A public health priority not addressed
The experience of COVID-19, Ebola and cholera demonstrates the importance of improving handwashing at key moments in reducing the transmission of significant communicable diseases. Diarrhoea, is the commonest cause of morbidity, the second leading cause of post-neonatal mortality, and is greatly associated with stunting, and thus linked to achieving SDG 3 targets. Evidence, including from our team, confirms that a mother’s effective handwashing before feeding can reduce food contamination for the child and diarrhoea.
The practice of communal bowl handwashing without soap before mealtimes (C-HW) involves a group of people (two or more) rinsing their hands in one small container of water, usually without soap and without changing the water between individuals. In Africa, C-HW is culturally engrained and believed to improve family cohesion, and is often followed by eating with hands from a large plate of food. Whenever at least one participant carries pathogens on their hands, C-HW before meals is a threat to all, especially young children who often wash last and have lower immunity; e.g. in a case-control study during the 2015 cholera epidemic in Kenya, there was an odds ratio (OR)=6.5(95% CI 2.30-18.11) of cholera cases in households that practised C-HW. Similarly, in Zimbabwe or a case-control study found that shared-bowl handwashing was a significant risk for diarrhoea in children under-5 years [OR = 2.95, 95% CI (1.47-5.89)].
We have conducted several studies to understand the prevalence of the practice in Africa, its motivators and interventions targeting C-HW, and have partners in ministries of health and international NGOs who are keen to develop effective interventions. Therefore, our team are seeking funding for the next steps.
Research project team leads:
University of Birmingham (UOB): Dr S Manaseki-Holland, Dr Evans A Asamane
University of Birmingham (UOB)- Professor Richard Lilford, Dr Sam Watson
University of Science Technique and Technology, Bamako (USTTB): Professor O Koita, Professor O Toure, Mr Youssouf Diarra, Dr Cheick Sidibe, Mr Modibo Telly
Co-developing and testing a culturally sensitive intervention package:
We have a multi-disciplinary team of intervention development experts, from the fields of social marketing, behaviour economics, public health and WASH. We wish to combine our experience and methodological toolkits to co-develop innovative solutions both at the household level and for delivery to the community.
For intervention delivery, we will leverage our experience in the Gambia (the MaaChampion project) and currently with the MRC-funded Mali 120-cluster RCT, a complex intervention for a community-level food safety, hygiene and nutrition programme, the MaaCiwara project. This Mali RCT intervention complements African performing arts (drama, songs, stories) with community leader involvement, peer education, competitions, branding and nudges.
For co-developing alternative behaviours (solutions) using soap at the household level, we have conducted a few community involvement/engagement activities, and qualitative studies and found that households were willing to participate in co-designing an intervention to address possible social or water-supply barriers, for example, washing with soap before or after C-HW in a second bowl, while community leaders promote behaviours. The exact form and nature of solutions and possible barriers will be identified through co-production/co-design with communities and stakeholders, and generic lessons identified for replication. We aim to define the mechanisms of action according to formative research such as the RANAS framework and refine our current theory of change (Logic Model) and the most appropriate behaviour change theory/s depending on the results of our interaction during co-development. At the initial stage, we have expert research and NGO partners in two distinct countries, Ghana (a large Christian population with fewer issues of security) and Mali (a Muslim-dominated country with significant security issues) and wish to develop, pilot and implement the proposed intervention in these countries at the first instance (although we remain open to the choice of country/ies).
Summary of draft publications for studies we have conducted so far
1. Systematic Review of the literature (Funding source: none)
Research Objectives/Methods: To summarise the literature and identify effective tested interventions, we comprehensively searched through several electronic databases and grey literature sources to identify potentially eligible papers for our review. A total of 10,711 records were identified from our search. After applying our inclusion and exclusion criteria, 16 studies were short-listed, from which we extracted data and appraised their methodological rigour using the Mixed Methods Appraisal Tool.
Results: Studies were from 10 African countries, but due to the scarcity of studies and their heterogeneity, a narrative synthesis approach was used to summarise and interpret the extracted data. Five of the included studies reported prevalence, which ranged from 30.7% to 79% among the sample studied. C-HW was practised in many settings, including households, schools, and social gatherings. Six of the included studies reported the association of C-HW practice with disease transmission measured for general diarrhoea rate, cholera, Hepatitis E virus, Shigella or human cysticercosis infections. Likewise, microbial analyses found evidence that C-HW aided the spread of pathogenic bacteria from infected hands to those that had no pathogens before C-HW. Cultural/traditional beliefs or practices were highlighted as the main reasons for engaging in this practice. Other motivations included the scarcity of water and soap. However, we were unable to identify any targeted intervention specifically addressing C-HW.
Given the high prevalence of this practice throughout Africa which has the highest rate of diarrhoeal disease and food-born infections globally, the findings of this review point to the importance of implementing culturally sensitive interventions to curb this practice.
2. Mixed methods multi-country study with WASH experts from 15 African countries (Funding source: Wellcome ISSF)
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 C-HW and the reasons behind its practice in Saharan Africa.
Methods: We used online quantitative surveys and qualitative semi-structured interviewing approach to elicit the views of Save the Children and Water Aid in-country WASH experts on the practice of C-HW. The experts were drawn from all counties that these large WASH orientated NGOs operated in and experts thus worked in West Africa, Central Africa, and East and Southern Africa. A quantitative survey was done via survey monkey, followed by one or more experts per country interviewed qualitatively virtually using zoom in English, French and Portuguese. The interviews analysed i) deductively, to quantify the responses to estimate the scale of the practice from the perspective of the experts, and ii) inductively using a thematic analysis approach to identify and describe the reasons behind this practice. We used elements of the socioecological framework to guide the data analysis, presentation, and interpretation of the results.
Results: 54 experts fully completed the quantitative survey and out of this, 22 experts were interviewed from 15 countries. The WASH Experts acknowledged that C-HWC-HW is widely practised across all countries in different settings. The practice was perceived to be more common in rural areas than in urban settings and usually during social events, such as weddings, naming ceremonies, funerals, birthdays, family gatherings and communal labour.
Factors motivating the practice included; i) traditional beliefs and practices: C-HW is seen as a symbol of togetherness, bringing a sense of unity, bonding and solidarity for community members; ii) lack of awareness and knowledge about the health risks of C-HW practice, iii) traditional hierarchy of control: men must wash hands first, then women and children, iii) education and social class: poor and uneducated more likely to wash hands together in one bowl, and iv) lack of handwashing facilities or water scarcity.
Conclusion: C-HW is widespread in Saharan Africa, and this threatens governments’ efforts in addressing 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 C-HW. Thus, future research should consider using an extensive within country survey to estimate the prevalence.
3. Investigating C-HW in Mali (Funding source- MRC UKRI)
Research Objectives: To describe C-HW, its prevalence, and the motivations underlying C-HW in urban and rural communities in Mali. Below, three studies are summarised together for brevity.
Methods: We conducted three types of data collection. First, in 7 urban and rural communities, we conducted qualitative focus group discussions separately with mothers, fathers, grandmothers and community elders, and observed daily routine activities regarding handwashing, cooking and feeding/eating in 45 households/mothers. Second, during a feasibility trial (see next study), we conducted qualitative interviews with mothers and heads of households identified earlier to be practising C-HW. Third, during the large baseline study of MaaCiwara, we conducted mealtime observations of 3400 mothers/families followed by a survey of mothers regarding the practice of C-HW which will be repeated at 4 and 15 months after an intervention that includes child food safety and hygiene and maternal handwashing with soap before feeding the child.
Findings/conclusions: In the first study, CHW was widely practised in almost all households before meals. Qualitative findings from the first and second study revealed that the use of the shared container (communal bowl) to wash hands “strengthens family solidarity”. They further explained that the custom of this form of handwashing has been passed over generations and families that wash hands together in the common bowl have “fewer disagreements and disunity”. Some participants insisted that it was important to continue C-HW for improving family unity, although some participants acknowledged that it was not the most hygienic practice and a few had some alternative solutions combined with C-HW. C-HW was also practised by the order of age in the family, where the youngest are often the last to wash their hands in the common bowl, making the youngest most vulnerable to transmission of diarrhoea pathogens from elders that already rinsed into the C-HW water. Only a few participants mentioned the scarcity of soap and water as factors influencing the practice of C-HW. Families said they were ready to explore other methods of handwashing that preserve their unity. Designing culturally acceptable interventions specifically targeting C-HW in consideration of these cultural motivations, are urgently needed. Such interventions, if co-created with communities will ensure maximum impact.
4. The effect of soap on pathogen transmission of E.Coli and coliforms into C-HW water and on hand swabs before mealtime in households using the same water in one bowl (Funding source: Institute for Global Innovation- University of Birmingham)
Research questions: Will adding soap and a rinse bowl during C-HW reduce hand-swab microbiological contamination compared to regular water-only single bowl use for C-HW?
Methods: We aimed to test a low cost intervention that was similar to C-HW in terms of family participation in pre-meal handwashing, thus reducing cultural barriers to behaviour change. We randomly allocated 280 households known to use C-HW 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, C-HW was done as normally practised, with one bowl of water without soap. Water samples, and hand-swaps of the last person, before and after C-HW 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 C-HW on average had double the rate of E.Coli contamination after C-HW.
Wellcome Trust ISSF and MRC UKRI