Our thanks go to the study participants who allowed us to spend hours with them, occasionally interrupting their routines for the purposes of study data collection. Our data collection team performed marvelously during an intense data collection period, despite challenging weather. We benefited greatly from wise input and thoughtful protocol reviews from Anna Bowen, John Colford, and Mark Sobsey. This study was commissioned by the Water and Sanitation Program (WSP) with funding from the Bill and Melinda Gates Foundation under the Global Scaling Up Handwashing project. International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) acknowledges with gratitude the commitment of these institutions to the Centre's research efforts. Global Scaling Up Handwashing is a WSP project focused on learning how to apply innovative promotional approaches to behavior change to generate widespread and sustained improvements in handwashing with soap on a large scale among women of reproductive age (ages 15–49 years) and primary school-aged children (ages 5–9 years). The project is being implemented by local and national governments, with technical support from WSP. For more information, please visit www.wsp.org/scalinguphandwashing. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP's donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill and Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank
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: 278–285.
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: 1015–1021.
Stanton BF, Clemens JD, Aziz KM, Rahman M, 1987. Twenty-four-hour recall, knowledge-attitude-practice questionnaires, and direct observations of sanitary practices: a comparative study. Bull World Health Organ 65: 217–222.
Luby SP, Halder AK, 2008. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med Int Health 13: 835-8-44.
Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston R, Luby SP, Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.
Hoque BA, Mahalanabis D, Alam MJ, Islam MS, 1995. Post-defecation handwashing in Bangladesh: practice and efficiency perspectives. Public Health 109: 15–24.
Luby SP, Agboatwalla M, Raza A, Sobel J, Mint ED, Baier K, Hoekstra RM, Rahbar MH, Hassan R, Qureshi SM, Gangarosa EJ, 2001. Microbiologic effectiveness of hand washing with soap in an urban squatter settlement, Karachi, Pakistan. Epidemiol Infect 127: 237–244.
Pinfold JV, 1990. Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. I. A case study in rural north-east Thailand. Epidemiol Infect 105: 363–375.
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: 366–371.
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: 765–771.
Pickering AJ, Davis J, Walters SP, Horak HM, Keymer DP, Mushi D, Strickfaden R, Chynoweth JS, Liu J, Blum A, Rogers K, Boehm AB. Hands, water, and health: fecal contamination in Tanzanian communities with improved, non-networked water supplies. Environ Sci Technol 44: 3267–3272.
Larson E, Aiello A, Lee LV, Della-Latta P, Gomez-Duarte C, Lin S, 2003. Short- and long-term effects of handwashing with antimicrobial or plain soap in the community. J Community Health 28: 139–150.
Islam MS, Alam MJ, Khan SI, Huq A, 1994. Faecal pollution of fresh water environments in Bangladesh. International Journal of Environmental Studies 46: 161–165.
Sobel J, Mahon B, Mendoza CE, Passaro D, Cano F, Baier K, Racioppi F, Hutwagner L, Mintz E, 1998. Reduction of fecal contamination of street-vended beverages in Guatemala by a simple system for water purification and storage, handwashing, and beverage storage. Am J Trop Med Hyg 59: 380–387.
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: 358–363.
Kaltenthaler EC, Pinfold JV, 1995. Microbiological methods for assessing handwashing practice in hygiene behaviour studies. J Trop Med Hyg 98: 101–106.
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: 3739–3744.
Moe CL, Sobsey MD, Samsa GP, Mesolo V, 1991. Bacterial indicators of risk of diarrhoeal disease from drinking-water in the Philippines. Bull World Health Organ 69: 305–317.
Stauber CE, Ortiz GM, Loomis DP, Sobsey MD, 2009. A randomized controlled trial of the concrete biosand filter and its impact on diarrheal disease in Bonao, Dominican Republic. Am J Trop Med Hyg 80: 286–293.
Brown JM, Proum S, Sobsey MD, 2008. Escherichia coli in household drinking water and diarrheal disease risk: evidence from Cambodia. Water Sci Technol 58: 757–763.
Pickering AJ, Boehm AB, Mwanjali M, Davis J, 2010. Efficacy of waterless hand hygiene compared with handwashing with soap: a field study in Dar es Salaam, Tanzania. Am J Trop Med Hyg 82: 270–278.