Communal Bowl-Hand Rinsing

Research Objectives/Methods: We systematically reviewed the literature to provide a better understanding of the spread and motivations for the practice, its association with disease or pathogen transmission, and targeted interventions. Several electronic databases and grey literature were searchded. We extracted data and appraised their methodological rigour using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis and Forest Plot were used to summarise the data.

Results: Fifteen studies (all from 10 Sub-Saharan Africa (SSA) countries) were identified from 10,711 records. Study settings were schools (n=4), funerals (n=1) and households (n=10). Four case-control studies reported increased odds of cholera (Adjusted-OR=6.50;95%CI,2.30, 18.11), dysentery (at households Adjusted-OR=10.52(95%CI,2.81, 39.0), and at public gatherings Adjusted-OR=2.92(95%CI,1.24,7.21)), diarrhoea (Adjusted-OR=2.89;95%CI,1.33, 6.39), Hepatitis E virus risk (Adjusted-OR=1.90; 95%CI,1.07, 3.38), and one found a lower height-for-age z-score in babies whose families perform CB-HR. A cross-sectional study reported odds of cysticercosis (Adjusted-OR=3.8;95%CI,2.5, 5.9). Two cross-sectional studies conducted laboratory water and/or hand-swab microbiology investigations, demonstrating pathogen transmission from CB-HR. No intervention studies were found.

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Conclusion: Research on CB-HR was sparse. CH-BR is widely practised in SSA and spreads diseases. However, there is a need for the development and evaluation of culturally sensitive interventions to address this practice in Africa.

Research Objectives:  To elicit the views of development experts working in the Water, Sanitation and Hygiene (WASH)sector on what they perceived to be the prevalence of CB-HR and the reasons behind its practice in Saharan Africa. 

Methods: Online survey invitations were emailed by WASH Leads from WaterAid and Save the Children International headquarters to countries (n=51 experts from 15 countries responded). Follow-up telephone qualitative interviews were conducted (n=20 experts from 15 countries). Interview data were recorded in English, French or Portuguese, transcribed/translated into English, and analysed using thematic analysis.

Results: People practiced CB-HR in all countries represented by the experts across west, east, south and central Africa. Experts explained that CB-HR is common in urban and rural areas, across a range of population groups. Cultural beliefs (such as strengthening family bonds), poor access to facilities or water, and inadequate awareness of the health risks of CB-HR were some of the reasons given by experts for CB-HR practice. There were no interventions explicitly aiming to reduce CB-HR. Experts expressed that such interventions were important but not yet addressed in Africa.

Conclusion: CB-HR is widespread in Saharan Africa, and this threatens governments’ efforts to addressg Africa’s public health challenges. A multisectoral approach to the problem is needed, and we recommend that educational interventions using a behavioural change approach have the potential to make an impact at addressing the factors acting at the community level. Due to the design of this study, we could not properly establish the scale of the practice of CB-HR.  Future research should consider using an extensive within country survey to estimate the prevalence

Research Objectives: To gain a better understanding of public perspectives on CB-HR, identifying the reasoning and exploring the beliefs behind the practice and determining factors preventing the improvement of hand hygiene before meals at homes

Methods: We recorded 59 semi-structured interviews and 26 focus groups, in the local language of Bambara, across both rural and urban communities in Mali. Participants included mothers, fathers, grandmothers and grandfathers. Recordings were transcribed into French, translated into English and analysed using thematic analysis. 

Results: CB-HR was commonplace amongst our participants, they confirmed that CB-HR was rooted in tradition for the purposes of social cohesion and family unity. The exact way in which CB-HR was practised varied. There was wide awareness of the infection-related risks associated with CB-HR. Various reasons were given for not practising and maintaining individual handwashing with soap. Ways of combining CB-HR and individual handwashing with soap were described, including the need for role models to maintain motivation.

Conclusion: CB-HR was widespread in our rural & urban sample despite knowledge of its health risks, and access to running water and handwashing equipment (vessels and soap) because of the belief that it maintained social cohesion. Programmes aimed at improving infection control need to address the social and cultural drivers of CB-HR, or to adapt interventions in ways that are not perceived to threaten family unity. 

Research objectives:  To explore the motivations for CB-HR practices in 3 communities in the Adaklu district of the Volta region of Ghana.

Methods: We conducted nine semi-structured qualitative interviews (SSI) and four focus group discussions (FGDs) among community members separately among males and females in two selected rural communities. SSI interviews were done with head of households and mothers/carers with children less than 5 years.  Participants were eligible if they were residents of of these communities for more than 6 months and able to communicate in either English or Ewe (the local language). Recordings were transcribed, translated into English for interviews done in local language, and analysed using thematic analysis. 

Results: CB-HR was widely practiced in almost every household in these communities prior meals. The use of tippy tap, someone pouring water over their hands to wash, and individuals pouring water with one hand to wash the other hand, were also reported by a few as forms of handwashing different from the CB-HR practice. For those using CB-HR with modifications of adding soap mentioned of instances they had to use 2 communal bowls, one containing soapy water and one containing normal water to rinse hands afterwards. CB-HR practices was reported to be cultural and passed on from previous generations. Some of the reasons stated for washing hands included to get rid of germs, prevent sickness and diseases (diarrhoea, stomach ulcer, typhoid), and maintain neatness and cleanliness. Hands were also washed after visiting the toilet and when returning from the farm. Health education from University students and also health workers during the covid-19, were reported as sources for education.

The participants indicated that they are aware of the need to wash their hands under running water or someone pouring water over their hands to wash, however, they resorted to CB-HR practices due to water scarcity. A few said that they wash their hands with soap, while more than half said they wash their hands with normal water as indicated in the SSI and GFDs.

Conclusion: CB-HR was widely practiced and in rare occasions soap was added and rinsed in another bowl. Given the motivations for the practice, working closely with community stakeholders to co-develop interventions to curb CB-HR will ensure maximum impact.

Research questions: Will adding soap and a rinse bowl during CB-HR reduce hand-swab microbiological contamination compared to regular water-only single bowl use for CB-HR?

Methods: We aimed to test a low-cost intervention that was similar to CB-HR in terms of family participation in pre-meal handwashing, thus reducing cultural barriers to behaviour change. We randomly allocated 280 households known to use CB-HR in 3 villages and 2 urban Bamako communities to intervention or control groups. Intervention households were asked to wash in a usual communal bowl but with soap and rinse in a separate communal bowl of water. In the control group, CB-HR was done as normally practised, with one bowl of water without soap. Water samples, and hand-swaps of the last person, before and after CB-HR were tested for E.coli and coliform. Water and hand swab samples were cultured using standard techniques for E.Coli (indicator for faecal coliforms) and coliforms.

Findings/conclusions: The intervention resulted in a rate ratio reduction of 55% (95% CI: 71%, 34%) in E.Coli colony growth (indicator for faecal coliforms) from hand-swabs after washing hands with soap. Control participants with no hand-swab contamination before traditional CB-HR on average had double the rate of E.Coli contamination after CB-HR.