Association between Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study (GEMS) and Types of Handwashing Materials Used by Caretakers in Mirzapur, Bangladesh

Abstract

Handwashing practices among caretakers of case and control children < 5 years of age enrolled in the Global Enteric Multicenter Study in Mirzapur, Bangladesh were characterized and analyzed for association with moderate-to-severe diarrhea. Soap or detergent ownership was common, yet 48% of case and 47.7% of control caretakers also kept ashes for handwashing, including 36.8% of the wealthiest households. Soap, detergent, and ash were used for multiple hygiene purposes and were kept together at handwashing areas. Caretakers preferred soap for handwashing, but frequently relied on ash, or a detergent/ash mixture, as a low-cost alternative. Moderate-to-severe diarrhea was equally likely for children of caretakers who kept soap versus those who kept ash (matched OR = 0.91; 0.62–1.32). Contact with ash and water reduced concentrations of bacterial enteropathogens, without mechanical scrubbing. Thus, washing hands with ash is a prevalent behavior in Mirzapur and may help diminish transmission of diarrheal pathogens to children.

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

“…15 The majority of informants reported that soap was kept inside their homes, similar to the 2011 national survey findings, where few (17%) rural Bangladeshi households were observed to have soap and water at their handwashing place. 21 Informants prioritized and limited soap use; bathing was accorded a high priority.…”

“…Although some informants described the removal of germs to prevent diseases as a motivator to wash hands, they believed that germs were present only on visibly dirty hands only. Findings from 23 years ago as well as more recently also suggest that these perceptions among Bangladeshis have not changed, 8,15 highlighting a failure or omission of handwashing with soap promotion during this long period. Perception on the importance of handwashing with soap when hands are visibly dirty is also similar to other research findings from low-income settings.…”

“…Almost all (22) informants said that ash is freely available from traditional cooking stoves (fuels include fire wood, cow dung, leaves, straw) commonly used in rural areas and soil is also available in rural courtyards. The majority (15) of informants said that because soap is expensive, they like to minimize the use of soap and use ash and soil to wash hands. One 26-year-old female said…”

“…14 Another study found that households that had ash as a handwashing agent experienced a similar burden of diarrhea compared with households that had soap as their handwashing agent. 15 Limited studies in Bangladesh have focused on the perceptions and observed current practices of communities regarding advantages and disadvantages of different hand cleansing agents, specifically ash, soil, and soap. Behavioral interventions are unlikely to be effective without an understanding of the current community contexts, practices, and perceptions related to hand hygiene.…”

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

“…The presence of soap at a latrine is strongly positively correlated with handwashing after defecation or contact with a child's feces (Luby, Halder, et al 2009, Hoque 2003, Baker et al 2014. However, Bangladeshi households often cite the inconvenience or expense of soap as a barrier to handwashing, and shared latrines make it especially challenging to keep soap near the latrine (ibid.…”