Volume 94, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Even though washing hands with soap is among the most effective measures to reduce the risk of infection, handwashing rates in infrastructure-restricted settings remain seriously low. Little is known about how context alone and in interaction with psychosocial factors influence hand hygiene behavior. The aim of this article was to explore how both contextual and psychosocial factors affect handwashing practices. A cross-sectional survey was conducted with 660 caregivers of primary school children in rural Burundi. Hierarchical regression analyses revealed that household wealth, the amount of water per person, and having a designated place for washing hands were contextual factors significantly predicting handwashing frequency, whereas the contextual factors, time spent collecting water and amount of money spent on soap, were not significant predictors. The contextual factors explained about 13% of the variance of reported handwashing frequency. The addition of the psychosocial factors to the regression model resulted in a significant 41% increase of explained variation in handwashing frequency. In this final model, the amount of water was the only contextual factor that remained a significant predictor. The most important predictors were a belief of self-efficacy, planning how, when, and where to wash hands, and always remembering to do so. The findings suggest that contextual constraints might be perceived rather than actual barriers and highlight the role of psychosocial factors in understanding hygiene behaviors.


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  1. Mattioli MC, Pickering AJ, Gilsdorf RJ, Davis J, Boehm AB, , 2012. Hands and water as vectors of diarrheal pathogens in Bagamoyo, Tanzania. Environ Sci Technol 47: 355363.[Crossref] [Google Scholar]
  2. Rabie T, Curtis V, , 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258267.[Crossref] [Google Scholar]
  3. Ejemot-Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA, , 2008. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev CD004265. [Google Scholar]
  4. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, Prüss-Üstun A, Bonjour S, Hunter PR, Fewtrell L, Curtis V, , 2014. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 19: 906916.[Crossref] [Google Scholar]
  5. Malik K, , 2014. Human Development Report 2014. Sustaining Human Progress: Reducing Vulnerabilities and Building Resilience. New York, NY: United Nations Development Programme. [Google Scholar]
  6. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE, , 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 21512161.[Crossref] [Google Scholar]
  7. Aiello AE, Coulborn RM, Perez V, Larson EL, , 2008. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. Am J Public Health 98: 13721381.[Crossref] [Google Scholar]
  8. Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, , 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 13: 1015.[Crossref] [Google Scholar]
  9. Mosler H-J, , 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431449.[Crossref] [Google Scholar]
  10. Huber AC, Tobias R, Mosler H-J, , 2014. Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion. Appl Psychol Health Well-Being 6: 96118.[Crossref] [Google Scholar]
  11. Inauen J, Mosler H-J, , 2014. Developing and testing theory-based and evidence-based interventions to promote switching to arsenic-safe wells in Bangladesh. J Health Psychol 19: 14831498.[Crossref] [Google Scholar]
  12. Contzen N, Meili IH, Mosler H-J, , 2015. hanging handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med 124: 103114. [Google Scholar]
  13. Gifford R, Steg L, Reser JP, Martin PR, Cheung FM, Knowles MC, Kyrios M, Littlefield L, Overmier JB, Prieto JM, , 2011. Environmental psychology. , eds. IAAP Handbook of Applied Psychology. Chichester, United Kingdom: John Wiley and Sons, 440470.[Crossref] [Google Scholar]
  14. Bronfenbrenner U, , 1977. Toward an experimental ecology of human development. Am Psychol 32: 513531.[Crossref] [Google Scholar]
  15. Schmidt W-P, Aunger R, Coombes Y, Maina PM, Matiko CN, Biran A, Curtis V, , 2009. Determinants of handwashing practices in Kenya: the role of media exposure, poverty and infrastructure. Trop Med Int Health 14: 15341541.[Crossref] [Google Scholar]
  16. Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB, Luby SP, , 2010. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.[Crossref] [Google Scholar]
  17. Hunter PR, MacDonald AM, Carter RC, , 2010. Water supply and health. PLoS Med 7: e1000361.[Crossref] [Google Scholar]
  18. Pickering AJ, Davis J, , 2012. Freshwater availability and water fetching distance affect child health in sub-Saharan Africa. Environ Sci Technol 46: 23912397.[Crossref] [Google Scholar]
  19. Scott BE, Lawson DW, Curtis V, , 2007. Hard to handle: understanding mothers' handwashing behaviour in Ghana. Health Policy Plan 22: 216224.[Crossref] [Google Scholar]
  20. Bowen A, Agboatwalla M, Ayers T, Tobery T, Tariq M, Luby SP, , 2013. Sustained improvements in handwashing indicators more than 5 years after a cluster-randomised, community-based trial of handwashing promotion in Karachi, Pakistan. Trop Med Int Health 18: 259267. [Google Scholar]
  21. Gilman RH, Marquis GS, Ventura G, Campos M, Spira W, Diaz F, , 1993. Water cost and availability: key determinants of family hygiene in a Peruvian shantytown. Am J Public Health 83: 15541558.[Crossref] [Google Scholar]
  22. World Health Organization and Unicef, 2014. Progress on Drinking Water and Sanitation—2014 Update. Geneva, Switzerland: World Health Organization. [Google Scholar]
  23. Luby SP, Halder AK, , 2008. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med Int Health 13: 835844.[Crossref] [Google Scholar]
  24. Wang X, Hunter PR, , 2010. A systematic review and meta-analysis of the association between self-reported diarrheal disease and distance from home to water source. Am J Trop Med Hyg 83: 582584.[Crossref] [Google Scholar]
  25. Cairncross S, Feachem R, , 1993. Environmental Health Engineering in the Tropics. Chichester, United Kingdom: John Wiley and Sons. [Google Scholar]
  26. Howard G, Bartram J, , 2003. Domestic Water Quantity, Service Level, and Health. Geneva, Switzerland: World Health Organization. [Google Scholar]
  27. Hartung C, Lerer A, Anokwa Y, Tseng C, Brunette W, Borriello G, , 2010. Open data kit: tools to build information services for developing regions. Proceedings of the 4th ACM/IEEE International Conference on Information and Communication Technologies and Development. London, United Kingdom: ACM, 18. [Google Scholar]
  28. Luby SP, Agboatwalla M, Bowen A, Kenah E, Sharker MAY, Hoekstra RM, , 2009. Difficulties in maintaining improved handwashing behavior, Karachi, Pakistan. Am J Trop Med Hyg 81: 140145.[Crossref] [Google Scholar]
  29. Kamm K, Feikin D, Bigogo G, Aol G, Audi A, Cohen A, Shah M, Yu J, Breiman R, Ram PK, , 2014. Associations between presence of handwashing stations and soap in the home and diarrhoea and respiratory illness, in children less than five years old in rural western Kenya. Trop Med Int Health 19: 398406.[Crossref] [Google Scholar]
  30. Devine J, Karver J, Coombes Y, Chase C, Hernandez O, , 2012. Behavioral Determinants of Handwashing with Soap among Mothers and Caretakers: Emergent Learning from Senegal and Peru. Learning note. Washington, DC: Water and Sanitation Program. [Google Scholar]
  31. Hoffmeyer-Zlotnik JH, Ferligoj A, Mrvar A, , 2003. New sampling designs and the quality of data. , eds. Developments in Applied Statistics. Ljubljana, Slovenia: FDV, 205217. [Google Scholar]
  32. Filmer D, Pritchett LH, , 2001. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography 38: 115132. [Google Scholar]
  33. Vyas S, Kumaranayake L, , 2006. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 21: 459468.[Crossref] [Google Scholar]
  34. Houweling TA, Kunst AE, Mackenbach JP, , 2003. Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter? Int J Equity Health 2: 8.[Crossref] [Google Scholar]
  35. Contzen N, Mosler H-J, , 2015. Identifying the psychological determinants of handwashing: results from two cross-sectional questionnaire studies in Haiti and Ethiopia. Am J Infect Control 43: 826832.[Crossref] [Google Scholar]
  36. Huber AC, Mosler H-J, , 2013. Determining behavioral factors for interventions to increase safe water consumption: a cross-sectional field study in rural Ethiopia. Int J Environ Health Res 23: 96107.[Crossref] [Google Scholar]
  37. Inauen J, Tobias R, Mosler H-J, , 2013. Predicting water consumption habits for seven arsenic-safe water options in Bangladesh. BMC Public Health 13: 417.[Crossref] [Google Scholar]
  38. Jaccard J, Turrisi R, , 2003. Interaction Effects in Multiple Regression. Thousand Oaks, CA: Sage.[Crossref] [Google Scholar]
  39. Gujarati DN, , 2004. Basic Econometrics. Boston, MA: McGraw Hill. [Google Scholar]
  40. Smith RL, Ager JW, Williams DL, , 1992. Suppressor variables in multiple regression/correlation. Educ Psychol Meas 52: 1729.[Crossref] [Google Scholar]
  41. Rosenberg M, , 1968. The Logic of Survey Analysis. New York, NY: Basic Books. [Google Scholar]
  42. Tao S, Cheng Y, Lu Y, Hu Y, Chen D, , 2013. Handwashing behaviour among Chinese adults: a cross-sectional study in five provinces. Public Health 127: 620628.[Crossref] [Google Scholar]
  43. Tüzün H, Karakaya K, Deniz EB, , 2015. Turkey Handwashing Survey: suggestion for taking the ecological model into better consideration. Environ Health Prev Med 20: 325331.[Crossref] [Google Scholar]
  44. Al-Mazrou YY, Aziz K, Khalil M, , 1991. Association of parents' education and fathers' occupation with prevalence of diarrhoea among children less than five years of age in Saudi Arabia. J Diarrhoeal Dis Res 9: 301304. [Google Scholar]
  45. Moy R, Booth I, Choto R-G, McNeish AS, , 1991. Risk factors for high diarrhoea frequency: a study in rural Zimbabwe. Trans R Soc Trop Med Hyg 85: 814818.[Crossref] [Google Scholar]
  46. Seksaria SA, Sheth MK, , 2014. Maternal knowledge and practices towards sanitation and their relationships with occurrence of diarrhoea in children. IJPHS 3: 206212. [Google Scholar]
  47. Ram PK, Halder AK, Granger SP, Jones T, Hall P, Hitchcock D, Wright R, Nygren B, Islam MS, Molyneaux JW, , 2010. Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg 83: 10701076.[Crossref] [Google Scholar]
  48. Gorter AC, Sandiford P, Pauw J, Morales P, Pérez RM, Alberts H, , 1998. Hygiene behaviour in rural Nicaragua in relation to diarrhoea. Int J Epidemiol 27: 10901100.[Crossref] [Google Scholar]
  49. Sakisaka K, Wakai S, Wongkhomthong S-A, , 2002. Domestic hygiene behaviour of mothers with children aged 0–5 years old in Tayabo village, Nueva Ecija, the Philippines. Asia Pac J Public Health 14: 9198.[Crossref] [Google Scholar]
  50. Mekasha A, Tesfahun A, , 2003. Determinants of diarrhoeal diseases: a community based study in urban south western Ethiopia. East Afr Med J 80: 7782. [Google Scholar]
  51. Ram PK, Sahli MW, Arnold B, Colford JM, Chase C, Briceño B, Orsola-Vidal A, Gertler PJ, , 2014. Validity of Rapid Measures of Handwashing Behavior: An Analysis of Data from Multiple Impact Evaluations in the Global Scaling Up Handwashing Project. Technical paper. Washington, DC: Water and Sanitation Program. [Google Scholar]
  52. Curtis V, Kanki B, Mertens T, Traore E, Diallo I, Tall F, Cousens S, , 1995. Potties, pits and pipes: explaining hygiene behaviour in Burkina Faso. Soc Sci Med 41: 383393.[Crossref] [Google Scholar]
  53. Biran A, Schmidt W-P, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V, , 2014. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2: e145e154.[Crossref] [Google Scholar]
  54. West S, Lynch M, Turner V, Munoz B, Rapoza P, Mmbaga B, Taylor HR, , 1989. Water availability and trachoma. Bull World Health Organ 67: 7175. [Google Scholar]
  55. Kupka K, Nižetič B, Reinhards J, , 1968. Sampling studies on the epidemiology and control of trachoma in southern Morocco. Bull World Health Organ 39: 547566. [Google Scholar]
  56. Esrey SA, Potash JB, Roberts L, Shiff C, , 1991. Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bull World Health Organ 69: 609621. [Google Scholar]
  57. Hoque BA, , 2003. Handwashing practices and challenges in Bangladesh. Int J Environ Health Res 13: S81S87.[Crossref] [Google Scholar]
  58. Zeitlyn S, Islam F, , 1991. The use of soap and water in two Bangladeshi communities: implications for the transmission of diarrhea. Rev Infect Dis 13: S259S264.[Crossref] [Google Scholar]
  59. World Bank 2005. Custom Cross-Tabulation of Data. Washington, DC: World databank. [Google Scholar]
  60. Biran A, Tabyshalieva A, Salmorbekova Z, , 2005. Formative research for hygiene promotion in Kyrgyzstan. Health Policy Plan 20: 213221.[Crossref] [Google Scholar]
  61. Luby SP, Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB, , 2009. Household characteristics associated with handwashing with soap in rural Bangladesh. Am J Trop Med Hyg 81: 882887.[Crossref] [Google Scholar]
  62. Biran A, Rabie T, Schmidt W-P, Juvekar S, Hirve S, Curtis V, , 2008. Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop Med Int Health 13: 278285.[Crossref] [Google Scholar]
  63. Luby SP, Halder AK, Huda TMN, Unicomb L, Johnston RB, , 2011. Using child health outcomes to identify effective measures of handwashing. Am J Trop Med Hyg 85: 882892.[Crossref] [Google Scholar]
  64. Stokols D, , 1992. Establishing and maintaining healthy environments: toward a social ecology of health promotion. Am Psychol 47: 622.[Crossref] [Google Scholar]
  65. McLeroy KR, Bibeau D, Steckler A, Glanz K, , 1988. An ecological perspective on health promotion programs. Health Educ Q 15: 351377.[Crossref] [Google Scholar]
  66. Sallis JF, Owen N, Fisher EB, Glanz K, Rimer BK, Viswanath K, , 2008. Ecological models of health behavior. , eds. Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass, 465486. [Google Scholar]

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  • Received : 10 Sep 2015
  • Accepted : 04 Mar 2016
  • Published online : 01 Jun 2016

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