Rahman Musarrat J, Nizame Fosiul A, Unicomb Leanne, Luby Stephen P, Winch Peter J
International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.
BMC Public Health. 2017 May 5;17(1):392. doi: 10.1186/s12889-017-4307-7.
Health programs commonly promote handwashing by drawing attention to potential fecal contamination in the environment. The underlying assumption is that the thought of fecal contamination will result in disgust, and motivate people to wash their hands with soap. However, this has not proven sufficient to achieve high rates of handwashing with soap at key times. We argue that handwashing with soap is influenced by broader range of antecedents, many unrelated to fecal contamination, that indicate to people when and where to wash their hands. This exploratory study aimed to identify and characterize this broader range of handwashing antecedents for use in future handwashing promotion efforts.
First, an initial list of behavioral antecedents was elicited through unstructured interviews, focus group discussions and observation with residents, from a low-income community in Dhaka, Bangladesh, who were also recipients of a handwashing intervention. Then, photographs representing three categories of behavioral antecedents were taken: activities of daily living, visual or tactile sensations, and handwashing-related hardware and activities. Finally, the research team conducted ranking exercises with a new set of participants, from the same area, to assess the perceived importance of each antecedent illustrated by the photographs. The research team probed about perceptions regarding how and why that particular antecedent, represented by the photograph, influences handwashing behavior.
After coming out of the bathroom and dirt (moyla) on hands were the two antecedents that ranked highest. In all the categories, intervention-related antecedents (three key times for handwashing which included handwashing after coming out of the bathroom, after cleaning a child's anus and before food preparation; intervention provided items that included handwashing station, soapy water bottle, handwashing reminders from posters and community health provider visits) that were being promoted actively in this community were perceived favorably in the qualitative responses, but did not consistently rank higher than non-intervention items. However, many other antecedents were reported to influence when and where people wash their hands: cutting greasy fish, starting a meal, contact with oil and fat stuck to dishes, oil and lice from hair, sweat, unwashed vegetables, reminders from son and daughter or observing others wash hands, and observing the sunset.
Beyond well-recognized antecedents related to fecal contact and dirt on hands, we identified a broader set of antecedents not reported in the literature. Adopting a handwashing promotional strategy to highlight existing antecedents that people themselves have identified as important can help inform the content of an intervention that is more relatable and effective in increasing handwashing practices.
健康项目通常通过提醒人们注意环境中潜在的粪便污染来推广洗手。其潜在假设是，想到粪便污染会引发厌恶感，并促使人们用肥皂洗手。然而，事实证明，仅靠这一点不足以在关键时段实现高比例的肥皂洗手率。我们认为，用肥皂洗手受到更广泛的先行因素影响，其中许多因素与粪便污染无关，这些因素会向人们表明何时何地该洗手。这项探索性研究旨在识别和描述这一更广泛的洗手先行因素，以便用于未来的洗手推广工作。
首先，通过与孟加拉国达卡一个低收入社区的居民进行非结构化访谈、焦点小组讨论和观察，得出行为先行因素的初始清单，这些居民也是一项洗手干预措施的接受者。然后，拍摄了代表三类行为先行因素的照片：日常生活活动、视觉或触觉感受，以及与洗手相关的硬件和活动。最后，研究团队与来自同一地区的一组新参与者进行了排序练习，以评估照片所展示的每个先行因素的感知重要性。研究团队探究了关于照片所代表的特定先行因素如何以及为何会影响洗手行为的看法。
从浴室出来后以及手上有污垢（“moyla”）这两个先行因素排名最高。在所有类别中，该社区积极推广的与干预相关的先行因素（三个洗手关键时段，包括从浴室出来后、清洁孩子肛门后以及准备食物前；干预提供的物品包括洗手台、肥皂水罐、海报上的洗手提醒以及社区卫生工作者的探访）在定性回答中得到了积极评价，但在排名上并不始终高于非干预项目。然而，据报告，还有许多其他先行因素会影响人们洗手的时间和地点：切油腻的鱼、开始用餐、接触粘在盘子上的油脂、头发上的油脂和虱子、汗水、未清洗的蔬菜、子女的提醒或观察他人洗手，以及观察日落。
除了与粪便接触和手上污垢等广为人知的先行因素外，我们还识别出了一组文献中未报道的更广泛的先行因素。采用一种洗手推广策略，突出人们自己认为重要的现有先行因素，有助于为一项在增加洗手行为方面更具相关性和有效性的干预措施提供信息。
