Volume 96, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Handwashing has been shown to considerably reduce diarrhea morbidity and mortality. To decontaminate hands effectively, the use of running water, soap, and various scrubbing steps are recommended. This study aims to identify the behavioral determinants of effective handwashing. Everyday handwashing technique of 434 primary caregivers in high-density suburbs of Harare, Zimbabwe, was observed and measured as an 8-point sum score of effective handwashing technique. Multiple linear and logistic regression analyses were performed to predict observed handwashing technique from potential contextual and psychosocial determinants. Knowledge of how to wash hands effectively, availability of a handwashing station with functioning water tap, self-reported frequency of handwashing, perceived vulnerability, and action planning were the main determinants of effective handwashing technique. The models were able to explain 39% and 36% of the variance in overall handwashing technique and thoroughness of handscrubbing. Memory aids and guided practice are proposed to consolidate action knowledge, and personalized risk messages should increase the perceived vulnerability of contracting diarrhea. Planning where, when, and how to maintain a designated place for handwashing with sufficient soap and water is proposed to increase action planning. Since frequent self-reported handwashing was associated with performing more effective handwashing technique, behavior change interventions should target both handwashing frequency and technique concurrently.


Article metrics loading...

Loading full text...

Full text loading...



  1. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JPT, Wolf J, Prüss-Ustün 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]
  2. Prüss-Ustün A, Bartram J, Clasen T, Colford JM, Cumming O, Curtis V, Bonjour S, Dangour AD, De France J, Fewtrell L, Freeman MC, Gordon B, Hunter PR, Johnston RB, Mathers C, Mäusezahl D, Medlicott K, Neira M, Stocks M, Wolf J, Cairncross S, , 2014. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894905.[Crossref]
  3. Curtis V, Cairncross S, , 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 3: 275281.[Crossref]
  4. Feachem RG, , 1984. Interventions for the control of diarrhoeal diseases among young children: promotion of personal and domestic hygiene. Bull World Health Organ 62: 467476.
  5. Borghi J, Guinness L, Ouedraogo J, Curtis V, , 2002. Is hygiene promotion cost-effective? A case study in Burkina Faso. Trop Med Int Health 7: 960969.[Crossref]
  6. Bloomfield SF, Aiello AE, Cookson B, O'Boyle C, Larson EL, , 2007. The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers. Am J Infect Control 35: 2764.[Crossref]
  7. Kampf G, Kramer A, , 2004. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev 17: 863893.[Crossref]
  8. Pinfold JV, Horan NJ, , 1996. Measuring the effect of a hygiene behaviour intervention by indicators of behaviour and diarrhoeal disease. Trans R Soc Trop Med Hyg 90: 366371.[Crossref]
  9. Pickering AJ, Davis J, Walters SP, Horak HM, Keymer DP, Mushi D, Strickfaden R, Chynoweth JS, Liu J, Blum A, Rogers K, Boehm AB, , 2010. Hands, water, and health: fecal contamination in Tanzanian communities with improved, non-networked water supplies. Environ Sci Technol 44: 32673272.[Crossref]
  10. World Health Organization, 2009. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization.
  11. Centers for Disease Control and Prevention, 2002. Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Atlanta, GA: Centers for Disease Control and Prevention.
  12. Food and Drug Administration, 2013. Food Code. Washington, DC: U.S. Department of Health and Human Services.
  13. Centers for Disease Control and Prevention, 2015. When and How to Wash Your Hands. Available at: http://www.cdc.gov/handwashing/when-how-handwashing.html. Accessed February 10, 2015.
  14. Friedrich MND, Julian TR, Kappler A, Nhiwatiwa T, Mosler H-J, . Handwashing, but how? Microbiological effectiveness of existing handwashing practices in high-density suburbs of Harare. Am J Infect Control. http://dx.doi.org/10.1016/j.ajic.2016.06.035.
  15. Lam B, Lee J, Lau YL, , 2004. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 114: 565571.[Crossref]
  16. Hoque BA, Mahalanabis D, Alam MJ, Islam MS, , 1995. Post-defecation handwashing in Bangladesh: practice and efficiency perspectives. Public Health 109: 1524.[Crossref]
  17. Huttly SR, Lanata CF, Gonzales H, Aguilar I, Fukumoto M, Verastegui H, Black RE, , 1994. Observations on handwashing and defecation practices in a shanty town of Lima, Peru. J Diarrhoeal Dis Res 12: 1418.
  18. Song IH, Kim S-A, Park W-S, , 2013. Family factors associated with children's handwashing hygiene behavior. J Child Health Care 17: 164173.[Crossref]
  19. Dobe M, Mandal RN, Jha A, , 2013. Social determinants of good hand-washing practice (GHP) among adolescents in a rural Indian community. Fam Community Health 36: 172177.[Crossref]
  20. Lilje J, Kessely H, Mosler H-J, , 2015. Factors determining water treatment behavior for the prevention of cholera in Chad. Am J Trop Med Hyg 93: 5765.[Crossref]
  21. Stocker A, Mosler HJ, , 2015. Contextual and sociopsychological factors in predicting habitual cleaning of water storage containers in rural Benin. Water Resour Res 51: 20002008.[Crossref]
  22. Sonego IL, Mosler H-J, , 2014. Why are some latrines cleaner than others? Determining the factors of habitual cleaning behaviour and latrine cleanliness in rural Burundi. J Water Sanit Hyg Dev 4: 257267.[Crossref]
  23. 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]
  24. Contzen N, Inauen J, , 2015. Social-cognitive factors mediating intervention effects on handwashing: a longitudinal study. J Behav Med 38: 956969.[Crossref]
  25. Contzen N, Meili IH, Mosler H-J, , 2015. Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med 124: 103114.[Crossref]
  26. 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]
  27. Contzen N, Mosler H-J, , 2012. Factors determining the effectiveness of Oxfam's public health promotion approach in Haiti. J Public Health (Bangkok) 21: 559573.[Crossref]
  28. Hartung C, Lerer A, Anokwa Y, Tseng C, Brunette W, Borriello G, , 2010. Open Data Kit: Tools to Build Information Services for Developing Regions. The 4th ACM/IEEE International Conference on Information and Communication Technologies and Development, December 13–16, 2010. London, United Kingdom: ACM, 112.
  29. Gould D, , 1994. Nurses' hand decontamination practice: results of a local study. J Hosp Infect 28: 1530.[Crossref]
  30. Chudleigh J, Fletcher M, Gould D, , 2005. Infection control in neonatal intensive care units. J Hosp Infect 61: 123129.[Crossref]
  31. Lucet JC, Rigaud MP, Mentre F, Kassis N, Deblangy C, Andremont A, Bouvet E, , 2002. Hand contamination before and after different hand hygiene techniques: a randomized clinical trial. J Hosp Infect 50: 276280.[Crossref]
  32. Fuls JL, Rodgers ND, Fischler GE, Howard JM, Patel M, Weidner PL, Duran MH, , 2008. Alternative hand contamination technique to compare the activities of antimicrobial and nonantimicrobial soaps under different test conditions. Appl Environ Microbiol 74: 37393744.[Crossref]
  33. Amin N, Pickering AJ, Ram PK, Unicomb L, Najnin N, Homaira N, Ashraf S, Abedin J, Islam MS, Luby SP, , 2014. Microbiological evaluation of the efficacy of soapy water to clean hands: a randomized, non-inferiority field trial. Am J Trop Med Hyg 91: 415423.[Crossref]
  34. United Nations Children's Fund, World Health Organization, 2009. Diarrhoea: Why Children Are Still Dying and What Can Be Done. New York, NY: United Nations Children's Fund, World Health Organization.
  35. Kaltenthaler E, Waterman R, Cross P, , 1991. Faecal indicator bacteria on the hands and the effectiveness of hand-washing in Zimbabwe. J Trop Med Hyg 94: 358.
  36. Scott BE, Schmidt WP, Aunger R, Garbrah-Aidoo N, Animashaun R, , 2008. Marketing hygiene behaviours: the impact of different communication channels on reported handwashing behaviour of women in Ghana. Health Educ Res 23: 392401.[Crossref]
  37. Sandhu MP, Goodnight J, , 2014. Community handwashing guide: utilizing available resources to initiate a handwashing intervention. World Med Health Policy 6: 3950.[Crossref]
  38. Tobias R, , 2009. Changing behavior by memory aids: a social psychological model of prospective memory and habit development tested with dynamic field data. Psychol Rev 116: 408.[Crossref]
  39. Gollwitzer PM, , 1999. Implementation intentions: strong effects of simple plans. Am Psychol 54: 493.[Crossref]

Data & Media loading...

  • Received : 05 Jul 2016
  • Accepted : 30 Oct 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error