Comparing the performance of indicators of hand‐washing practices in rural Indian households

Abstract

Summaryobjective To compare the results obtained from 26 proxy indicators of domestic hand-washing practices with those obtained from direct, 'structured' observation of hand-washing in a sample of 387 households and to assess the potential of these indicators for use in the evaluation of hygiene promotion campaigns.methods Fieldwork in rural India between February 2005 and April 2006. Household-level data on hand-washing practices and the availability of soap and water were collected by structured observation, questionnaire survey, pocket voting, hand-wash demonstration and environmental check.Between them these techniques produced 27 binary indicators of hand-washing practices, each of which was used to classify households as 'hand-washing' or 'non-hand-washing. To assess the extent to which household classification based on each of 26 proxy indicators concurred with classification based on observation, we used the kappa statistic. The prevalence of households defined as 'handwashing' according to each indicator was compared statistically with the prevalence according to structured observations by testing for a significant difference between two proportions.results Agreement between all the proxy indicators and the observation data was poor and all but two of the indicators produced estimates of hand-washing prevalence that were significantly different from that resulting from observation.conclusion Although some interventions may be able to use proxy indicators as a guide to the magnitude and direction of their impact, these indicators do not provide an accurate guide to the actual practice or prevalence of hand-washing. Structured observation remains the best indicator of those tested.

Sustained Uptake of a Hospital-Based Handwashing with Soap and Water Treatment Intervention (Cholera-Hospital-Based Intervention for 7 Days [CHoBI7]): A Randomized Controlled Trial

“…Second, the use of previously validated measures to assess handwashing with soap practices such as structured observation to assess hand washing with soap events and spot checks of the presence of soap at latrine and cooking areas as proxy measures of household hand washing with soap behavior. 39,42 Finally, the use of WHO measures to assess water quality and the use of the CDC cutoff for the presence of free available chlorine in household stored drinking water. 38,39 CONCLUSION These findings demonstrate that the hospital-based CHoBI7 intervention can lead to sustained handwashing with soap practices and improved household stored water quality, and therefore presents a promising approach for WASH program delivery.…”

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

“…As with water treatment, survey methods for measuring handwashing are subject to both courtesy and social desirability bias (Stanton et al 1987, Biran et al 2008. To reduce these biases, we measured handwashing using structured observation, in which enumerators would observe handwashing behaviors during a 5-hour session in each compound.…”

Using Child Health Outcomes to Identify Effective Measures of Handwashing

“…The most common approach is to assume that structured observation provides a gold-standard assessment of handwashing behavior, and then researchers assess how well other indicators singly or in combination are associated with structured observation. 6,7,20,21 This approach has failed to identify a valid, low-cost robust alternative to structured observation. Even when some measures are associated with structured observation, sensitivity and specificity are poor.…”

“…Even when some measures are associated with structured observation, sensitivity and specificity are poor. 20 Moreover, because structured observation exaggerates actual handwashing practice, the relevance of proxy measures of structured observation is unclear.…”