Informal discussions were commonly conducted with mothers, the primary caregivers; 93% (74/80) during the first assessment, 98% (78/80) during the second assessment and 95% (76/80) for the final assessment. The average age of respondents was 24 years in the study HWS group and 23 years in the self-made HWS group. The reported average household income was lower in the study HWS group (BDT. 10,200, US$ 127) than for the self-made HWS group (BDT. 15,700, US$ 196 per month) (Table
1). The educational status for the two groups was similar. The average number of schooling years did not differ between groups (mean = 5.25 and 6.42,
p = 0.16).
Table 1
Demographic information of the study participants
Average age of respondents | 23.7 | 23.2 |
Household Income per month |
Taka ≤5000 ($63) | 16 | 11 |
Taka 6000–10,000 ($75–125) | 11 | 10 |
Taka 11,000–20,000 ($138–250) | 11 | 13 |
Taka 21,000–30,000 ($263–375) | 1 | 1 |
Above 30,000 ($375) | 2 | 5 |
Average of household income (monthly) | US$127 | US$196 |
Mother’s educational level |
No institutional education | 9 | 8 |
Primary school (I-V) | 10 | 8 |
High School (VI-X) | 19 | 21 |
Higher education (XI & above) | 2 | 3 |
Have own water source | 30 | 37 |
TV available at home | 16 | 20 |
Mobile phone available at home | 28 | 36 |
Radio available at home | 3 | 11 |
Have electricity at home | 21 | 23 |
Self-made handwashing station
By end of the trial, 39/40 households developed their own handwashing station (both water vessel and soap placed together). The self-made handwashing station developed by the community members often comprised an existing household bucket for water storage, a jug or mug to pour water over hands, and a plastic bottle for making and storing soapy-water (Fig.
3). Although a few households placed bar soap with the water storage vessel in addition to soapy-water, all caregivers placed a bottle of soapy-water at the location. Two major factors that motivated caregivers to develop their own handwashing station were ease of use and no cost. For example one caregiver from Dinajpur said, "
I am using a big plastic bucket which was unused for many days. I haven't spent money and that unused casket became a very useful thing. Even this is not a big deal to store water here close to my hands". Another important factors reported by the caregivers was home visits by community health workers. All mothers received home visits and assistance in setting up a handwashing station with a reminder sticker placed close to the cooking and feeding the child areas. Frequent home visits made caregivers habituated to set up a handwashing station. For example one caregiver from Manikgonj said, "
Our apa (CHW)
visits our para (neighborhood)
very frequently and observes whether I placed water or not, even if somehow I met her outside my home she has just one question to me that whether I am using that bucket and washing my hands or not. So it helps me a lot to become habituated day by day". One barrier for developing a self-made handwashing station was lack of available resources in the households. Some caregivers reported having old vessels that they thought were not suitable for storing water and they used these functional buckets for other purposes. Due to financial difficulties they were unable to buy new vessels to use for handwashing.
Handwashing practices
Field researchers observed handwashing with soap before food preparation and before feeding a child among 80% (8/10) of caregivers in the study-HWS group and 50% (5/10) from the self-made HWS group at the final assessment. Although there is increasing trends of handwashing with soap in the study-HWS group, greater than for the self-made HWS group, the small sample size did not permit a rigorous statistical assessment. During group discussions and interviews, for both HWS group categories, study participants explained that the main motivation to wash hands with soap was child’s health and having water and soap in one place near the food preparation and child feeding area facilitated the practice. Mothers explained that nutritious food that they were providing to their children will not provide nourishment if they do not wash their hands before feeding their child. For example one mother from the self-made HWS group said- "If I do not wash my hands with soap then all germs remain on my hands and my child’s food will be contaminated. Therefore these germs will enter my child’s stomach and it may cause my child’s illness. For my child’s wellbeing I wash my hands with soap". Regarding increasing handwashing behavior one mother from study-HWS group said- “Before getting this handwashing station I needed to go to the tube well for washing hands; therefore I didn’t wash my hands sometime because I was not motivated. Now I get water and soap together close to my hands; so I always wash my hands with soap.” For both intervention groups mothers reported that they forgot to wash their hands due to the pressure of household chores. In the self-made HWS group another barrier was that sometimes water and soap were not easily accessible. For example one caregiver explained that "My husband is a farmer and sometimes he takes the water vessel to the farmland for cultivation purposes, and we don't have another suitable vessel that I can use to keep at the designated place. In that case sometimes I forgot to wash hands before food preparation".
Motivators and barriers to regular use and maintenance of handwashing stations
Respondents from both study groups reported that a handwashing station was easy to use, and that the presence and placement of the handwashing station motivated people to regularly use and maintain it, encouraging handwashing at promoted times. Study participants explained that having water and soap in one place near food preparation and child feeding areas reduced the need to go to a distant, inconvenient location to wash hands with soap. For example one caregiver explained that “handwashing station makes my handwashing easier because we get water and soap near my cooking place and no need to go to the tube well frequently. I can wash my hands by sitting at my cooking place.” Another caregiver said “We have no tubewell at our home. Before getting this handwashing station we had to go outside (to a common tube well for several households) for washing our hands and utensils. Moreover many households use one tube well and no one keeps soap beside tube well. Now we get water and soapy-water together and we don’t need to go outside and we can wash our hands whenever we need".
Similarly, caregivers in the self-made HWS group described the advantages and benefits of keeping water and soap together and close at hand as they didn’t need to go far if they maintain a stocked handwashing station near the food preparation and child feeding area(s). Community members of both intervention groups reported a preference for soapy-water over bar soap as it is easier to use than bar soap.
During the interviews caregivers in the study HWS group also reported that they liked the appearance and free provision of the handwashing station and that it acted as a reminder to wash hands.
Study participants reported some strengths of the handwashing stations that influenced regular use. Study participants in the study HWS group explained that the tap on the bucket increased convenience in providing running water while washing their hands. They reported that the station facilitated handwashing among children providing readily available water by turning the tap, compared to the alternative where they need to pump water from tube wells, which can be strenuous and thus act as a barrier to handwashing. Although, in the self-made HWS group nobody had a tap on the water vessel they arranged, they used a mug to pour water over hands. Study participants reported that this arrangement had an advantage of the tap. They explained that, "we could not set up a tap with our water vessel by ourselves because we need to spend money to buy a tap to hire a mechanic to set it on the bucket. Also the tap can become cracked after a certain moment".
The bowl with the study-provided bucket was considered a strength as it held residual rinse water and reduced the risk of water remaining on the floor. Many participants in the self-made HWS group placed a bowl at their own handwashing station for this purpose. In addition, the lid on the study provided bucket kept water clean and the study participants reported that children can’t waste water when the lid is kept locked. They also reported that the lid enhanced safety by preventing children from falling into the water. On the other hand, lack of a lid for the self-made handwashing stations acted was considered a weakness. Study participants from the self-made HWS group mentioned that their handwashing water vessel that was uncovered encouraged children to play with the water. None from the self-made HWS group used an existing bucket that had a lid. Caregivers feared that playing with water may cause a child to develop a cough or a cold. They also described a risk for young child to fall into the uncovered water vessel. Although, the main reported barrier for both intervention group categories was wastage as children frequently play with the water and soap/soapy-water which was more frequently reported by respondents from the self-made HWS group.
Participants from the study HWS group liked the large size of the bucket they received, so that they could store water for all household members for a full day. They reported that they kept the handwashing station inside their living room at night so that they can wash their hands whenever necessary. For example one mother said, "My son and his father can also wash their hands from this handwashing station. Now we don’t need to go outside at night for washing hands and utensils.” However, in the self-made HWS group field researchers didn’t observe any water vessel of a similar size to the bucket provided with model handwashing station. Study participants from both groups explained that the handwashing station was convenient for other purposes related to cooking and feeding/eating, not just for handwashing.
Another strength of handwashing intervention was provision of soapy-water. Dispensing soapy-water from the bottle with a hole in the cap onto the palm of their hands reduced the duration of handwashing and this product was less likely to be wasted by children. For example one mother from Manikgonj said, “Our tube well is located so far and in an open place. If I keep soap (bar soap) in that place, sometimes a crow will take away the soap, and sometimes it becomes spoiled. But the soapy-water is better than soap. It’s easy to use, and is less likely to be damaged.” Caregivers in the self-made HWS group reported that soapy-water was inexpensive to make; most of the observed households from this group made their own soapy-water, even though they didn’t receive a bottle or detergent. For example, one caregiver from Dinajpur said, "Soap (bar soap) is expensive. Detergent powder remains available in my home all the time for washing my clothes; and I can use a small amount for making soapy-water. So I don't need to expend extra money for making soapy-water. Even some of my neighbors prepared and are using soapy-water by their own initiative even though they don't have children under 2 years of age (were not part of the intervention)." This was detected during the final assessment, when field researchers observed neighbors that were not included in promotion activities prepared their own soapy-water.
Understanding IYCF messages:
The majority of participants (caregivers) recalled intervention messages on social and health benefits of infant and young child feeding correctly. They described appropriate frequency, amount and variety of complementary food and how this helps a child’s physical and mental growth. They also reported the health risk if they did not follow recommended practices. In addition to the IYCF messages, all of the caregivers recalled the importance of handwashing with soap before food preparation and feeding a child. One caregiver explained that "we are giving good food to my child for his good health, but if we do not wash our hands before feeding him then the food will not work at all".