WATER AND SANITATION PROGRAM: TECHNICAL PAPER 90745 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Pavani K. Ram, Bertha Briceño, and Claire Chase, with Ben Arnold, John M. Colford, Paul Gertler, and Alexandra Orsola-Vidal August 2014 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. By Pavani K. Ram, Bertha Briceño, and Claire Chase, with Ben Arnold, John M. Colford, Paul Gertler, and Alexandra Orsola-Vidal The authors acknowledge with gratitude the diligence and dedication of the country teams, particularly the principal investigators, along with the data collection teams. Thanks also to Adam Biran, Orlando Hernandez, and Stephen Luby, who provided thoughtful input into the development of handwashing measures included in the impact evaluation baseline surveys. Global Scaling Up Handwashing is a project by the Water and Sanitation Program (WSP) focused on applying innovative behavior change approaches to improve handwashing with soap behavior among women of reproductive age (ages 15–49) and primary school-age children (ages 5–9). It was implemented by local and national governments with technical support from WSP in four countries: Peru, Senegal, Tanzania, and Vietnam. For more information, please visit www.wsp.org/ scalinguphandwashing. WSP is a multidonor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to worldbankwater@worldbank.org. WSP encourages the dissemination of its work and will normally grant permission promptly. For more information, please visit www.wsp.org. © 2014 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Pavani K. Ram, Bertha Briceño, and Claire Chase, with Ben Arnold, John M. Colford, Paul Gertler, and Alexandra Orsola-Vidal August 2014 Executive Summary Handwashing with soap has been shown to reduce diarrhea together were present in two handwashing places in 15 per- and respiratory disease, the two leading causes of childhood cent of Peru households, 13 percent of Senegal households, deaths in low- and middle-income settings. Global Scal- and 27 percent of Vietnam households. ing Up Handwashing is a Water and Sanitation Program (WSP) project focused on applying innovative behavior Handwashing with soap after defecation was reported change approaches to improve handwashing with soap be- nearly universally in Peru and Vietnam, and by 84 percent havior among women of reproductive age (ages 15–49) and of households in Senegal. Soap and water were observed primary school-age children (ages 5–9). The project was together at the handwashing place used after defecation implemented by local and national governments with tech- in 55 percent of Peru households, 29 percent of Senegal nical support from WSP in four countries: Peru, Senegal, households, and 80 percent of Vietnam households. Hand- Tanzania, and Vietnam. washing with soap before food preparation was reported in the majority of households in each country. Soap and water In the impact evaluation of Global Scaling Up Handwash- were observed together at the handwashing place used be- ing, handwashing behavior is measured at the individual fore food preparation in 57 percent of Peru households, and household levels using self-report, rapid observations, 21 percent of Senegal households, and 79 percent of Viet- and structured observations. The objective of this report is nam households. to describe handwashing behavior at baseline in three proj- ect countries: Peru, Senegal, and Vietnam. Data from Tan- Nearly two-thirds of caregivers in Peru (62 percent) and zania was not available at the time of this analysis. Vietnam (63 percent) indicated washing hands with soap after fecal contact (after cleaning a child or defecating) dur- In all three countries, rapid observations and self-reports ing the day preceding the interview, compared to 30 per- were collected among all households included in the base- cent of Senegal caregivers. Reports of washing hands with line surveys. Structured observations were carried out in a soap before food preparation during the previous day was subset of households included in the baseline survey in Peru more common among Peru caregivers (70 percent) than and Senegal. Self-report and structured observation data among caregivers in Vietnam (31 percent) and Senegal were used to describe individual handwashing behavior at (12 percent). critical times. The following critical times for handwashing behavior were of interest in these analyses: after fecal con- Enumerators in Peru more frequently rated caregivers as tact, before food preparation, and before eating or feeding having visible dirt than did enumerators in Senegal and a child. Vietnam. Hand cleanliness was categorized on a three- point scale based on the observations of nails, palms, and At least one type of soap for handwashing was observed fingerpads. If all three aspects of the hand were recorded as in almost all households in Vietnam (97 percent), and “clean,” overall hand cleanliness was rated as “clean.” Hands in 82 percent of Peru households and 59 percent of Sen- were rated as “clean” in 42 percent of Peru caregivers, egal households. There was no handwashing place in 8 to 71 percent of Senegal caregivers, and 63 percent of Vietnam 45 percent of households, one handwashing place in 32 to caregivers. Hands were rated as “very unclean” in 24 per- 61 percent of households, and two handwashing places in cent of Peru caregivers, 7 percent of Senegal caregivers, and 23 to 31 percent of households. Soap and water together 4 percent of Vietnam caregivers. were present at one handwashing place in 53 percent of Vietnam households, 46 percent of Peru households, and In five-hour structured observations, soap use for hand- 21 percent of Senegal households. Both soap and water washing was observed at least once among all household iv Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Executive Summary members in 73 percent of Peru households and 39 percent to improve handwashing behavior in all three Scaling Up of Senegal households. Soap use was noted among primary countries, especially in Senegal. Although soap is available caregivers in 56 percent of Peru households and 27 percent in most homes, it is often not located in places designated of Senegal households. In both countries, household mem- for washing hands after defecation and before food prep- bers in fewer than half of the households with a fecal contact aration. Handwashing with soap at these critical times is event were observed to use soap for handwashing at least practiced by a minority in Peru and Senegal, underscoring once after that event. Among all household members, soap the need to improve compliance with handwashing with use was observed at least once after a fecal contact event in soap at times relevant to pathogen transmission. Those who 42 percent of Peru households and 25 percent of Senegal maintained a handwashing place often kept soap and water households. Among primary caregivers, soap use was ob- at that place, suggesting the importance of designating a served at least once after a fecal contact event in 40 percent location for handwashing as part of making handwashing of Peru households and 30 percent of Senegal households. a habit. Forthcoming work in these countries will examine Among all household members, soap use was observed at the impact of at-scale handwashing interventions on hand- least once before food preparation in 23 percent of Peru washing behavior, as measured by self-report, rapid obser- households and 6 percent of Senegal households, with simi- vations, and structured observations. lar findings among primary caregivers. The baseline surveys for Global Scaling Up Handwashing in Peru, Senegal, and Vietnam indicate a substantial need www.wsp.org v Contents I. Introduction ............................................................................... 1 II. Methods ..................................................................................... 3 2.1 Data Analysis ..................................................................... 3 III. Results ....................................................................................... 7 3.1 Handwashing Behavior Measured at the Household Level ................................................................ 7 3.2 Handwashing Behavior Measured at the Individual Level ................................................................ 10 3.3 Handwashing Behavior Measured by Structured Observations .................................................................... 12 IV. Discussion ............................................................................... 13 References ............................................................................... 16 Tables ....................................................................................... 18 Figures 1: Inclusion and Exclusion of Households in Analysis of Data Regarding Fixed Handwashing Places ....................... 4 2: Flowcharts to Describe Inclusion and Exclusion of Households for Measurement of Handwashing Places Used after Defecation and before Food Preparation (Peru, Senegal, and Vietnam)............................................... 9 Tables 1: Indicators of Handwashing Behavior, by Level and Method of Data Collection, Peru, Senegal, and Vietnam, 2009 .................................................................... 18 2: Presence of Soap and Water Anywhere in the Home and at Handwashing Places, Peru, Senegal, and Vietnam, 2009 .................................................................... 19 3: Description of Place for Washing Hands after Defecation, Peru, Senegal, and Vietnam, 2009 .................................... 20 4: Observations of Soap and Water at Handwashing Places Used after Defecation, Peru, Senegal, and Vietnam, 2009 .................................................................... 20 5a: Description of Place for Washing Hands before Food Preparation, Peru and Senegal, 2009 ................................ 21 5b: Description of Place for Washing Hands before Food Preparation, Vietnam, 2009 ............................................... 21 vi Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Contents 6: Observations of Handwashing Places for Use before Food Preparation, Peru, Senegal, and Vietnam, 2009....... 22 7: Self-Reported Handwashing Behavior and Observations of Hand Cleanliness among Individual Caregivers, Peru, Senegal, and Vietnam, 2009 ................. 23 8: Observations of Soap Use for Handwashing during Structured Observations, Peru and Senegal, 2009 ........... 24 www.wsp.org vii I. Introduction Handwashing with soap has been shown to reduce diarrhea help identify gaps in the uptake in the intervention being and respiratory disease, the two leading causes of childhood implemented. deaths in low- and middle-income settings. Most studies contributing to the literature on handwashing and health Handwashing can be measured using a variety of meth- impact in low-income settings have been small efficacy ods, with each approach having advantages and limita- studies, and only a few have been rigorously conducted tions (Ram 2013). Self-report is most widely used and is randomized controlled trials. Moreover, many studies have highly efficient since the necessary questions can be easily either examined health impact or behavior change, but few integrated into survey instruments. However several studies have examined the extent to which a given intervention have demonstrated that, when queried directly, individuals results in handwashing behavior change as well as health tend to overestimate their true behavior (Biran et al. 2008; impact. The latter limits researchers’ understanding of how Manun’Ebo et al. 1997; Stanton et al. 1987). Self-report much handwashing behavior needs to be changed in order may inform about the overall awareness of a population re- to realize health impacts. garding handwashing at critical times of interest. Of note, a number of recent studies, most of which are yet to be pub- Global Scaling Up Handwashing was initiated in 2006 by lished, have demonstrated that self-reported handwashing is the Water and Sanitation Program (WSP) in Peru, Senegal, associated with a decreased risk of adverse health outcomes Tanzania, and Vietnam. WSP is leading an intensive evalu- (Rhee et al. 2008). Observations, such as whether soap is ation to understand the impacts of at-scale handwashing present in the home or whether soap or water are present promotion on health, growth, household productivity, and at handwashing places, have been shown to be associated handwashing behavior. with health outcomes and are easily integrated into surveys. Such observations represent proxies or intermediates in the The handwashing promotion interventions deployed in the handwashing behavior process; they indicate awareness of Global Scaling Up countries were developed using a frame- the need for soap, intention to wash hands at critical times work known as FOAM (Focus, Opportunity, Ability, and such as after toileting, or the presence of a visual cue such as Motivation) (Coombes and Devine 2010). Focus consists a handwashing location adjacent to a toilet. Some of these of the target behavior (handwashing with soap at critical rapidly observed measures have also been shown to be as- times) amongst the target population (primary caregivers of sociated with health outcomes such as all-cause diarrhea or young children). Opportunity reflects the access to and avail- epidemic cholera (DuBois et al. 2006; Luby and Halder ability of the necessary products, product attributes, and 2008). the social norms that reinforce use of the products. Ability is based on individuals’ knowledge and the social support for An objective approach used primarily in research studies carrying out the target behavior. Finally, motivation is built has been the quantification of microbes on hands (Luby around a set of psychosocial determinants, including belief et al. 2007; Luby et al. 2001). But, hand microbiology re- and attitudes, outcome expectations, threat, and intention mains expensive, so difficult to use in large-scale studies. to carry out the behavior. Moreover, this work has demonstrated that hand contami- nation is highly variable; thus, a single effort to quantify A handwashing promotion intervention can only result in microbes on hands risks misclassification of the individual improved health or other downstream benefits if it results with respect to handwashing behavior (Ram et al. 2011). in increased handwashing behavior. Thus, information on Structured observations consist of recording handwash- handwashing behavior change as a result of a handwash- ing behaviors at critical times when hands should likely be ing promotion intervention can provide evidence for in- washed, such as after fecal contact or before food prepara- termediate pathways between handwashing and health, or tion (Biran et al. 2008). Since a human observer is pres- ent in the household, rich contextual details are available www.wsp.org 1 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Introduction with respect to handwashing behavior. However, persons handwashing, the availability of materials necessary for under observation may alter their usual behavior as a result handwashing, and the practice of washing hands at critical of being observed (Cousens et al. 1996; Ram et al. 2010). times. Specifically, with respect to the FOAM framework, Still, the depth of detail and the objective nature of the data this report addresses constructs within the Focus, Opportu- collection make structured observation a useful method for nity, and Ability domains. The goal of this report is to de- measuring handwashing behavior change. scribe handwashing behavior of households included in the project impact evaluation, as measured during the baseline In the impact evaluation of Global Scaling Up Handwash- surveys conducted in Peru, Senegal, and Vietnam. Forth- ing, handwashing is measured using self-reports, rapid ob- coming work will examine the impact of the intervention servations, and structured observations, recognizing that on handwashing behavior within each of these countries as each method provides useful insights into awareness about measured by follow-up surveys. 2 Global Scaling Up Handwashing II. Methods In each country, representative samples of households with children under 2 years Handwashing was measured old were identified in preselected geographic clusters for inclusion in the impact evaluation. The baseline survey of the impact evaluation was conducted in Peru at the household and (2008), Senegal (2009), and Vietnam (2009) (Chase and Do 2010; Galiani and Orsola-Vidal 2010; Orsola-Vidal and Yusuf 2011). Information regarding the individual levels using several data collection methods for the baseline surveys can be found in the country- methods of data collection: specific reports published by WSP (ibid.). Here, the focus is on the methods rele- vant to the measurement of handwashing behavior and analysis of the baseline sur- rapid observations, self- vey data. Country-specific analyses are reported here, without aggregation of data beyond the country level. These data were analyzed for the entire set of households report, and structured and individuals measured at baseline, irrespective of treatment arm. Equivalence observations. of the treatment arms has been established in the country-specific reports. Handwashing was measured at the household and individual levels using the methods of data collection described above: rapid observations, self-reports, and structured observations (Ram 2013). Key indicators of handwashing behavior are described by the level and method of data collection in Table 1. In all three coun- tries, both rapid observations and self-reports were obtained among all house- holds included in the overall baseline surveys. Structured observations were carried out in a subset of households included in the baseline survey in Peru and Senegal. Structured observations were not carried out in the Vietnam baseline survey. Observations for individual-level data col- lection were carried out among primary caregivers of children. In Peru, observa- tions began between 6:30 and 9:30 a.m., and lasted 4 to 5 hours. Self-report and structured observation data are used to describe individual handwashing behavior at critical times. The following critical times for handwashing behavior were of interest in these analyses: after fecal contact, before food preparation, before eat- ing and before feeding a child. 2.1 Data Analysis This section describes the various measures of handwashing collected using rapid observations, self-reports, and structured observations. Presence of soap anywhere in the home The indicator is defined as the presence of at least one type of soap observed by the enumerator anywhere in the home. Following observations of handwashing places, enumerators asked the household respondent to show soap typically used for washing hands, irrespective of where it was located in the home. All households that allowed observation of soap any- where in the home are included in this analysis. www.wsp.org 3 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Methods Number of fixed handwashing places in the home Questions to describe the location of the handwashing place Fixed locations identified by respondents as places used for and materials observed at that place followed an introduc- handwashing after defecation and before food preparation tory question regarding whether hands are usually washed were examined. The number of handwashing places was after defecation. Inclusion and exclusion criteria for this tallied to determine whether there were one or two distinct analysis are presented in Figure 1. Households in which the locations. Since respondents were not asked about hand- respondents indicated washing hands after defecation, and washing places other than those used after defecation and where respondents allowed observation of the handwashing before food preparation, the maximum number of hand- place and the presence of soap and water at that place, were washing places that could have been recorded in the base- eligible for analysis (Figure 1). line surveys was two. Enumerators recorded whether the handwashing place Presence of soap and water at a fixed handwashing was inside the toilet or cooking place, or elsewhere in the place used post-defecation yard. In Peru and Senegal, if the handwashing place was The indicator is defined as the presence of at least one type located elsewhere in the yard, the distance from the toilet of soap observed by the enumerator at the fixed handwash- was recorded (less than 3 feet from the toilet, 3 to 10 feet ing place reportedly used after defecation. from the toilet, or more than 10 feet from the toilet). In FIGURE 1: INCLUSION AND EXCLUSION OF HOUSEHOLDS IN ANALYSIS OF DATA REGARDING FIXED HANDWASHING PLACES Households in dataset Queried about Queried about handwashing handwashing before food after defecation preparation Missing response Missing response or response of or response of “don’t know” “don’t know” Answered query Answered query regarding regarding handwashing handwashing before food Did not allow Did not allow after defecation preparation observation of observation of handwashing handwashing place, or soap place, or soap or water at or water at Households eligible for Households eligible for place place analysis of handwashing analysis of handwashing place used after place used before food defecation preparation 4 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Methods Vietnam, if the handwashing place was located elsewhere introductory question regarding whether hands are usually in the yard, enumerators recorded the distance in meters, washed before food preparation. All households in which but the pre-coded categories approximated to the ones the respondents indicated washing hands before food prep- used in Peru and Senegal. aration were eligible for analysis, and where respondents al- lowed observation of the location of the handwashing place Enumerators recorded the type of soap present at the hand- and the presence of soap and water at that place (Figure 1). washing place. In Peru and Senegal, the types of soap ob- In the baseline survey, if households used the same location served were beauty bar soap, multipurpose bar soap, and for washing hands after defecation and before food prepara- powder/detergent soap. In Vietnam, the types of soap ob- tion, observations of soap and water at that location were served were liquid soap, multipurpose bar soap, and pow- not recorded for the food preparation handwashing place; der/detergent soap. For the indicator, a household was for the analysis below, the values recorded for the post-defe- considered as having soap at the handwashing place if at cation handwashing place were used to impute data for the least one type of soap, irrespective of type, was present at pre-food preparation handwashing place. the handwashing place. The presence of water was recorded at the handwashing place, irrespective of the type of device Enumerators recorded whether the handwashing place was located therein. inside the toilet or cooking place, or elsewhere in the yard. Distance of the handwashing place from the cooking place Presence of soap and water at a fixed handwashing was recorded as described above for the post-defecation place used before food preparation handwashing place. Soap and water observations were also The indicator is defined as the presence of at least one type recorded similarly. of soap observed by the enumerator at the fixed handwash- ing place reportedly used before food preparation. Cleanliness index of caregiver hands (index based on observation of nails, palms, and fingerpads) Questions to describe the location of the handwashing place This is a three-point index based on the enumerator’s obser- and materials observed at that place followed an introductory vation of the cleanliness of the nails, palms, and fingerpads question regarding whether hands are usually washed before of individual caregivers. food preparation. Observations of soap and water were carried out if the handwashing place used before food preparation If all three aspects of the hand were observed to be “clean,” differed from the handwashing place used after defecation. the caregiver was categorized as having “clean” hands. If at least one aspect of the hand was observed to have visible To identify households eligible for this analysis, the study dirt, the caregiver was categorized as having “very unclean” started with those who showed a handwashing place used hands. All other caregivers who allowed observations of before food preparation that was distinct from the hand- the hands were categorized as having “somewhat unclean washing place used after defecation, and for which obser- hands.” Caregivers who did not allow observation of one or vation of the location, soap, and water were all completed more aspects of the hand were not included in the analysis (Figure 1). Households in which the handwashing place of the cleanliness index. used after defecation was located in the kitchen and was the same place used to wash hands before food preparation Self-reported handwashing with soap at critical times were also included. Households in which the respondent during the previous day indicated not usually washing hands before food prepara- The indicator is defined as self-reported handwashing with tion, or that had no specific place for washing hands before soap at one of the three critical times during the previous day. food preparation, were then added. Individual caregivers were asked whether they had washed Questions to describe the location of the handwashing hands with soap at least once during the previous day (since place and materials observed at that place followed an the same time the day before the enumerator’s visit). If they www.wsp.org 5 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Methods reported washing hands, they were asked in an unprompted Observed handwashing with soap at critical times fashion about the context in which hands were washed Structured observation data can be analyzed and reported with soap and all other times that hands were washed with in numerous ways. Here, handwashing behavior is ana- soap during the previous day. Although information about lyzed at the household level, rather than based on the role a number of times for handwashing was captured, those of observed individuals within the household (e.g., pri- of principal interest were after fecal contact, before food mary caregiver versus other adult versus child). The next preparation or serving food, before eating, and before feed- section reports whether specific critical events were ob- ing a child. served during structured observation and whether hands were washed with soap at least once for each type of criti- In Senegal and Peru, caregivers described as being alone cal event. The events of interest were the same as those at the time of the interview were included in the analysis, for self-reported handwashing behavior: after fecal con- since the presence of others may have influenced caregivers’ tact, before food preparation or serving food, and before responses to handwashing questions. This information was eating or feeding a child. Behavior as measured among not captured in the Vietnam survey but enumerators were all household members, and among primary caregivers in trained to ensure respondents’ privacy. particular, is reported. 6 Global Scaling Up Handwashing III. Results 3.1 Handwashing Behavior Measured at the Household Level Only a minority of Presence of soap anywhere in the home Observation of soap anywhere in the home was possible in 3,658 Peru house- households in each country holds, 1,373 Senegal households, and 3,129 Vietnam households (Table 2). At least one type of soap for washing hands was observed in the majority of house- had soap and water together holds in all three countries, but was nearly universal in Vietnam (97 percent). In at two handwashing places. contrast, 82 percent of Peru households and 59 percent of Senegal households had at least one type of soap for washing hands somewhere in the home. The most common type of soap observed was powder soap in Vietnam (83 percent) and Peru (60 percent), and multipurpose bar soap in Senegal (47 percent). Number of handwashing places, and presence of soap and water in those places The number of handwashing places present in each household was tallied based on the inclusion and exclusion criteria outlined above and in Table 2. Because re- spondents were asked about handwashing places specifically used after defecation and before food preparation, the maximum number of handwashing places pos- sible was two. In Peru, among 3,448 households, 8 percent had no handwashing place, 61 percent had only one place, and 31 percent had two places. In Senegal, among 1,513 households, 45 percent had no handwashing place, 32 percent had only one place, and 23 percent had two places. In Vietnam, among 3,143 house- holds, 11 percent had no handwashing place, 58 percent had only one place, and 31 percent had two places. The availability of soap and water at one or more handwashing places in 3,448 households in Peru, 1,513 households in Senegal, and 3,143 households in Viet- nam was examined. Soap was present at only one handwashing place in 55 per- cent of Vietnam households and 51 percent of Peru households, in contrast to 23 percent of Senegal households. Soap was present in two handwashing places in a minority of households in all three countries: Peru (18 percent), Senegal (15 percent), and Vietnam (29 percent). Whereas soap was not present at any handwashing place in 63 percent of Senegal households, this was true of only 17 percent of Vietnam households and 32 percent of Peru households. Water was present at one handwashing place in 58 percent of Peru households, 28 per- cent of Senegal households, and 57 percent of Vietnam households. Water was present at two handwashing places in 23 percent of Peru households, 15 per- cent of Senegal households, and 30 percent of Vietnam households. Soap and water together were present at one handwashing place in the majority of Vietnam (53 percent) and Peru (46 percent) households, in contrast to 21 percent of Sen- egal households. Only a minority of households in each country had soap and water together at two handwashing places. Soap and water together were present in two handwashing places in 15 percent of Peru households, 13 percent of Sen- egal households, and 27 percent of Vietnam households. www.wsp.org 7 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Results Notably, among households that had one or two handwash- in the majority of Vietnam (86 percent) and Peru (74 per- ing places, many had soap and water at those locations. In cent) households, in contrast to only 36 percent of Senegal Vietnam, 87 percent of households with only one hand- households. Both soap and water together were observed washing place had both soap and water there, and 89 per- at the post-defecation handwashing place in 80 percent of cent of households with two handwashing places had soap Vietnam households, in contrast to 55 percent of house- and water at both places. In Peru, 64 percent of households holds and just 29 percent of Senegal households. with only one handwashing place had both soap and water at that place, and 48 percent of households with two hand- Location of handwashing place and presence of soap washing places had soap and water at both places. Some- and water at handwashing place used before food what similar to Peru, 49 percent of Senegal households with preparation only one handwashing place had both soap and water at The number of households eligible for analysis regarding that place, and 55 percent of households with two hand- the handwashing place used before food preparation was washing places had soap and water at both places. 3,236 in Peru, 1,425 in Senegal, and 3,040 in Vietnam (Figure 2). In each country, the majority of respondents Details regarding availability of soap and/or water among in households eligible for analysis reported washing hands households with one or two handwashing places are in- before food preparation (Tables 5a and 5b). The most com- cluded in Table 2. mon location of the handwashing place used before food preparation varied. In Peru, the handwashing place was in- Location of handwashing place and presence of soap side the cooking area in 40 percent of Peru households. In and water at handwashing place used after defecation Vietnam, the handwashing place was more than 3 meters The number of households eligible for analysis regarding from the toilet facility in 37 percent of homes. In contrast, the handwashing place used after defecation was 3,438 in in Senegal, the most common fixed location for handwash- Peru, 1,471 in Senegal, and 3,124 in Vietnam (Figure 2). ing was within 3 feet of the cooking area (18 percent) but, In each country, the majority of respondents in households more importantly, 56 percent of eligible households had no eligible for analysis reported washing hands after defecation specific place for washing hands before food preparation. In (Table 3). The most common location of the handwash- contrast to Senegal, 10 percent of Vietnam households and ing place used after defecation varied. In Peru, the hand- 9 percent of Peru households had no specific place. washing place was more than 10 feet away from the toilet facility in 34 percent of Peru households and 35 percent Enumerators observed at least one type of soap at the hand- of Vietnam households. In contrast, in Senegal, the most washing place used before food preparation in 80 percent common fixed locations for handwashing were inside the of Vietnam households, 64 percent of Peru households, toilet facility (22 percent) and within 3 feet of the toilet and just 24 percent of Senegal households (Table 6). The facility (22 percent). Whereas only 9 percent of households most common type of soap observed was powder soap in in Vietnam and 13 percent of households in Peru had no households in Peru (47 percent) and Vietnam (60 percent). specific place for washing hands, 45 percent of households In Senegal, 16 percent of households had multipurpose in Senegal had no such place. bar soap at this handwashing place. Water was present at the food preparation handwashing place in the majority of Enumerators observed at least one type of soap at the Vietnam (85 percent) and Peru (76 percent) households, handwashing place used after defecation in 82 percent of in contrast to only 27 percent of Senegal households. Both Vietnam households, 61 percent of Peru households, and soap and water together were observed at the food prepara- 32 percent of Senegal households (Table 4). The most com- tion handwashing place in 79 percent of Vietnam house- mon type of soap observed was powder soap at the post- holds and 57 percent of Peru households, unlike Senegal, defecation handwashing place in Peru (40 percent), and where soap and water were observed together at the food multipurpose bar soap in Vietnam (45 percent) and Senegal preparation handwashing place in only 21 percent of Sen- (25 percent). Water was present at the handwashing place egal households. 8 Global Scaling Up Handwashing FIGURE 2: FLOWCHARTS TO DESCRIBE INCLUSION AND EXCLUSION OF HOUSEHOLDS FOR MEASUREMENT OF HANDWASHING PLACES USED AFTER DEFECATION AND BEFORE FOOD PREPARATION (PERU, SENEGAL, AND VIETNAM) a. PERU Households in dataset (N ‫ ؍‬3,721) Handwashing Handwashing after before food defecation preparation Missing response Missing response or response of “don’t or response of “don’t know” (N ‫ ؍‬229) Answered query Answered query know” (N ‫ ؍‬231) regarding regarding handwashing handwashing after before food preparation defecation (N ‫ ؍‬3,492) (N ‫ ؍‬3,490) Did not allow Did not allow observation of observation of handwashing handwashing place, or soap Households eligible for Households eligible for place, or soap or water at analysis of handwashing analysis of handwashing or water at place (N ‫ ؍‬54) place used after place used before food place (N ‫ ؍‬254) defecation (N ‫ ؍‬3,438) preparation (N ‫ ؍‬3,236) b. SENEGAL Households in dataset (N ‫ ؍‬1,550) Handwashing Handwashing after before food defecation preparation Missing response Missing response or response of “don’t or response of “don’t know” (N ‫ ؍‬9) Answered query Answered query know” (N ‫ ؍‬5) regarding regarding handwashing handwashing after before food preparation defecation (N ‫ ؍‬1,541) (N ‫ ؍‬1,545) Did not allow Did not allow observation of observation of handwashing handwashing place, or soap Households eligible for Households eligible for place, or soap or water at analysis of handwashing analysis of handwashing or water at place (N ‫ ؍‬70) place used after place used before food place (N ‫ ؍‬120) defecation (N ‫ ؍‬1,471) preparation (N ‫ ؍‬1,425) www.wsp.org 9 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Results c. VIETNAM Households in dataset (N ‫ ؍‬3,150) Handwashing Handwashing after before food defecation preparation Missing response Missing response or response of “don’t or response of “don’t know” (N ‫ ؍‬10) Answered query Answered query know” (N ‫ ؍‬14) regarding regarding handwashing handwashing after before food preparation defecation (N ‫ ؍‬3,140) (N ‫ ؍‬3,136) Did not allow Did not allow observation of observation of handwashing handwashing place, or soap Households eligible for Households eligible for place, or soap or water at analysis of handwashing analysis of handwashing or water at place (N ‫ ؍‬16) place used after place used before food place (N ‫ ؍‬96) defecation (N ‫ ؍‬3,124) preparation (N ‫ ؍‬3,040) 3.2 Handwashing Behavior Measured at the with soap at least once during the previous day. Whereas Individual Level nearly two-thirds of caregivers in Peru (62 percent) and Handwashing behavior was measured among individual Vietnam (63 percent) indicated washing hands with soap caregivers of children less than 5 years old in Peru, Sen- after fecal contact (after cleaning a child or defecating) egal, and Vietnam (Table 7). The analysis below reports on during the day preceding the interview, only 30 percent of all caregivers queried, rather than only one caregiver per Senegal caregivers cited this critical time for having washed household. Analysis in Peru and Senegal was restricted to all hands with soap. caregivers who were interviewed alone since the presence of another person may have impacted their responses; in Viet- Washing hands with soap before food preparation dur- nam, enumerators were trained to ensure that caregivers ing the previous day was far more commonly reported by were alone when interviews were done. The vast majority Peru caregivers (70 percent) than by caregivers in Viet- of caregivers in all three countries reported washing hands nam (31 percent) and Senegal (12 percent). One-third of 10 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Results caregivers in Peru and Vietnam reported having washed hands with soap before The vast majority of feeding a child during the previous day in contrast to only 5 percent of Senegal caregivers. Similar proportions of caregivers in Senegal (16 percent) and Vietnam caregivers in all three (20 percent) reported washing hands with soap before eating; this data was not available for Peru due to an error in the data collection tool. Whereas 91 percent countries reported washing of Peru caregivers and 81 percent of Vietnam caregivers reported washing hands hands with soap at least once with soap at one or more of these critical times, only 46 percent of Senegal care- givers reported doing so. Few caregivers in each country indicated washing hands during the previous day. with soap at each of these critical times, but it is possible that the critical time did not occur (for example, they may not have had to feed a child themselves). The proportion of respondents indicating that washing with soap is the best way to clean hands was nearly identical in the three countries: Peru (85 percent), Sen- egal (88 percent), and Vietnam (86 percent). Enumerators rated the cleanliness of caregivers’ nails, palms, and fingerpads. Rat- ings among caregivers in Senegal and Vietnam were similar to each other but dissimilar to ratings among Peru caregivers. In Peru, enumerators indicated the presence of visible dirt under nails (26 percent), on palms (19 percent), and on fingerpads (19 percent). Visible dirt was much less commonly recorded in Sen- egal: nails (10 percent), palms (4 percent), and fingerpads (4 percent). Similar to Senegal, in Vietnam, visible dirt was recorded for 5 percent of nails, 2 percent of palms, and 2 percent of fingerpads. Hand cleanliness was categorized on a three-point scale based on the observations of nails, palms, and fingerpads. If all three aspects of the hand were recorded as “clean,” overall hand cleanliness was rated “clean.” If at least one aspect of the hands was recorded as having “visible dirt,” overall hand cleanliness was rated as “very unclean.” All others were rated as “somewhat unclean.” Hands were rated as “clean” in 42 percent of Peru care- givers, 71 percent of Senegal caregivers, and 63 percent of Vietnam caregivers. Hands were rated as “very unclean” in 24 percent of Peru caregivers, 7 percent of Senegal caregivers, and 4 percent of Vietnam caregivers. It should be noted that ratings of cleanliness on one aspect of the hand were significantly correlated with ratings of cleanliness on another aspect of the hand. For example, in Senegal, palm cleanliness ratings were highly correlated with fingerpad cleanliness (R = 0.92, p < 0.0001); palm cleanliness ratings were also significantly correlated with fingernail cleanliness ratings, although the strength of the correlation was some- what lower (R = 0.67, p < 0.0001). Similar findings were noted for both Peru and Vietnam (data not shown). www.wsp.org 11 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Results 3.3 Handwashing Behavior Measured by households. Among those with at least one food prepara- Structured Observations tion event observed, only 23 percent of Peru household Structured observations were conducted in 159 households members (22 percent of primary caregivers) were observed in Peru and 110 households in Senegal (Table 8). The to wash hands with soap. The proportion of Senegal house- median number of events observed among all household hold members observed to wash hands with soap at least members was 11 in Peru (range 4–50) and 9 in Senegal once before a food preparation event was even lower at (range 1–31). The median number of events among pri- 6 percent (7 percent of primary caregivers). mary caregivers was 8 in Peru (range 1–22) and 3 in Sen- egal (range 0–11). Soap use for handwashing was observed Events of feeding young children were observed among all at least once among all household members in 73 percent household members in 83 percent of Peru households and of Peru households, in contrast to 39 percent of Senegal 83 percent of Peru primary caregivers. In Senegal, 73 per- households. Soap use was noted among primary caregivers cent of household members and 71 percent of primary care- in 56 percent of Peru households and 27 percent of Senegal givers were observed at a feeding event. Soap use was low households. The median proportion of events accompanied in both countries, with just 12 percent of Peru household by soap use was 16 percent in Peru (range 0–67 percent) members and 5 percent of Senegal household members ob- and 0 percent in Senegal (0–75 percent). served to wash hands with soap before a feeding event. Fecal contact events were observed in a majority of Peru Eating events were observed among 89 percent of Peru households but in fewer than half of Senegal households. In household members and 72 percent of Senegal household both countries, household members in fewer than half of members. Only 43 percent of Peru primary caregivers and the households with a fecal contact event were observed to 24 percent of Senegal primary caregivers were observed eat- use soap for handwashing at least once, with the proportion ing. Soap use was far more common among Peru household using soap somewhat higher in Peru than in Senegal. members overall (46 percent) than among Peru primary caregivers (17 percent). Senegal household members and Events of preparing or serving food were also observed primary caregivers had similarly low rates of handwashing overall and among primary caregivers in a majority of with soap before eating (9 and 7 percent, respectively). Peru households and in far lower proportions of Senegal 12 Global Scaling Up Handwashing IV. Discussion The baseline surveys for Global Scaling Up Handwashing in Peru, Senegal, and Vietnam indicate a substantial potential and need to improve handwashing be- havior in all three Scaling Up countries. Based on the authors’ experience and that of others engaged in measuring handwashing (Ram 2013; Biran et al. 2008; Ram et al. 2010) several measures of handwashing behavior were employed to de- scribe related but distinct constructs. These constructs describing the Focus, Op- portunity, and Ability domains of the FOAM framework (Coombes and Devine 2010) include the availability of materials required for handwashing, behavior at critical times for handwashing, and cleanliness of hands. The various measures paint relatively consistent pictures of the state of handwashing within each proj- ect country, with the greatest opportunity to improve handwashing behavior in Senegal, but also robust potential to do so in both Peru and Vietnam. In Senegal, only a minority of households were found to have a fixed handwash- ing place near toileting and food preparation areas, and soap was available any- where in the home in only about 60 percent of households. Moreover, small minorities of Senegal households observed were found to have washed hands with soap at least once after fecal contact and before food preparation. Even in Peru, fewer than half of households under structured observation were found to wash hands with soap after fecal contact, and far fewer did so before food preparation. Washing hands with soap, or even with water alone, at these two critical times (after defecation and before food preparation) has been associated with reduced diarrhea risk (Luby et al. 2010). These findings indicate the substantial need to improve handwashing at critical times in both Senegal and Peru. There may be several explanations for the low frequency of handwashing with soap at critical times in the Scaling Up countries. It was common in Senegal not to have a specific place to wash hands, even after defecation. In both Peru and Vietnam, the handwashing place was more than 10 feet away from the toilet facil- ity in a third of households. The presence of a fixed handwashing place, particu- larly inside or in close proximity to the toilet facility, may provide a useful visual cue to stimulate handwashing behavior. In particular, such visual cues may be critical to the development of handwashing habits, described by Curtis as “auto- mated behaviors produced by cues, often as part of a routine” (Curtis et al. 2009). In high-income countries, hand hygiene in healthcare settings was believed to be hampered because clinicians were forced to walk away from patient care areas in order to access sinks for handwashing with soap. The placement of waterless hand sanitizer dispensers in large-volume in-patient care areas has led to improvements in hand hygiene behavior by providing the visual cue and by improving access to the necessary materials (Luby and Halder 2008; CDC 2002). www.wsp.org 13 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Discussion The presence of a fixed Even if a fixed handwashing location exists, soap and water for washing hands must be present in order to allow the behavior to occur. The presence of water at handwashing place, a fixed handwashing place has been found to be independently associated with reduced respiratory illness risk in a low-income urban setting (Luby and Hal- particularly inside or in der 2008). A number of observational studies demonstrate lower risk of diar- close proximity to the toilet rhea among households with soap observed anywhere in the home, compared to households without soap (DuBois et al. 2006; Peterson et al. 1998). An in- facility, may provide a useful vestigation in western Kenya also found that the presence of soap in the home is associated with a lower risk of respiratory illness (Kamm et al. 2011). Unlike visual cue to stimulate Vietnam, where most households were found to have soap and water present at a post-defecation handwashing place, far lower proportions of households in handwashing behavior. Peru and Senegal were found to have soap and water at that place. Water was more commonly present at either fixed handwashing location than was soap. It is notable that large proportions of households that designated places for wash- ing hands after defecation and before food preparation kept both soap and water at those locations. This suggests that the practice of designating a handwashing location may contribute to building a handwashing habit at these critical times. As indicated by more frequent self-report of handwashing after defecation than before food preparation, awareness of the importance or at least the social desir- ability of handwashing appears to be greater for washing hands after fecal contact than before food preparation. Recent work from Bangladesh suggests that hand- washing with soap before food preparation is associated with a decreased risk of child diarrhea (Luby et al. 2011), indicating the importance of increasing aware- ness around handwashing at this critical time. Self-reported handwashing behavior has been found repeatedly to overestimate observed handwashing behavior (Biran et al. 2008; Manun’Ebo et al. 1997; Stanton et al. 1987). Here too, this phenomenon was found, with 62 percent of Peru caregivers reporting having washed hands at least once following fecal contact during the day preceding intervention; in contrast, during structured observation, only 40 percent of Peru caregivers observed at a fecal contact event washed hands with soap. In Senegal, although the observed and reported fre- quencies of handwashing after fecal contact were similar, they differed somewhat with respect to food preparation. Even behavior during structured observation is probably subject to reactivity based on the presence of the observer (Ram et al. 2010). Self-report and behavior displayed during observation are likely subject to the respondent’s awareness of social norms around handwashing behavior, as observed in high- and low-income settings (Ram et al. 2010; Pedersen et al. 1986; Drankiewicz and Dundes 2003; Munger and Harris 1989). Awareness of a social norm, that a given behavior is expected by society, as represented by the outside observer, may be useful to improve that behavior. For example, the Community- Led Total Sanitation (CLTS) approach exploits social norms for behavior change by changing societal expectations for social behavior based on engendering disgust and shame around open defecation. In particular, perceptions that handwashing is 14 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Discussion practiced by those more affluent or more desirable may be handwashing place (Halder et al. 2010); as indicated above, important motivators for handwashing behavior (Curtis et al. the latter measure has been associated with reduced risk of 2009). The extent to which interventions modulate percep- respiratory illness. Future analyses of project data will pro- tions of determinants of handwashing behavior, including vide an opportunity to learn how well this measure corre- social norms, shall be evaluated in the endline surveys for lates with other measures of handwashing behavior. the project. In conclusion, the baseline surveys of Global Scaling Up Whereas most of the measures of handwashing appear to Handwashing indicate opportunities to improve hand- be consistent in describing current behaviors, the ratings of washing behavior in all of the countries where interventions hand cleanliness do not. For example, most of the measures are being tested. There is substantial potential to improve of handwashing would seem to indicate that there is great- handwashing in order to reduce diarrhea and respiratory est room for improvement in handwashing behavior in Sen- illness, particularly in Senegal and Peru, and to a lesser ex- egal. In contrast, a higher proportion of Senegal caregivers tent in Vietnam. Future analyses of handwashing behav- were rated as having “very clean” hands, compared to Peru ior measures are expected to address relationships between and Vietnam caregivers. Similar instructions were provided the measures and socioeconomic status, a very important in training manuals for this question to the investigators confounder of handwashing behavior and childhood illness responsible for all three countries. The measure is observed risk. In addition, in the future, correlations could be de- but is subjective, based on the enumerator’s perceptions of scribed between measures and relationship with disease risk skin cleanliness and skin pigment. One prior investigation and other hygiene behaviors in the home, including sanita- conducted in Bangladesh demonstrated the association be- tion and household water treatment. tween observed hand cleanliness and presence of water at a www.wsp.org 15 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam References References Biran, A., T. Rabie, W. Schmidt, S. Juvekar, S. Hirve, and and Other Measures of Handwashing Behavior in Rural V. 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Gangarosa. 2001. “Microbio- haviour: Structured Observations from Burkina Faso.” logic Effectiveness of Hand Washing with Soap in an Soc Sci Med 43 (9): 1299–1308. Urban Squatter Settlement, Karachi, Pakistan.” Epide- Curtis, V. A., L. O. Danquah, and R. V. Aunger. 2009. miol Infect 127 (2): 237–244. “Planned, Motivated and Habitual Hygiene Behav- Luby, S. P., and A. K. Halder. 2008. “Associations among iour: An Eleven Country Review.” Health Educ Res 24 Handwashing Indicators, Wealth, and Symptoms of (4): 655–673. Childhood Respiratory Illness in Urban Bangladesh.” Drankiewicz, D., and L. Dundes. 2003. “Handwashing Trop Med Int Health 13 (6): 835–844. among Female College Students.” Am J Infect Control Luby, S. P., A. K. Halder, T. Huda, L. Unicomb, and R. B. 31 (2): 67–71. Johnston. 2011. “The Effect of Handwashing at Rec- DuBois, A. E., M. Sinkala, P. Kalluri, M. Makasa- ommended Times with Water Alone and with Soap Chikoya, and R. E. 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Sanitation Program, World Bank. www.wsp.org 17 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables Tables TABLE 1: INDICATORS OF HANDWASHING BEHAVIOR, BY LEVEL AND METHOD OF DATA COLLECTION, PERU, SENEGAL, AND VIETNAM, 2009 Countries in Which Indicator Method of Data Level of Data Was Assessed at Indicator Collection Collection Baseline Presence of soap anywhere in the home Rapid observation Household All Presence of soap and water at the Rapid observation Household All handwashing place used post-defecation Presence of soap and water at the Rapid observation Household All handwashing place used before food preparation Cleanliness index of caregiver hands Rapid observation Individual—caregiver All (index based on observation of nails, palms, and fingerpads) Handwashing with soap after fecal Self-report Individual—caregiver All contact during previous day Handwashing with soap before food Self-report Individual—caregiver All preparation during previous day Handwashing with soap before feeding a Self-report Individual—caregiver All child during previous day Handwashing with soap before eating Self-report Individual—caregiver Senegal and during previous day Vietnam (error in Peru’s data collection tool) Handwashing with soap after fecal Structured Individual—all household Peru and Senegal contact observation members and primary caregivers (subsets) Handwashing with soap before food Structured Individual—all household Peru and Senegal preparation observation members and primary caregivers (subsets) Handwashing with soap before feeding a Structured Individual—all household Peru and Senegal child observation members and primary caregivers (subsets) Handwashing with soap before eating Structured Individual—all household Peru and Senegal observation members and primary caregivers (subsets) 18 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 2: PRESENCE OF SOAP AND WATER ANYWHERE IN THE HOME AND AT HANDWASHING PLACES, PERU, SENEGAL, AND VIETNAM, 2009 Peru Senegal Vietnam Observation of soap presence anywhere in the home Number of households in which respondent was asked to show 3,721 1,372 3,129 soap located anywhere in home Observation allowed 3,658 1,373 3,129 At least one type of soap for washing hands observed anywhere 3,004 82% 813 59% 3,031 97% in the home Type(s) of soap observed in the home* Beauty bar soap 1,101 30% 17 1% — — Multipurpose bar soap 697 19% 650 47% 1,774 57% Liquid soap — — — — 725 23% Powder/detergent soap 2,191 60% 241 18% 2,596 83% Number of handwashing places** and presence of soap and/or water at those handwashing places Number of households in which respondent answered question 3,492 1,549 3,143 about whether hands are ever washed after defecation or before preparing food Number of households that allowed observation of a handwashing 3,448 1,513 3,143 place or who did not have a designated handwashing place Households without any handwashing place 281 8% 678 45% 337 11% Only one handwashing place 2,087 61% 491 32% 1,836 58% Handwashing place has soap 1,499 44% 282 19% 1,659 53% Handwashing place has water 1,807 52% 347 23% 1,772 56% Handwashing place has both soap and water 1,346 39% 240 16% 1,597 51% Two handwashing places 1,080 31% 344 23% 970 31% One handwashing place has soap 243 7% 61 4% 54 2% One handwashing place has water 181 5% 74 5% 34 1% One handwashing place has both soap and water 255 7% 71 5% 83 3% Two handwashing places have soap 605 18% 220 15% 928 30% Two handwashing places have water 804 23% 232 15% 902 29% Two handwashing places have soap and water 523 15% 190 13% 864 28% *Multiple types of soap were observed in some households. ** Handwashing places reportedly used after defecation and before food preparation but did not inquire about any other handwashing places in the home. Thus, the maximum number of handwashing places recorded in the baseline surveys was two. www.wsp.org 19 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 3: DESCRIPTION OF PLACE FOR WASHING HANDS AFTER DEFECATION, PERU, SENEGAL, AND VIETNAM, 2009 Peru Senegal Vietnam Number of households in dataset 3,721 1,550 3,150 Number of households in which respondent answered yes or no to 3,492 1,541 3,140 question about whether hands are ever washed after defecation Households that allowed observation of handwashing place, and 3,438 1,471 3,124 soap and water at that place, or that denied washing hands after defecation Report washing hands after defecation 3,399 99% 1,230 84% 3,065 98% Location of handwashing place Inside toilet facility 334 10% 270 22% 718 23% Inside kitchen/cooking place 337 10% 17 1% 133 4% Within 3 ft. of toilet facility 626 18% 276 22% 514 17% >3 ft. but <10 ft. from toilet facility 477 14% 88 7% 344 11% >10 ft. from toilet facility 1,169 34% 29 2% 1,065 35% No specific place 455 13% 547 45% 291 9% TABLE 4: OBSERVATIONS OF SOAP AND WATER AT HANDWASHING PLACES USED AFTER DEFECATION, PERU, SENEGAL, AND VIETNAM, 2009 Peru Senegal Vietnam Number of households in dataset 3,721 1,550 3,150 Number of households in which respondent answered yes or 3,492 1,541 3,140 no to question about whether hands are ever washed after defecation Households that allowed observation of handwashing place, 3,438 1,471 3,124 and soap and water at that place, or that denied washing hands after defecation Households with soap present at the handwashing place 2,089 61% 468 32% 2,577 82% Beauty bar soap 697 20% 13 1% — — Multipurpose bar soap 432 13% 372 25% 1,416 45% Liquid soap — — — — 543 17% Powder/detergent soap 1,365 40% 87 6% 1,906 61% Households with water present at the handwashing place 2,557 74% 532 36% 2,680 86% Households with soap and water together at the handwashing 1,892 55% 423 29% 2,488 80% place 20 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 5A: DESCRIPTION OF PLACE FOR WASHING HANDS BEFORE FOOD PREPARATION, PERU AND SENEGAL, 2009 Peru Senegal Number of households in dataset 3,721 1,550 Number of households in which respondent answered yes or no 3,490 1,545 to question about whether hands are ever washed before food preparation Households that allowed observation of handwashing place, and 3,236 1,425 soap and water at that place, or that denied washing hands before food preparation Report washing hands before food preparation 3,213 99% 1,242 87% Location of handwashing place Inside toilet facility 58 2% 11 1% Inside cooking area 1,295 40% 80 6% Within 3 ft. of cooking area 578 18% 225 18% >3 ft. but <10 ft. from cooking area 558 17% 160 13% >10 ft. from cooking area 443 14% 70 6% No specific place 281 9% 693 56% TABLE 5B: DESCRIPTION OF PLACE FOR WASHING HANDS BEFORE FOOD PREPARATION, VIETNAM, 2009 Number of households in dataset 3,150 Number of households in which respondent answered yes or no to question about whether 3,136 hands are ever washed before food preparation Households that allowed observation of handwashing place, and soap and water at that 3,040 place, or that denied washing hands before food preparation Report washing hands before food preparation 2,936 97% Location of handwashing place Inside toilet facility 99 3% Inside kitchen/cooking area 463 16% Elsewhere in yard <1 m of toilet facility 553 19% Elsewhere in yard <3 m and <1 m of toilet facility 470 16% Elsewhere in yard >3 m from toilet facility 1,049 37% No specific place 299 10% www.wsp.org 21 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 6: OBSERVATIONS OF HANDWASHING PLACES FOR USE BEFORE FOOD PREPARATION, PERU, SENEGAL, AND VIETNAM, 2009 Peru Senegal Vietnam (N = 3,236) (N = 1,425) (N = 3,040) Number of households in dataset 3,721 1,550 3,150 Number of households in which respondent 3,490 1,545 3,136 answered yes or no to question about whether hands are ever washed before food preparation Households that allowed observation of 3,236 1,425 3,040 handwashing place, and soap and water at that place, or that denied washing hands before food preparation Households identified with soap present at 2,074 64% 338 24% 2,437 80% the handwashing place Beauty bar soap 541 17% 3 <1% — — Multipurpose bar soap 365 11% 232 16% 1,229 40% Liquid soap — — — — 491 16% Powder/detergent soap 1,529 47% 150 11% 1,830 60% Households identified with water present at 2,461 76% 391 27% 2,595 85% the handwashing place Households identified with soap and water 1,852 57% 293 21% 2,396 79% present at the handwashing place 22 Global Scaling Up Handwashing Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 7: SELF-REPORTED HANDWASHING BEHAVIOR AND OBSERVATIONS OF HAND CLEANLINESS AMONG INDIVIDUAL CAREGIVERS, PERU, SENEGAL, AND VIETNAM, 2009 Peru Senegal Vietnam Number of caregivers included in dataset 3,602 2,037 3,090 Number of caregivers alone at time of interview and for 3,596 2,004 3,080 whom data was available Self-reported handwashing with soap at critical times After fecal contact 2,216 62% 592 30% 1,944 63% Before food preparation 2,503 70% 249 12% 965 31% Before feeding a child 1,153 32% 96 5% 1,025 33% Before eating — — 313 16% 625 20% At least one of these critical times 3,284 91% 927 46% 2,492 81% All of these critical times 505 14% 7 <1% 225 7% Perception of best way to clean hands Wash with water alone 433 12% 36 2% 406 14% Wash with soap 3,068 85% 1,776 88% 2,579 86% Wash with ash/mud 4 <1% 5 <1% 1 <1% Other 47 1% 194 10% 0 0% Ratings of hand cleanliness Palms observed (N) 3,596 2,008 3,074 Clean 2,013 56% 1,688 84% 2,421 79% Unclean appearance 894 25% 246 12% 593 19% Visible dirt 689 19% 74 4% 60 2% Fingerpads observed (N) 3,595 2,005 3,074 Clean 2,010 56% 1,668 82% 2,406 78% Unclean appearance 900 25% 259 13% 615 20% Visible dirt 685 19% 78 4% 53 2% Fingernails observed (N) 3,596 2,000 3,074 Clean 1,536 43% 1,441 72% 1,947 63% Unclean appearance 1,125 31% 351 18% 962 31% Visible dirt 935 26% 208 10% 165 5% Hand cleanliness index (N)* 3,594 1,992 3,074 Very clean 1,493 42% 1,413 71% 1,932 63% Somewhat unclean 1,254 35% 430 22% 1,026 33% Very unclean 847 24% 149 7% 116 4% * The hand cleanliness index was calculated only for caregivers for whom all three aspects of the hand were observed. www.wsp.org 23 Analysis of Handwashing Behaviors Measured in Baseline Impact Evaluation Surveys: Findings from Peru, Senegal, and Vietnam Tables TABLE 8: OBSERVATIONS OF SOAP USE FOR HANDWASHING DURING STRUCTURED OBSERVATIONS, PERU AND SENEGAL, 2009 Peru (N = 159) Senegal (N = 110) All Household Primary All Household Primary Members Caregivers Members Caregivers Events of any type At least one event of any type 159 100% 159 100% 110 100% 105 95% observed Number of events observed (median 11 4–50 8 1–22 9 1–31 3 0–11 and range) Households with soap use at least 116 73% 89 56% 43 39% 28 27% once during observation Proportion of events accompanied 16% 0–67% 11% 0–100% 0 0–75% 0 0–100% by soap use (median and range) Fecal contact events At least one event observed 139 87% 132 83% 53 48% 37 34% Number of events observed (median 2 0–7 2 0–5 0 0–6 0 0–2 and range) Households with soap use at least 58 42% 53 40% 13 25% 11 30% once after a fecal contact event Food preparation events At least one event observed 148 93% 145 91% 63 57% 43 39% Number of events observed (median 2 0–6 2 0–6 1 0–6 0 0–5 and range) Households with soap use at least 34 23% 32 22% 4 6% 3 7% once before a food preparation event Feeding events At least one event observed 132 83% 132 83% 80 73% 77 71% Number of events observed (median 1 0–16 1 0–10 1 0–5 1 0–5 and range) Households with soap use at least 16 12% 16 12% 4 5% 3 4% once before a feeding event Eating events At least one event observed 141 89% 49 43% 80 73% 27 24% Number of events observed (median 2 0–11 0 0–4 1 0–12 0 0–2 and range) Households with soap use at least 65 46% 12 17% 7 9% 2 7% once before an eating event 24 Global Scaling Up Handwashing