Maternal hand hygiene behaviors, as reported and observed
The hand hygiene behavior is a complex issue, combination of multiple overlapping factors. The maternal hand hygiene behaviors often influenced by her individual’s perceptions, physical environmental, or multiple social determinants to execute required hand hygiene:
Handwashing behavior
In in-depth interviews and group discussions, respondents described that their typical handwashing practice involves the use of water alone, generally without mention of soap. Respondents reported typically washing their hands, face and feet at least twice a day to clean themselves, after waking up in the morning and after finishing daily household chores or after returning home from daily work (for fathers) in the evening. Most mothers and other caregivers stated that they usually wash their hands if they are involved in cooking, sweeping, cutting vegetables or fish, or when hands are ‘visibly dirty’ (this refers to contact with mud, sand, dust, oily substances, soot, cooking spices, biomass fuel, and if there is contact with own feces, child and animal feces). Respondents perceived that after cutting when they washed vegetables, fish, or meat with water alone, or washing utensils or clothes, their hands were also being washed and thus did not need to be washed again before cooking. In addition, fathers reported that they washed their hands with soap after handling cow dung as such contact is considered profane; they also reported washing hands with soap after agricultural work in the field, such as harvesting or spraying pesticide. According to all types of respondents, hands need to be washed with soap after eating to remove bad smells, chilies, or spices; otherwise, the mothers/other caregivers’ hands would irritate a child’s skin. If a mother cared for her child during her leisure time, she usually did not wash her hands at any of the event identified above, as she perceived her hands as clean. Only two mothers mentioned handwashing as part of a ritual ablution before performing prayers, 5 times each day, customary among many Bangladeshi Muslims.
We observed that washing hands with soap and water was rarely performed [Figs.
2 and
3]. In both sites, handwashing with water alone was most frequently observed before eating, before preparing food for the family, before breastfeeding and after a few events of cleaning the child’s anus and only one event (
n = 2) after visiting the toilet.
Perceived risk of neonatal diseases and perceived advantages and disadvantages of handwashing
In in-depth interviews, few mothers reported perceiving that a child was at higher risk of having illnesses during the first month(s) of life. Their common belief was that the risk is greater during later infancy as the child begins crawling which could increase exposure to illnesses or accidents. As mothers reported that those exposures mainly leading to diarrhea but they did not directly link with other infections. Mothers commonly perceived that neonates are very vulnerable to catching colds (respiratory infection) through ways unrelated to hand hygiene: if the baby is kept in a wet bed soiled with urine or if the mother gets a cold through frequent contact with water or by eating cold food and passing it to her breastfeeding baby through breastmilk. Mothers are also commonly advised to eat warm food and warm water, particularly up to 40 days after delivery to prevent the neonate from getting a cold. Related to these humoral concerns, mothers reported that they avoided frequent contact with water, including decreasing handwashing; mothers avoid handwashing after cleaning a neonate’s anus by wiping with a wet piece of cloth instead of washing the anus by hand. Fathers also reported the similar concern that a mother’s cold can be transmitted to her child. Otherwise, fathers perceived that children get affected by viruses during any seasonal change during the year. However, as we talked, both mothers and fathers did not link the neonate’s ‘cold with ‘respiratory infection’ or other health risks that could lead to neonatal mortality compared to mortality of older infants.
Respondents perceived that cleanliness could protect children from getting ill. Soap was perceived as necessary for cleanliness; it removes visible dirt, germ and bad smells. Mothers reported that they typically wash their hands with or without soap before feeding a child with bare hands, after using the toilet, cleaning a child’s bottom, contact with an older child’s feces, and before preparing food for an infant or family that needs contact with bare hands and is not cooked further (e.g. mashed potato).To mothers, handwashing is important during these events to prevent children or other family members from getting diarrhea from dirty hands. Mothers perceived that, if one held the child with ‘dirty hands’, the child could get diarrhea, skin irritations, cold and fever. Mothers said that ‘visible dirt’ in hands always persuaded them to wash their hands. When hands were ‘visibly dirty’, they reported washing their hands with soap prior to holding a young child to prevent those illnesses. Fathers and others caregivers endorsed the drivers that described above for their or a mother’s handwashing practice. Our observational data also supported this reporting that “visible dirt” (mothers were handling biomass fuel or cooking spices) facilitated required handwashing.
Only one disadvantage of handwashing was cited: one mother in Habigonj stated that if she washes her hands with soap before mashing foods by hand, a common food preparation process in Bangladesh, the mashed item would have a soapy smell.
Normative beliefs and subjective norms
We defined subjective norm as the perception that a given behavior is practiced widely in one’s reference network (e.g. neighbors or other mothers of young children). The predominant existing social norms related to childcare contributed to mothers’ normative beliefs. As reflection, mothers performed the expected hygiene behavior for caring her child from the perceived expectation of her close surroundings. According to mothers, feces of an infant who already started eating semi-solid foods including fish and meat, contains germs and smells foul like adult feces; so after defecation or cleaning a child’s anus, they were motivated to wash their hands, mostly with soap, to remove the foul smell from hands and alleviate perceived disgust. In contrast, feces of a young child who breastfeeds, does not contain any germs nor bad smells, and is not ‘disgusting’ to mothers; so handwashing after cleaning the anus of a young breastfeeding child was often perceived as unnecessary.
A normative belief unique to the neonatal period was the possible harmful effect of “bad air” (alga batash) or “evil eyes” (evil spirit) during the first 40 to 45 days after birth. All types of respondents typically perceived that an evil spirit could enter the room of an unattended baby and could harm or kill the baby; harm might be reflected in the baby subsequently developing a lack of interest in breastfeeding or having stomach pain. To mitigate this supernatural risk, mothers reported being advised not to go outside, or to leave neonates unattended, especially at mid-day and after dusk. This mobility restriction prevented new mothers’ movement away from the newborn, such that, if the newborn defecated at night, mothers were unable to wash hands because handwashing facilities were typically located outside the sleeping space. This existing normative believe compounded by physical environment that negatively influenced mother’s required handwashing behavior. A mother of a neonate said,
It is not good to keep the baby unattended in his bed (room) during his first 40 days. Satan may come to the child during this time. It would be better to stay in the post-natal room with the baby....so if required, I wipe up my hands with cloth diaper after cleaning him.
In Habigonj, we observed two events, when two mothers were about to go outside for handwashing after cleaning a child’s anus but family elders warned mothers about postnatal risk of leaving neonate unattended; as a result, mothers did not go. In both cases, elders were busy with household chores and no one was available to attend the newborn.
However, some social norms also encourage handwashing. Most mothers reported that elder female family members advised and reminded new mothers to wash hands if eating after breastfeeding; otherwise it is believed a mother ingesting her own breastmilk from her hands could cause the death of the child.
Mothers reported that except when elders’ hands were visibly dirty or soiled with dirt, they could not request them to wash hands before holding a child. Mothers generally believed that elders usually do not hold a child with dirty hands.
Many mothers and secondary caregivers perceived that handwashing is not important before holding a child; though it is important before feeding a child. They further explained that a young child is usually wrapped with clothing and does not come into direct contact with one’s hands. Fathers in contrast mentioned that it is important to wash hand first after coming from outside and then hold a young child.
Even though respondents identified the importance of handwashing, they reported not washing hands out of “carelessness” (lack of motivation). One mother of an infant said,
…from the beginning, Ma advised me to wash hands before breastfeeding…but it (the newborn) breastfeeds frequently… it defecates frequently… (I) wash (only) if hands are visibly dirty, otherwise I do not… I know I should wash hands before every feed…after cleaning (the newborn)…I do not have any problem to wash hand; but I feel idle (lack of motivation/careless) to wash hands every time…I just do not go (for handwash) indolently.
A number of mothers indicated that, even if they wished to adopt improved handwashing practices during the neonatal period, they would be teased by others. A primiparous mother of neonate said,
Washing hands before and after every task is not the system (practice) in our place….If I wash hands frequently before or after doing tasks and handling baby, elders (mother in-law/aunts) tease and say, ‘she only has a newborn baby, (as if) we never had’!
Fathers also added that after coming from outside if anyone wanted to hold a child, it would not possible to ask for a handwash beforehand, otherwise s/he could mind.
While some mothers intended to practice a good handwashing behavior in their daily activities, mothers’ existing habit of handwashing within a certain culture drove them to define when handwashing was required. One multiparous mother of a neonate said,
I do not wash hands all the time; if my hands are (visibly) dirty, I wash them. If they are less dirty, we wipe them on the door (smiling). We are living in rural area, we cannot do like you people (referring interviewer as urban people); even if you give me so much advice!
Some mothers, other female caregivers and fathers indicated this habit of infrequent handwashing as a social norm in their rural area, unlike urban culture. One mother of an infant said,
….(I do not wash hands) because it is not in my habit. If everybody practiced it, I would also follow.
Handwashing as habit
All respondents, regardless of educational and economical status, reported that washing hands with or without soap was habitual only at certain times, such as before and after a meal; they reported developing these habits during early childhood. Despite reported practices, field researchers observed that mothers rarely used soap to wash their hands [Figs.
2 and
3].
Nurturing child and maternal intent to improve handwashing behavior
Mothers perceived that a “good mother” always keeps herself and her child clean and soap is a necessary item to maintain cleanliness. One primiparous mother of a newborn who passed sixth grade of schooling said,
I have to take care of my baby in a good manner... keep him clean (with soap) so that he will get less illness…need to wash him with water after defecation; so he (child) would get less germs. A good mother keeps her child’s clothes, and feeding dishes clean….
With these characteristics fathers also added that when a child becomes sick, a good mother gives it medicine. Fathers perceived that mother is mainly responsible for nurturing a young child and other family members support her in this process.
Mothers used bar soap (e.g. available brands of antiseptic soap) when bathing or cleaning babies and detergent for washing baby clothes. Mothers underscored that sometimes they might have financial crisis, they always tried to ensure buying soap for a young infant. Only a few mothers said that they could not buy required quantity of soap due to their financial ability. The fathers of young infants and secondary caregivers also mentioned that they know soap is important to keep the baby clean but could not always afford required soaps for their young children due to their financial crisis.
The majority of mothers reported that their handwashing behaviors had increased because of the additional responsibilities of new motherhood, particularly by washing children’s clothes, bathing or sponging the child, washing hands after putting on lotion or an oil massage, after breastfeeding and feeding the infants.
We observed some mothers were simultaneously occupied in multiple chores while caring for their newborns, confirming their reports during interviews that the responsibilities of nurturing a newborn added to regular household chores sometimes prevented mothers from washing their hands. This condition multiplied for mothers who have multiple children. For instance, in the Habigonj site, mothers of multiple children sometimes had to feed the neonate while serving food or cleaning the bottom of an older child after defecation; they often neglected to wash hands after each task. The social construction of woman role being a wife and a mother, often impacted her child nurturing behaviors that restricted her intent to improve handwashing.
Maternal self-efficacy and neonatal health protection: Perceived verses actual control over handwashing behavior
Mothers in Matlab reported that they customarily delivered the baby at their parents’ house and that the mother of a newborn was not usually asked to do any household chores when she was at her parents’ house. However, she was expected to perform certain chores at her marital home. During the neonatal period, these mothers often got support from their family for handwashing, e.g. bringing a handwashing station (jug or bucket of water) or soap, or attending to neonates so that the mother could wash hands. Mothers in Habigonj more commonly delivered at their marital home [Table
3]; during neonatal period, if no one was available to help the mother, they brought a female family member to support her in household chores. Conversely, a lack of family support negatively impacted maternal self-efficacy for improving and maintaining good handwashing behavior.
Mothers reported and we also observed in both study sites that when a secondary caregiver was absent, mothers were struggling to carry out varieties household chores and at a time caring a neonate. In such situations, mothers were observed not washing their hands at critical times, for instance after cleaning child’s anus, because the baby became fussy and no one there to attend the baby, mother soothed her child first by breastfeeding. Multiparous mothers in Habigonj who belong to a nuclear family were observed to face this barrier more frequently with the lack of secondary caregivers while they were tending to numerous daily household responsibilities, including caring for neonates and older children.
Many of our mother respondents from both sites reported that if they wished to adopt improved handwashing practices or keep any handwashing materials inside their bedroom during this period for an enabling physical environment, they would be scolded by family elders and neighbors. In this regard, one mother of an infant stated,
They (in-laws) wouldn’t like it… they wouldn’t allow me to keep it (bucket near bedside)… …They would say ‘they are doing all the tasks and daughter-in-law is not doing anything; she does not even go that little distance (i.e. to the handwashing station)’… she (mother-in-law) will be angry with me.
Moreover, mothers said that although they often identified items deemed necessary for the child, they didn’t have the power of purchasing materials themselves within existing family roles in social structure. Many of the mothers in Habigonj specifically said that their husbands or sometimes in-laws made the final decisions and purchased related to items needed for childcare. Two mothers of neonates also reported that, when they use too much soap, their husbands scold them as they cannot afford it. Fathers, from the other end confirmed this decision making process and told that they were mainly responsible for outside tasks and also led the treatment related decision (e.g. where to take) when a child got sick.
Cues to action: Availability of materials and reminders to wash hands
Mothers in both sites discussed that presence of handwashing materials sometimes facilitated mothers as cues to action for handwashing at times of potential pathogen transmission. When family members supported the mother by bringing required water or soap to her location, she would have been more able to do required handwashing. Sometimes, family members reportedly reminded mothers to wash hands before nurturing. We also observed that when family elders were reminding mothers, mothers washed their hands after household chores and before breastfeeding and holding the child.
Mothers reported and field researchers also observed that, in some cases, mothers avoided some handwashing with their stored water or used only a little water because of the distance to the water source. Some mothers identified lack of soap availability in the places where soap was needed as a hindrance to practicing handwashing. Lack of affordability of soap was also cited as a barrier for some mothers and fathers respondents.