample size was achieved. The absent and reluctant households were skipped during the survey, and subsequent household was selected for the study.
A total of 100 households in each of the two study areas were studied during the baseline survey as well as for intervention. Study techniques consisted of interview of the respondents with a predesigned and pretested pro forma and observations of different aspects of hand washing, as per IFH guidelines,  such as material used for hand washing, time of hand washing (stopwatch used), six steps of hand-washing, and hand washing mainly after defecation. All these components with correct methods were taught to the respondents through interpersonal communication for behavioral changes as part of the intervention, concurrently at the time of the baseline survey. These activities were performed by some field level workers trained beforehand and under the direct supervision of the investigators. The same respondent was studied in the baseline and final evaluation. The analysis was done using SPSS 16.0 version.
| Results|| |
In both the study areas of Sibpur and South Chandrapur, 100 households were covered during the preintervention phase. However during postintervention phases, in Sibpur, only 78 households could be covered due to nonavailability of the person assessed during the preintervention phases, shifting to other areas due to migration and occupation, deaths, and refusal; however in south Chandrapur, all the 100 households of preintervention phases were covered. In Sibpur, the source of water was intermittent water supply from the municipal tap which was stored in the bucket for hand washing. In south Chandrapur, water used was mainly from ponds (52%), tube wells (26%), and wells (22%).
In south Chandrapur, the majority of the respondents washed hands with stored water from the bucket (89%) and not much variation (74%) could be observed following intervention. Hand washing by water directly from the tap in Sibpur increased from 11% during the baseline survey to 43.58% during first intervention and finally to 61.54% during second intervention, and the differences were found to be significant in both the phases (P < 0.05). This was accompanied by a marked decline in the use of bucket water, i.e. from 88% at the time of the baseline survey to 41% after first and 25% following second intervention (P < 0.01).
Regarding the situations where the respondents actually practiced hand-washing, findings of South Chandrapur and Sibpur did not show much difference. In both the studied areas, hand washing after defecation was practiced by almost all the respondents. However it was concerning to note that in both the areas hand washing was not practiced by a substantial proportion of the respondents in situations such as "after changing babies' nappies and "disposing off their faeces", "before preparing food", "immediately after handling raw vegetables", and "after handling pets and domestic animals" [Figure 1].
|Figure 1 :Distribution of households of the study areas according to hand washing practices in different situations|
Click here to view
Use of soap for hand washing during both pre- and postintervention phases was observed to be much higher in Sibpur (92%, 98.75% and 97.4% in baseline, first and second interventions, respectively), but in South Chandrapur, it had improved from baseline 65% to 98% following intervention and the difference was found to be statistically significant (P = 0.000). At south Chandrapur, some of the respondents used plain water and ash for hand washing mainly after defecation, during the baseline survey.
The baseline survey revealed that only 11% of the respondents were washing their hands for more than 15-30 s in Sibpur, which was improved significantly to 25% and 42% after the first and second interventions, respectively (P = 0.009 and P = 0.02). None of the respondents at south Chandrapur washed hands for this stipulated time period both before and after intervention.
In both the areas, none of the respondents followed all the six steps of hand washing before intervention. Following intervention, improvement was observed to the extent of 44% in south Chandrapur; whereas in Sibpur, it was 17.9% and 47.4% after the first and second interventions, respectively, and the difference was found to be significant (P = 0.000). The majority of the respondents (>95%) in both the study areas were found to be practicing step 1 of hand washing in the baseline survey. However, there was significant improvement in other steps of hand washing in both the areas following interventions and it was more in regards to steps 2, 3, 4, and 6 [Table 1].
|Table 1 :Steps of hand washing followed by the respondents of Sibpur and South Chandrapur before and after intervention|
Click here to view
It was observed during the baseline survey that only 42% of the respondents in Sibpur used clean material for drying hands after hand washing, and it had significantly improved to 67.9% (P = 0.001) after first intervention; though not changed much following second intervention (66.6%). In South Chandrapur, 37% and 93% of respondents used clean material at pre- and post-intervention phases, respectively, and the improvement was found to be significant (P = 0.000).
| Discussion|| |
This study observed little differences in between two study areas in respect to the practice of hand washing. Almost all of the respondents practiced hand washing after defecation, but it was concerning to note that in both the areas, hand washing was not practiced by a substantial proportion of the respondents in situations such as "after changing babies' nappies and disposing off their faeces", "before preparing food", "immediately after handling raw vegetables", and "after handling pets and domestic animals". The reasons might be due to the similarity in sociocultural and linguistic background of the study areas. Earlier studies by Ray et al. also highlighted similar findings. The majority of the people wrongly considered child's feces to be free of germs. A community-based behavior change communication program on these important issues should be taken up so that the knowledge and practice of the respondents could be improved.
In one study area, the majority of the respondents washed hands with water stored in buckets and no change following intervention was observed due to nonavailability of tap water supply in that area. Whereas, washing hands with running water from tap improved significantly in another study area following interventions wherever such facilities existed close to the household. The study revealed that repeated interventions as well as availability of facilities for running water were required to improve the practices of hand washing. BCC activities with involvement of health and Integrated Child Development Services (ICDS) functionaries could help in its sustainability.
This study observed use of plain water and ash for washing hands in the study area situated in Tripura in the baseline survey, which might be due to the age old habits of hand washing in the area. However following intervention, it was significantly improved to use of soap and water. Interventions might have resulted in a changed and improved behavior, but question remains regarding sustainability in future. In the study area of West Bengal, use of soap for hand washing (92%) was more observed during the preintervention phase, which was sustained subsequently. The intervention study at Jerusalam  revealed that there was threefold increase in hand washing with soap among preschool children, exposed to the intervention.
In this study the majority of the respondents were not washing their hands for more than 15-30 s as recommended by IFH  in both the study areas, although improvements were observed in one study area following intervention. Ray et al. also revealed the practice of hand washing for less than 10 s in their earlier study.
None of the respondents in both the studied areas followed all the six steps before intervention. Similar findings were also observed in a study in Kolkata and nearby area.  Postintervention significant improvement was observed in regard to steps 2, 3, and 5 in both areas. However, improvements in regard to step 4, i.e. "backs of finger with opposite hand, palms with fingers interlocked" was less marked. The authors felt that step 4 was a difficult step for the respondents to understand. The authors suggested that the number of steps of hand washing should be minimized and made simple and less time consuming so that it could be followed by even illiterate groups as well as children. At the same time, it should prevent the communicable diseases such as diarrhea and ARI. This could be achieved through a community-based study with the co-operation of the department of microbiology. The need for such an effort could be substantiated by the evidenced-based study at Dhaka, Bangladesh,  which revealed that simple hand washing with soap only on a regular basis could bring down the incidence of episodes of diarrhea; however, the study did not mention anything about the steps of hand washing. Cairnross also opined that the promotion of hand washing in poor communities can significantly reduce the risk of ARIs, and then we may at least have an explanation for the Mills-Reinicke phenomenon that water supplies improve hand hygiene and reduce child mortality not only from diarrhea, but also from respiratory infections. 
Whatever might be the material used for drying, it was important to know whether it was clean or not. This study observed marked improvement in using clean material for drying hands following intervention compared to the baseline survey.
Use of soap, cleanliness of material for drying hands, time and steps of hand washing were important components of hand washing. Even if 100% of the population washed hands after defecation as well as after other situations, diarrhea, ARI, etc. could not be reduced, if these components of hand washing were ignored.
| Conclusion|| |
Hand washing is a neglected issue both by the community and care-providers (including government). Its enormous importance in prevention and reduction of occurrence of diseases such as diarrhea, ARI and skin infections, based on the evidence, was not properly understood and thus priority has not been given by the community and government to that extent as given for other programs such as immunization, ORT, RCH, etc. Based on the findings of this intervention study, it could be suggested that BCC program should be well planned with emphasis on hand washing after changing nappies and disposal of child's faeces, handling pets and animals, before preparing food, etc. If running water is not available, water may be used from the bucket, but bucket should be clean and pond water should be kept in the bucket after treatment. Usage of soap, hand washing for 15-30 s following all the six steps, drying of washed hands with clean towel or a piece of clean cloth should be emphasized. Repeated intervention at frequent interval is required to have a sustainable effect.
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