Volume 85, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



We assessed which practical handwashing indicators were independently associated with reduced child diarrhea or respiratory disease. Fieldworkers collected 33 indicators of handwashing at baseline in 498 households in 50 villages in rural Bangladesh. Community monitors visited households monthly and asked standard questions about diarrhea and symptoms of respiratory illness among children under 5 years of age. In multivariate analysis, three handwashing indicators were independently associated with less child diarrhea—mothers reporting usually washing hands with soap before feeding a child, mothers using soap when asked to show how they usually washed their hands after defecation, and children having visibly clean finger pads. Two indicators were independently associated with fewer respiratory infections—mothers allowing their hands to air dry after the handwashing demonstration and the presence of water where the respondents usually wash hands after defecation. These rapid handwashing indicators should be considered for inclusion in handwashing assessments.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Bryce J, Boschi-Pinto C, Shibuya K, Black RE, , 2005. WHO estimates of the causes of death in children. Lancet 365: 11471152.[Crossref] [Google Scholar]
  2. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA, , 2008. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev 1: CD004265. [Google Scholar]
  3. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM, , 2005. Effect of handwashing on child health: a randomised controlled trial. Lancet 366: 225233.[Crossref] [Google Scholar]
  4. Master D, Hess Longe SH, Dickson H, , 1997. Scheduled hand washing in an elementary school population. Fam Med 29: 336339. [Google Scholar]
  5. Ryan MA, Christian RS, Wohlrabe J, , 2001. Handwashing and respiratory illness among young adults in military training. Am J Prev Med 21: 7983.[Crossref] [Google Scholar]
  6. Manun'Ebo M, Cousens S, Haggerty P, Kalengaie M, Ashworth A, Kirkwood B, , 1997. Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaire. Trop Med Int Health 2: 10151021.[Crossref] [Google Scholar]
  7. Curtis V, Cousens S, Mertens T, Traore E, Kanki B, Diallo I, , 1993. Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility. Bull World Health Organ 71: 2332. [Google Scholar]
  8. Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston R, Luby SP, , 2010. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.[Crossref] [Google Scholar]
  9. Drankiewicz D, Dundes L, , 2003. Handwashing among female college students. Am J Infect Control 31: 6771.[Crossref] [Google Scholar]
  10. Pedersen DM, Keithly S, Brady K, , 1986. Effects of an observer on conformity to handwashing norm. Percept Mot Skills 62: 169170.[Crossref] [Google Scholar]
  11. Munger K, Harris SJ, , 1989. Effects of an observer on handwashing in a public restroom. Percept Mot Skills 69: 733734.[Crossref] [Google Scholar]
  12. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV, , 2004. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 141: 18.[Crossref] [Google Scholar]
  13. Ram PK, Halder AK, Granger SP, Jones T, Hall P, Hitchcock D, Wright R, Nygren B, Islam MS, Molyneaux JW, Luby SP, , 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]
  14. Luby SP, Agboatwalla M, Billhimer W, Hoekstra RM, , 2007. Field trial of a low cost method to evaluate hand cleanliness. Trop Med Int Health 12: 765771.[Crossref] [Google Scholar]
  15. Kaltenthaler EC, Pinfold JV, , 1995. Microbiological methods for assessing handwashing practice in hygiene behaviour studies. J Trop Med Hyg 98: 101106. [Google Scholar]
  16. Ram PK, Jahid I, Halder AK, Nygren B, Islam MS, Granger SP, Molyneaux JW, Luby SP, , 2011. Variability in hand contamination based on serial measurements: implications for assessment of hand-cleansing behavior and disease risk. Am J Trop Med Hyg 84: 510516.[Crossref] [Google Scholar]
  17. 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]
  18. Gorter AC, Sandiford P, Pauw J, Morales P, Perez RM, Alberts H, , 1998. Hygiene behaviour in rural Nicaragua in relation to diarrhoea. Int J Epidemiol 27: 10901100.[Crossref] [Google Scholar]
  19. Bhuiya A, Streatfield PK, Meyer P, Caldwell J, , 1990. Mother's hygienic awareness, behaviour, and knowledge of major childhood diseases in Matlab, Bangladesh. , ed. What We Know About Health Transition: The Cultural, Social and Behavioural Determinants of Health. Canberra, Australia: Health Transition Centre, 462477. [Google Scholar]
  20. Biran A, Rabie T, Schmidt W, 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]
  21. Larson EL, Aiello AE, Cimiotti JP, , 2004. Assessing nurses' hand hygiene practices by direct observation or self-report. J Nurs Meas 12: 7785.[Crossref] [Google Scholar]
  22. Strina A, Cairncross S, Barreto ML, Larrea C, Prado MS, , 2003. Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. Am J Epidemiol 157: 10321038.[Crossref] [Google Scholar]
  23. Webb AL, Stein AD, Ramakrishnan U, Hertzberg VS, Urizar M, Martorell R, , 2006. A simple index to measure hygiene behaviours. Int J Epidemiol 35: 14691477.[Crossref] [Google Scholar]
  24. Ruel MT, Arimond M, , 2002. Spot-check observational method for assessing hygiene practices: review of experience and implications for programmes. J Health Popul Nutr 20: 6576. [Google Scholar]
  25. Semmelweis I, , 1983. Etiology, Concept and Prophylaxis of Childbed Fever. Madison, WI: University of Wisconsin Press. [Google Scholar]
  26. Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, Luby S, , 2007. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 76: 11661173. [Google Scholar]
  27. Larson EL, Early E, Cloonan P, Sugrue S, Parides M, , 2000. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 26: 1422.[Crossref] [Google Scholar]
  28. Talaat M, Afifi S, Dueger E, El-Ashry N, Marfin A, Kandeel A, Mohareb E, El-Sayed N, , 2011. Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt. Emerg Infect Dis 17: 619625.[Crossref] [Google Scholar]
  29. Loevinsohn BP, , 1990. Health education interventions in developing countries: a methodological review of published articles. Int J Epidemiol 19: 788794.[Crossref] [Google Scholar]
  30. Iyer P, Sara J, Curtis V, Scott B, Cardosi J, , 2005. The Handwashing Handbook. A Guide for Developing a Hygiene Promotion Program to Increase Handwashing with Soap. Washington, DC: World Bank. [Google Scholar]
  31. Centers for Disease Control and Prevention, 2010. Handwashing: Clean Hands Save Lives. Atlanta, GA: Centers for Disease Control and Prevention. [Google Scholar]
  32. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB, , 2011. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med 8: e1001052.[Crossref] [Google Scholar]
  33. 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]
  34. Vyas S, Kumaranayake L, , 2006. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 21: 459468.[Crossref] [Google Scholar]
  35. Hanley JA, Negassa A, Edwardes MD, Forrester JE, , 2003. Statistical analysis of correlated data using generalized estimating equations: an orientation. Am J Epidemiol 157: 364375.[Crossref] [Google Scholar]
  36. Roberts L, Smith W, Jorm L, Patel M, Douglas RM, McGilchrist C, , 2000. Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial. Pediatrics 105: 738742.[Crossref] [Google Scholar]
  37. Niffenegger JP, , 1997. Proper handwashing promotes wellness in child care. J Pediatr Health Care 11: 2631.[Crossref] [Google Scholar]
  38. Barker J, Stevens D, Bloomfield SF, , 2001. Spread and prevention of some common viral infections in community facilities and domestic homes. J Appl Microbiol 91: 721.[Crossref] [Google Scholar]
  39. Boone SA, Gerba CP, , 2007. Significance of fomites in the spread of respiratory and enteric viral disease. Appl Environ Microbiol 73: 16871696.[Crossref] [Google Scholar]
  40. Sallis JF, Owen N, Fisher EB, Glanz K, Rimer BK, Viswanath K, , 2008. Ecological models of health behavior. , eds. Health Behavior and Health Education. San Francisco, CA: Josey–Bass, 465485. [Google Scholar]
  41. Rabie T, Curtis V, , 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258267.[Crossref] [Google Scholar]
  42. Nasreen S, Azziz-Baumgartner E, Gurley ES, Winch PJ, Unicomb L, Sharker MA, Southern D, Luby SP, , 2010. Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh. Trop Med Int Health 15: 762771.[Crossref] [Google Scholar]
  43. Walther BA, Ewald PW, , 2004. Pathogen survival in the external environment and the evolution of virulence. Biol Rev Camb Philos Soc 79: 849869.[Crossref] [Google Scholar]
  44. NIPORT, 2007. Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh: National Institute of Population Research and Training, Mitra and Associates. [Google Scholar]
  45. Schell CO, Reilly M, Rosling H, Peterson S, Ekstrom AM, , 2007. Socioeconomic determinants of infant mortality: a worldwide study of 152 low-, middle-, and high-income countries. Scand J Public Health 35: 288297.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 11 Mar 2011
  • Accepted : 27 Jul 2011
  • Published online : 01 Nov 2011

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