Abstract
Limited studies in India had captured the gap in knowledge and practice of handwashing in the community. This study assesses the gap in knowledge and practice of handwashing in rural India. The study was conducted across 10 districts in five states of India – Andhra Pradesh, Assam, Maharashtra, Odisha and West Bengal from December 2021 to January 2022 by the SIGMA Foundation, Kolkata in collaboration with UNICEF India. Descriptive statistics, bivariate analysis, creation of indices and multinomial logistic regression were employed. Findings demonstrated that both knowledge of different aspects of hand hygiene and practice of handwashing with soap and water (HWWS) at critical times varied by socio-economic groups and also across the districts/states. Half of the respondents used only water to wash their hands after taking meals, before serving food, whenever their hands seemed dirty and before eating or cooking. Overall, the ‘HWWS knowledge index’ was 0.46, whereas the ‘HWWS practice index’ was 0.36. The correlation coefficient between the two was 0.36. The HWWS practice index was lower than the HWWS knowledge index for 50% of the sampled households. Both HWWS knowledge and practice indices were higher among females, higher educated and younger population. The gap between handwashing practice and knowledge was also higher among females and higher educated.
HIGHLIGHTS
First multi-state study in rural India aimed at understanding the gap between knowledge and handwashing practice after COVID-19.
Knowledge and practice of handwashing with soap and water at critical times are inadequate.
Substantial gap in knowledge and practice of handwashing with soap and water exists by socio-economic status and by districts.
Graphical Abstract
INTRODUCTION
The Joint Monitoring Programme (JMP) by UNICEF and the World Health Organization (WHO) defines hand hygiene as washing hands with soap and water at a dedicated handwashing facility (WHO 2021). Hand hygiene, particularly handwashing with soap and water (HWWS) (or an alcohol-based formulation), is recognised as a highly cost-effective public health intervention, having the potential to significantly reduce disease burden globally (Jamison et al. 2006). It is the most important measure to avoid the transmission of harmful germs and viruses and prevent health care-associated infections. Handwashing with soap and water (HWWS) at five critical times – after defecation, after cleaning a child's bottom, before feeding infants/children, before eating and before food preparation – is estimated to reduce diarrhoeal diseases by 47% and respiratory infections by 23%, thereby meaningfully contributing to reductions in infant and child mortality (Greenland et al. 2013; Wolf et al. 2022) and reduce risk of respiratory infections by 21–23% (Aiello et al. 2008). Previous studies showed that handwashing can decontaminate hands and avert cross-transmission (Larson 1995). On the onset of the COVID-19 pandemic, hand hygiene became a critical need of the hour to save human lives.
The determinants of handwashing that were most commonly reported were knowledge, risk, psychological trade-offs or discounts, gender, wealth, education and infrastructure (White et al. 2020). Similar to many hygiene practices, handwashing is highly influenced by individual behaviour and usually has biological and social origins (Deodhar 2003). Prior research on handwashing practices indicated that having a basic handwashing facility at a dedicated place in the home is a key determinant of good handwashing practice in developing countries (Jenkins et al. 2013). Detailed research revealed that India has low threat perception of hand hygiene and is in dire need of social behavioural change communication. Levels of education of the household head, monthly per capita expenditure (MPCE) of the household, access to water (other than drinking water) resources and sanitation facilities, and the availability of water with soap in and around latrines are major socio-economic and demographic factors that impact handwashing practices (Biswas & Karmakar 2022). The most cited reasons for not practising handwashing are the lack of a place to wash hands, lack of soap and limited water access. 67% of the respondents reported that they needed more information on handwashing, in particular, the critical times and steps of HWWS. Only 33% of the households had piped water available for handwashing (WaterAid India 2020).
The existing literature on hand hygiene in India revealed that knowledge and practice of hand hygiene is generally low. Around 26% of the people in India do not wash hands with soap or detergent after defecation and 13.4% of households (15.2% rural and 9.8% urban) wash hands with only water after defecation (NARSS 2020). In 2017, a report by WaterAid suggested that almost all the respondents in the states of Odisha, Chhattisgarh, Bihar and Rajasthan washed their hands in the last 24 h and they were more likely to wash their hands after defecation (99.3%) and before taking meals (91.9%) rather than before preparing food (50%), serving food (30.9%) or feeding (12.6%) children or cleaning children (8%). For activities that did not require much contact, between two-fifths and half of the respondents used water only for washing hands. About half of the respondents could correctly demonstrate all the steps of handwashing and more women and children had better knowledge of the steps of handwashing (WaterAid India 2020). The recent 76th round of the National Sample Survey Organization (NSSO) report (2018) revealed that 25.3% of rural household members washed their hands with soap and water or detergent before a meal, whereas 2.7% of households in India wash their hands with ash/mud or sand before meals. Additionally, 70% of the rural people washed their hands with water and without soap or detergent before a meal (MSPI 2018).
Concurrently, 93% of the people in the highest wealth quintile used both soap and water for handwashing as compared to 24% of the poorest people (IIPS & ICF 2017). In a recent study, Pradhan & Mondal (2021) using NFHS-4 data (2015–16) concluded that two-fifths of Indian households do not use both soap/detergent and water for handwashing. Households using both the cleansing elements vary considerably by socio-economic characteristics and it is worse for the socio-economically disadvantaged groups. There is spatial clustering in the use of soap/detergent and water for handwashing: lower in a cluster of districts in eastern India (Pradhan & Mondal 2021).
However, after the COVID-19 pandemic, both the awareness and practice of handwashing have improved across all the socio-economic sections in the community. A study based on 18 states done by SIGMA Foundation (2020) showed that, during the pandemic, handwashing practices improved a lot after the beginning of the pandemic (87 vs. 53% always; 36 vs. 9% sometimes). Furthermore, the improvement was larger in the rural areas, which had a lower base as compared to their urban counterparts before the pandemic started. However, 13% of people who were going out did not practice handwashing (SIGMA Foundation 2020). The frequency of HWWS per day, on average, increased from 5 to 10 before and after the outbreak of the pandemic in the rural areas. Improvement in handwashing behaviour was more significant for persons going out of home as compared to home-bound people (SIGMA Foundation 2020). However, handwashing at all critical times is yet to be reached and the frequency of handwashing remained low for COVID-19-related critical times and child-related activities. Soap was used by the vast majority to wash hands, with 80% washing hands for at least 20 s (WaterAid India 2020).
Most of the available data on handwashing in the community level unravels that the gap between knowledge and practice of handwashing depends on both the supply-side bottlenecks as well as the behaviour of the individuals (Rabbi & Dey 2013). The association between practising handwashing and access to handwashing infrastructure is bidirectional. Unless the supply-side is invigorated through enabling factors such as the construction of improved handwashing facilities through community outreach and mobilization and proper fund allocation, it will be difficult to inculcate the habit of safe and proper HWWS in the community. The latest JMP ‘Hygiene Baselines pre-COVID-19 Global Snapshot’ also clearly indicates that there are large data gaps on the components of hand hygiene such as Knowledge, Attitude and Practice (KAP) and availability of hygiene supplies. A quick scoping of the existing literature on hand hygiene in India has revealed that even though many studies in India had focused on hand hygiene in hospitals, schools and other public institutions, there is limited evidence of the gap between knowledge and practice of hand hygiene at the domestic/community level, particularly in the rural areas (Modi et al. 2017; Dutta et al. 2020; Pratinidhi et al. 2020; Sagar et al. 2020). With this backdrop, the objective of the study was to assess the knowledge and practice of handwashing and understand the gap between handwashing knowledge and handwashing practices in rural India.
DATA AND METHODS
Study area and design
The field work for this cross-sectional study was conducted during 15 December, 2021 and 28 January, 2022 in the rural areas of five states of India – Assam, Andhra Pradesh, Maharashtra, Odisha and West Bengal. The selection criterion for the states was based on factors in which UNICEF and their partner agencies had built handwashing stations during COVID-19. Self-reported data were collected from household members, aged 18 years and above, who had adequate knowledge about handwashing infrastructure and hand hygiene.
Sampling strategy
A multi-stage sampling design was followed in drawing the sample. In the first stage, two districts with high and low functional household tap connection (FHTC) coverage were chosen from each study state. For the low FHTC coverage districts, Krishna from Andhra Pradesh, Udalguri from Assam, Palghar from Maharashtra, Rayagada from Odisha and Puruliya from West Bengal were chosen having the lowest FHTC coverage at the respective states. For the high FHTC coverage districts, Chittoor from Andhra Pradesh, Barpeta from Assam, Nashik from Maharashtra, Ganjam from Odisha and South 24 Parganas from West Bengal were chosen based on the highest FHTC coverage in the respective states.
Subsequently, five Gram Panchayats (GPs) were chosen from each district. GP is a basic village-governing political institute in Indian villages. The Panchayat system covers the village level (GP), cluster of villages (Block Panchayat) and district level (District Panchayat). It is a formal and democratic structure at the grassroot level in the country. The District Development Council links the state government and the GP. Therefore, the village development activities undertaken by the states are basically implemented at the GP level. The GP representatives are responsible for the overall development of villages and play a key role in administrative functions such as public works and welfare functions – repair and maintenance of village roads, providing basic services vital for the health and well-being of rural people like drinking water and sanitation, etc.
In order to assess the existing handwashing infrastructure setup, out of the five GPs, two were purposively chosen from the list shared by UNICEF where they have provided direct or indirect support in building handwashing stations. For the remaining three GPs, one GP was chosen randomly that was near to the district headquarters (within 20 km), one was chosen randomly away (more than 50 km) from the district headquarters and the remaining one was chosen randomly somewhere in the middle (between 20 and 50 km). From each GP, 30 households were chosen randomly which were at least 20 houses away from each other.
Sample size
The total sample size covered from the GPs distributed in the two districts from each state was 30 × 5 × 2. Thus, each state yielded 300 samples which was large enough to provide robust statistical measures. Thus the total sample size from the five states was 1,500. On the whole, 5% extra data were collected from the GPs, of which 16 were retained due to satisfactory data quality. Thus, the total sample size for this study comprised 1,516 households.
Development of survey tools
Research tools were designed by SIGMA Foundation to collect quantitative information using structured schedules from the households. All the survey tools were prepared in English which were translated in five local languages – Assamese, Telegu, Marathi, Odiya and Bengali. The household schedule canvassed numerous questions related to the availability of handwashing infrastructure, household characteristics, household preparedness for handwashing infrastructure, aspects of KAP of HWWS, associated barriers, factors affecting handwashing practices – COVID-19, external factors and messages, communications received and bottlenecks of upscaling handwashing infrastructures in the households. The field data were collected using Computer Assisted Personal Interviews (CAPI) and stored electronically which were regularly monitored and data cleaning was administered in the case of illogical answers or missing data. KoboCollect software was used for conducting the interviews.
Data management and analysis
For the data analysis, the software STATA 16 was used. Table 1 presents the details of the variables used in the study. Descriptive statistics, bivariate analysis, specific tests (χ² test, t-test and ANOVA), ratios and indices were created along with multinomial logistic regression was employed.
Variables used in the study
Knowledge of handwashing | |
Illness prevention | Agrees that washing hands with soap reduced the transmission of diseases – No: 0; Yes: 1 |
Type of soap to be used | Agrees that anti-bacterial soap is required for handwashing – No: 0; Yes: 1 |
Alcohol content of hand sanitizer | Agrees that alcohol content should be >60% in hand sanitizer – No: 0; Yes: 1 |
Time required for handwashing per occasion | Do not know how many seconds to invest for handwashing: 0; Knows time required for handwashing per occasion: 1 |
Steps of HWWS – (i) wet hands with water, (ii) apply soap, (iii) lather hands/back of hands/fingers/nails, (iv) washing hands and drying hands. | No steps: 0; Could explain only one step: 1; Could explain only two steps: 2; Could explain only three steps: 3; Could explain four steps: 4; Could explain all steps: 5 |
HWWS knowledge index | Continuous variable with value lying between 0 and 1 |
Practice of handwashing | |
Time invested for handwashing per occasion | Upto 10 s: 1; 20 s: 2; 30 s: 3; More than 30 s: 4; Do not know: 5 |
Substance used for handwashing at critical times | water only: 1; soap and water: 2; hand sanitizer: 3; ash/mud/sand: 4 |
HWWS practice index | Continuous variable with value lying between 0 and 1 |
Sex | Male: 1; Female: 2 |
Age | <30 years: 1; 30–44 years: 2; 45–59 years: 3; >60 years: 4 |
Highest educational level | No education: 0; Primary: 1; Secondary: 2; Higher Secondary: 3 |
Religion | Hindu: 1; Muslim: 2; Others: 3 |
Social category | Scheduled caste: 1 Scheduled tribe: 2 Other backward classes: 3 Others: 4 |
MPCE | Below INR 3,000: 1; INR: 3,000–5,000: 2; INR 5,000–10,000: 3; INR 10,000 and above: 4 |
Type of building of household | Kutcha: 1; Semi pucca: 2; Pucca: 3 |
Type of main water source | Piped water: 1; Public tap/pipe: 2; Tubewell: 3; Unimproved sources: 4 |
Type of toilet facility | No facility/Open defecation: 0; Flush/Pour flush toilet: 1; Pit latrine: 2; Composting toilet: 3 |
Type of main handwashing facility | No arrangement/at water source: 0; Wash basin with stored/running water: 1; Tubewell: 2; Fixed place in the premises with bucket/mug/jug/bottles: 3; Others: 4 |
Drainage system | None: 0; Open drain: 1; Soak pit/magic pit: 2; Covered drain/Connected to a sewer: 3 |
Access to basic handwashing facility | No: 0; Yes: 1 |
HH having soap/hand sanitizer available at home | None: 0; Both soap and hand sanitizer: 1; Only soap: 2; Don't know/only hand sanitizer: 3 |
HHs having handwashing infrastructure readily available | None: 0; All: 1; Most: 2; Some: 3 |
HH having under-five children | No: 0; Yes: 1 |
Thinks handwashing is necessary | No: 0; Yes: 1 |
Received messages on hand hygiene | No: 0; Yes: 1 |
State | Andhra Pradesh: 1; Assam: 2; Maharashtra: 3; Odisha: 4; West Bengal: 5; Low FHTC Coverage: 6; High FHTC Coverage: 7 |
Critical times of handwashing | After using toilet: 1; Before cooking food: 2; Before eating: 3; After cleaning child's faeces: 4; Before feeding children: 5 |
Extended critical times of handwashing | After using toilet: 1; Before cooking food: 2; Before eating: 3; After cleaning child's faeces: 4; Before feeding children: 5; Before serving food: 6; Cleaning home/handling garbage: 7; Returning home from outside by adults: 8; After sneezing/coughing: 9; After coming in contact with sick children: 10; Whenever hands seem dirty: 11; After eating: 12; Returning home from outside by children: 13 |
Knowledge of handwashing | |
Illness prevention | Agrees that washing hands with soap reduced the transmission of diseases – No: 0; Yes: 1 |
Type of soap to be used | Agrees that anti-bacterial soap is required for handwashing – No: 0; Yes: 1 |
Alcohol content of hand sanitizer | Agrees that alcohol content should be >60% in hand sanitizer – No: 0; Yes: 1 |
Time required for handwashing per occasion | Do not know how many seconds to invest for handwashing: 0; Knows time required for handwashing per occasion: 1 |
Steps of HWWS – (i) wet hands with water, (ii) apply soap, (iii) lather hands/back of hands/fingers/nails, (iv) washing hands and drying hands. | No steps: 0; Could explain only one step: 1; Could explain only two steps: 2; Could explain only three steps: 3; Could explain four steps: 4; Could explain all steps: 5 |
HWWS knowledge index | Continuous variable with value lying between 0 and 1 |
Practice of handwashing | |
Time invested for handwashing per occasion | Upto 10 s: 1; 20 s: 2; 30 s: 3; More than 30 s: 4; Do not know: 5 |
Substance used for handwashing at critical times | water only: 1; soap and water: 2; hand sanitizer: 3; ash/mud/sand: 4 |
HWWS practice index | Continuous variable with value lying between 0 and 1 |
Sex | Male: 1; Female: 2 |
Age | <30 years: 1; 30–44 years: 2; 45–59 years: 3; >60 years: 4 |
Highest educational level | No education: 0; Primary: 1; Secondary: 2; Higher Secondary: 3 |
Religion | Hindu: 1; Muslim: 2; Others: 3 |
Social category | Scheduled caste: 1 Scheduled tribe: 2 Other backward classes: 3 Others: 4 |
MPCE | Below INR 3,000: 1; INR: 3,000–5,000: 2; INR 5,000–10,000: 3; INR 10,000 and above: 4 |
Type of building of household | Kutcha: 1; Semi pucca: 2; Pucca: 3 |
Type of main water source | Piped water: 1; Public tap/pipe: 2; Tubewell: 3; Unimproved sources: 4 |
Type of toilet facility | No facility/Open defecation: 0; Flush/Pour flush toilet: 1; Pit latrine: 2; Composting toilet: 3 |
Type of main handwashing facility | No arrangement/at water source: 0; Wash basin with stored/running water: 1; Tubewell: 2; Fixed place in the premises with bucket/mug/jug/bottles: 3; Others: 4 |
Drainage system | None: 0; Open drain: 1; Soak pit/magic pit: 2; Covered drain/Connected to a sewer: 3 |
Access to basic handwashing facility | No: 0; Yes: 1 |
HH having soap/hand sanitizer available at home | None: 0; Both soap and hand sanitizer: 1; Only soap: 2; Don't know/only hand sanitizer: 3 |
HHs having handwashing infrastructure readily available | None: 0; All: 1; Most: 2; Some: 3 |
HH having under-five children | No: 0; Yes: 1 |
Thinks handwashing is necessary | No: 0; Yes: 1 |
Received messages on hand hygiene | No: 0; Yes: 1 |
State | Andhra Pradesh: 1; Assam: 2; Maharashtra: 3; Odisha: 4; West Bengal: 5; Low FHTC Coverage: 6; High FHTC Coverage: 7 |
Critical times of handwashing | After using toilet: 1; Before cooking food: 2; Before eating: 3; After cleaning child's faeces: 4; Before feeding children: 5 |
Extended critical times of handwashing | After using toilet: 1; Before cooking food: 2; Before eating: 3; After cleaning child's faeces: 4; Before feeding children: 5; Before serving food: 6; Cleaning home/handling garbage: 7; Returning home from outside by adults: 8; After sneezing/coughing: 9; After coming in contact with sick children: 10; Whenever hands seem dirty: 11; After eating: 12; Returning home from outside by children: 13 |
HH-household; HWWS-handwashing with soap and water; MPCE-monthly per capita consumption; FHTC-functional household tap connection.
Knowledge of handwashing
The knowledge of different aspects of hand hygiene has been studied through the lens of illness prevention, type of soap to be used, time required for handwashing per occasion, steps of HWWS at critical times.
Practice of handwashing
For understanding the practice of handwashing, frequency of handwashing with and without soap, time required for handwashing per occasion, handwashing material used (soap, alcohol-based hand sanitizer, sand/mud/ash) and practising handwashing at extended critical occasions were considered. After COVID-19, handwashing has received much more importance beyond the WHO-recommended critical times. Henceforth, extended critical times were considered which referred to instances apart from the WHO-recommended critical times comprising cleaning home/handling garbage, returning home from outside by adults and children, after sneezing/coughing, after coming in contact with sick children and whenever hands seem dirty.
The HWWS knowledge index and HWWS practice index
An index based on the knowledge of practising HWWS at the WHO-recommended critical times – before cooking, before serving food, before feeding children, before eating, after cleaning children and after using toilet-was created. For constructing the index, a value of ‘1’ for highest score of self-reported handwashing practice with soap at critical times was assigned, whereas a value of ‘0’ was assigned if hands were not washed with soap and water. Subsequently, the values were summed up and divided by the total number of indicators so that our index lay between 0 and 1. A value closer to 1 represents higher likelihood of knowing about HWWS at the critical times. This variable will henceforth be termed as the ‘HWWS knowledge index’. In the similar lines, another index, based on the practice of HWWS at WHO-recommended critical times was also created, which is termed as the ‘HWWS practice index’ (practice of HWWS index). Knowledge < Practice referred to the HWWS practice index was higher than the HWWS knowledge index and Knowledge > Practice implied that the HWWS practice index was lower than the HWWS knowledge index.
As a summary measure to understand the gap in handwashing knowledge and practice, ratios of the HWWS practice index to the HWWS knowledge index (HWWS practice index/HWWS knowledge index) have been shown.
Dependent variables
The gap between knowledge and practice of HWWS at critical times was categorised into Knowledge < Practice, Knowledge = Practice and Knowledge > Practice. This was also used as the dependent variable for the multivariate analysis.
Independent variables
The Sustainable Development Goal (SDG) service ladder defines basic hand hygiene service as availability of a handwashing facility with soap and water at home. Households that have a handwashing facility but lack water and/or soap are classified as having limited hygiene services. The highest educational level of the respondents was categorized as no education, up to primary, up to secondary and secondary and above. The religion variable was sub-categorized into Hinduism, Islam and Others comprising Christianity, Jainism and Buddhism. The social category was further sub-categorized as scheduled caste (SC), scheduled tribe (ST), other backward class (OBC) and others. The main water source was sub-categorized as improved sources such as piped water at home/yard/neighbour's home, public tap, tube well, unimproved sources such as dug well, protected well, unprotected well, protected spring, unprotected spring, tanker/truck/at water surface and others. The toilet facility was sub-grouped into no facility/open defecation, flush/pour flush toilet, pit latrine and composting toilet. The drainage system was classified into none, open drain, soap pit/magic pit, covered drain and connected to a sewer. The main handwashing facility was classified as no arrangement/at water source, wash basin with running/stored water, fixed place in the premises with water stored in buckets/mugs/jugs/bottles, etc. tap water without a basin, tube well, others along with tippy tap.
Multinomial logistic regression
A multinomial logistic regression analysis was run to assess the factors associated with the gap in knowledge and practice of HWWS at critical times as the dependent variables controlling for socio-economic factors. The dependent variable was coded as Knowledge < Practice – 0, Knowledge = Practice – 1 and Knowledge > Practice – 2. Different sets of the independent variables were run and evaluated using the lowest Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) values to select the final model. For the selected model, the AIC was 2,379.5 and BIC was 2,603.5.
Ethical considerations
The study was done by SIGMA Foundation, Kolkata in collaboration with UNICEF Country Office. Ethical approval was sought from the internal review committee. Verbal informed consent was obtained from the participants before conducting the household interviews. The enumerators read out the informed consent form to make the respondents aware of the general objectives of the study. They also stated that participation in the study was voluntary and they could withdraw from the interview at any point of time or they could skip certain questions. Confidentiality in data handling was strictly maintained. Due to the ongoing pandemic situation, the field investigators made sure to follow COVID-appropriate protocols during the field survey.
RESULTS
Socio-economic characteristics of respondents from household survey
Table 2 presents the socio-economic characteristics of the respondents and the handwashing infrastructure in their households. Overall, around 90% of the households had access to improved water source (37.9% piped water, 13.1% public taps/pipes and 38.2% tube well). The districts with low FHTC coverage had lower access to improved water sources as compared to the districts with high FHTC coverage (χ2 value = 100.9, p < 0.01). More than half of the households had an arrangement of water stored in a fixed place in the premises with stored water in buckets/mugs/jugs, etc. 11.8% of them had no arrangement/water source and 17.8% of them had a washbasin with stored/running water. The majority (65.1%) of the main handwashing facilities in the low FHTC coverage districts were a fixed place in the premises with water stored in buckets/mugs/jugs/bottles, etc. as compared to one-fourth of the households located in the high FHTC coverage districts with tube well and wash basin as the main handwashing facility.
Descriptive statistics of socio-economic characteristics and handwashing infrastructure
Socio-economic characteristics and handwashing infrastructure . | n . | % . |
---|---|---|
Age of the respondent (in years) | ||
18–29 | 304 | 20.1 |
30–49 | 773 | 51.1 |
50–85 | 437 | 28.9 |
Sex of the respondent | ||
Male | 493 | 32.5 |
Female | 1,023 | 67.5 |
Highest educational level of household head | ||
No education | 451 | 29.8 |
Primary | 338 | 22.3 |
Secondary | 509 | 33.6 |
Higher secondary | 218 | 14.4 |
Religion | ||
Hindu | 1,255 | 83 |
Muslim | 182 | 12 |
Others | 76 | 5 |
Social category | ||
Scheduled caste | 438 | 30 |
Scheduled tribe | 299 | 20.4 |
Other backward class | 215 | 14.7 |
Others | 508 | 34.7 |
MPCE in INR | ||
<3,000 | 269 | 19 |
3,000–5,000 | 452 | 31.9 |
5,000–10,000 | 564 | 39.8 |
Above 10,000 | 132 | 9.3 |
Type of building of household | ||
Kutcha | 334 | 22 |
Semi pucca | 467 | 30.8 |
Pucca | 715 | 47.2 |
Type of main water source | ||
Piped water | 575 | 37.9 |
Public tap/pipe | 198 | 13.1 |
Tubewell | 579 | 38.2 |
Unimproved sources | 164 | 10.8 |
Type of toilet facility | ||
No facility/Open defecation | 372 | 24.7 |
Flush/Pour Flush toilet | 220 | 14.6 |
Pit latrine | 704 | 46.7 |
Composting toilet | 212 | 14.1 |
Access to basic handwashing facility | ||
No | 365 | 24.1 |
Yes | 1,151 | 75.9 |
State | ||
Andhra Pradesh | 303 | 20 |
Assam | 308 | 20.3 |
Maharashtra | 300 | 19.8 |
Odisha | 302 | 19.9 |
West Bengal | 303 | 20 |
Low FHTC coverage | 756 | 49.9 |
High FHTC coverage | 760 | 50.1 |
HH having soap/hand sanitizer available at home | ||
Both soap and hand sanitizer | 679 | 44.8 |
Only soap | 805 | 53.1 |
None | 23 | 1.5 |
Don't know/only hand sanitizer | 8 | 0.5 |
Type of main handwashing facility | ||
No arrangement/at water source | 179 | 11.8 |
Wash basin with stored/running water | 270 | 17.8 |
Tube well | 245 | 16.2 |
Fixed place in the premises with bucket/mug/jug/bottles | 793 | 52.3 |
Others | 29 | 1.9 |
Drainage system | ||
None | 902 | 68 |
Open drain | 147 | 5.4 |
Soak pit/magic pit | 99 | 7.5 |
Covered drain/Connected to a sewer | 179 | 13.5 |
Socio-economic characteristics and handwashing infrastructure . | n . | % . |
---|---|---|
Age of the respondent (in years) | ||
18–29 | 304 | 20.1 |
30–49 | 773 | 51.1 |
50–85 | 437 | 28.9 |
Sex of the respondent | ||
Male | 493 | 32.5 |
Female | 1,023 | 67.5 |
Highest educational level of household head | ||
No education | 451 | 29.8 |
Primary | 338 | 22.3 |
Secondary | 509 | 33.6 |
Higher secondary | 218 | 14.4 |
Religion | ||
Hindu | 1,255 | 83 |
Muslim | 182 | 12 |
Others | 76 | 5 |
Social category | ||
Scheduled caste | 438 | 30 |
Scheduled tribe | 299 | 20.4 |
Other backward class | 215 | 14.7 |
Others | 508 | 34.7 |
MPCE in INR | ||
<3,000 | 269 | 19 |
3,000–5,000 | 452 | 31.9 |
5,000–10,000 | 564 | 39.8 |
Above 10,000 | 132 | 9.3 |
Type of building of household | ||
Kutcha | 334 | 22 |
Semi pucca | 467 | 30.8 |
Pucca | 715 | 47.2 |
Type of main water source | ||
Piped water | 575 | 37.9 |
Public tap/pipe | 198 | 13.1 |
Tubewell | 579 | 38.2 |
Unimproved sources | 164 | 10.8 |
Type of toilet facility | ||
No facility/Open defecation | 372 | 24.7 |
Flush/Pour Flush toilet | 220 | 14.6 |
Pit latrine | 704 | 46.7 |
Composting toilet | 212 | 14.1 |
Access to basic handwashing facility | ||
No | 365 | 24.1 |
Yes | 1,151 | 75.9 |
State | ||
Andhra Pradesh | 303 | 20 |
Assam | 308 | 20.3 |
Maharashtra | 300 | 19.8 |
Odisha | 302 | 19.9 |
West Bengal | 303 | 20 |
Low FHTC coverage | 756 | 49.9 |
High FHTC coverage | 760 | 50.1 |
HH having soap/hand sanitizer available at home | ||
Both soap and hand sanitizer | 679 | 44.8 |
Only soap | 805 | 53.1 |
None | 23 | 1.5 |
Don't know/only hand sanitizer | 8 | 0.5 |
Type of main handwashing facility | ||
No arrangement/at water source | 179 | 11.8 |
Wash basin with stored/running water | 270 | 17.8 |
Tube well | 245 | 16.2 |
Fixed place in the premises with bucket/mug/jug/bottles | 793 | 52.3 |
Others | 29 | 1.9 |
Drainage system | ||
None | 902 | 68 |
Open drain | 147 | 5.4 |
Soak pit/magic pit | 99 | 7.5 |
Covered drain/Connected to a sewer | 179 | 13.5 |
Findings suggest that three-fourths of the sampled households had basic handwashing facilities ranging from 95.4% in Andhra Pradesh to 63.3% in Maharashtra. Overall, 1% of the households had limited handwashing facilities. The share of basic handwashing facilities differed significantly across the districts belonging to the low and high FHTC coverage, respectively (72 vs. 80%; χ2 value = 13, p < 0.01) (figures not shown).
Knowledge of hand hygiene
Table 3 presents the socio-economic variations and Appendix 1 (Supplementary material) presents the geographical variations in the knowledge related to hand hygiene among the respondents.
Knowledge related to hand hygiene by socio-economic characteristics
Independent variables . | Anti-bacterial soap is required for handwashing (%) . | Alcohol content should be >60% in hand sanitizer (%) . | Using soap reduces chance of disease transmission (%) . | Don't know how many seconds to invest for handwashing (%) . | Could explain all the steps of HWWS(%) . |
---|---|---|---|---|---|
Sex of the respondent | |||||
Male | 41.3 | 21.9 | 92.3 | 22.3 | 30.8 |
Female | 45.1 | 19.8 | 91 | 24.4 | 29.6 |
Age of the respondent | |||||
< 30 years | 49.1 | 26 | 93.1 | 14.1 | 32.6 |
30–44 years | 43.3 | 21.6 | 91.9 | 23.2 | 30 |
45–59 years | 43.1 | 17.9 | 88.4 | 27.4 | 29 |
> 60 years | 38.7 | 14.3 | 93.9 | 32.1 | 28.6 |
Highest educational level | |||||
No education | 37.6 | 9.3 | 87.4 | 39 | 19.3 |
Primary | 43 | 17.2 | 89.9 | 24.6 | 26.3 |
Secondary | 44.7 | 23.4 | 93.7 | 15.9 | 33.6 |
Higher secondary | 55.7 | 41.7 | 96.8 | 9.2 | 49.5 |
Religion | |||||
Hindu | 44.5 | 19.5 | 92.4 | 23.7 | 26.5 |
Muslim | 35.8 | 21.4 | 82.4 | 22.5 | 46.2 |
Others | 53.4 | 34.2 | 98.7 | 27.6 | 50 |
Social category | |||||
Scheduled caste | 44.8 | 24 | 90.2 | 20.6 | 29.2 |
Scheduled tribe | 33.7 | 7.7 | 91.3 | 39.5 | 18.1 |
Other backward classes | 43.9 | 20.5 | 96.3 | 16.7 | 27 |
Others | 47.1 | 25.4 | 91.5 | 19.5 | 40.6 |
MPCE | |||||
Below INR 3,000 | 43.2 | 22.7 | 89.6 | 34.6 | 31.2 |
INR 3,000–5,000 | 40.5 | 18.6 | 94.9 | 25.2 | 31.6 |
INR 5,000–10,000 | 45.7 | 21.3 | 91.8 | 18.6 | 28.2 |
Above INR 10,000 | 57.9 | 25.8 | 88.6 | 12.9 | 24.2 |
Total | 43.9 | 20.5 | 92.1 | 23.7 | 30 |
Independent variables . | Anti-bacterial soap is required for handwashing (%) . | Alcohol content should be >60% in hand sanitizer (%) . | Using soap reduces chance of disease transmission (%) . | Don't know how many seconds to invest for handwashing (%) . | Could explain all the steps of HWWS(%) . |
---|---|---|---|---|---|
Sex of the respondent | |||||
Male | 41.3 | 21.9 | 92.3 | 22.3 | 30.8 |
Female | 45.1 | 19.8 | 91 | 24.4 | 29.6 |
Age of the respondent | |||||
< 30 years | 49.1 | 26 | 93.1 | 14.1 | 32.6 |
30–44 years | 43.3 | 21.6 | 91.9 | 23.2 | 30 |
45–59 years | 43.1 | 17.9 | 88.4 | 27.4 | 29 |
> 60 years | 38.7 | 14.3 | 93.9 | 32.1 | 28.6 |
Highest educational level | |||||
No education | 37.6 | 9.3 | 87.4 | 39 | 19.3 |
Primary | 43 | 17.2 | 89.9 | 24.6 | 26.3 |
Secondary | 44.7 | 23.4 | 93.7 | 15.9 | 33.6 |
Higher secondary | 55.7 | 41.7 | 96.8 | 9.2 | 49.5 |
Religion | |||||
Hindu | 44.5 | 19.5 | 92.4 | 23.7 | 26.5 |
Muslim | 35.8 | 21.4 | 82.4 | 22.5 | 46.2 |
Others | 53.4 | 34.2 | 98.7 | 27.6 | 50 |
Social category | |||||
Scheduled caste | 44.8 | 24 | 90.2 | 20.6 | 29.2 |
Scheduled tribe | 33.7 | 7.7 | 91.3 | 39.5 | 18.1 |
Other backward classes | 43.9 | 20.5 | 96.3 | 16.7 | 27 |
Others | 47.1 | 25.4 | 91.5 | 19.5 | 40.6 |
MPCE | |||||
Below INR 3,000 | 43.2 | 22.7 | 89.6 | 34.6 | 31.2 |
INR 3,000–5,000 | 40.5 | 18.6 | 94.9 | 25.2 | 31.6 |
INR 5,000–10,000 | 45.7 | 21.3 | 91.8 | 18.6 | 28.2 |
Above INR 10,000 | 57.9 | 25.8 | 88.6 | 12.9 | 24.2 |
Total | 43.9 | 20.5 | 92.1 | 23.7 | 30 |
Knowledge on illness prevention
Nearly all of the respondents (91.4%) knew that washing hands with soap reduces the chance of transmission of many diseases including COVID-19 – more than 95% in Chittoor, Krishna both in Andhra Pradesh and Nashik in Maharashtra to 85% both in Barpeta in Assam and Ganjam in Odisha. The knowledge on illness prevention varied significantly across the educational groups (no education 87.4% and higher secondary 96.8%, χ2 value = 29.6, p < 0.01).
Knowledge on soap and hand sanitizer for effective hand hygiene
Respondents were asked about their knowledge of the type of soap that should be used for effective handwashing. 43.9% of the respondents stated that anti-bacterial soaps should be used, whereas 7.6% of them stated that any kind of soap can be used for effective handwashing. The district-wise distribution suggests that the majority of the respondents in Ganjam (81.1%) and Rayagada (69.8%), both in Odisha, stated that anti-bacterial soaps should be used for effective handwashing. In contrast to this, 33.3% of the respondents in Barpeta in Assam and 16.8% in Puruliya in West Bengal stated that any kind of soap can be used for effective handwashing.
Knowledge on the time invested for handwashing per occasion
Almost one-fourth of the respondents were unaware of the time required for handwashing per occasion. Moreover, the minimum time that should be invested for handwashing per occasion as reported by the respondents varied from 27.8% of them stating up to 20 s, whereas it was 25.7% who reported more than 30 s and 23.8% of them did not know, 55% of the respondents belonging to South 24 Parganas stated that the minimum time required for handwashing was up to 20 s, whereas 53.3% of them in Palghar in Maharashtra did not know the answer. 45.3% (53.3% in Palghar and 37.3% in Nashik) of the respondents in Maharashtra did not know how much time should be spent on handwashing per occasion. Nearly one-fourth of the respondents in each of the districts of Andhra Pradesh and Odisha did not know the same. The knowledge of the time required for handwashing per occasion was more among the higher educated respondents (χ2 value = 116.6, p < 0.01). For example, 39% of the uneducated respondents did not know how many seconds one should invest for handwashing every time. The corresponding figure for the higher educated respondents was 15.9% for those above secondary and 9.2% completing higher secondary.
Knowledge on demonstration of handwashing steps
Percent distribution of respondents with correct knowledge of steps of HWWS.
Knowledge on extended critical times of HWWS
Practice of handwashing
Frequency of handwashing and time invested for handwashing
Overall, the mean frequency of handwashing in a day excluding bathing was 6–7 times and HWWS was 4 times. Handwashing varied between 6 and 8 times a day while HWWS varied between 2 and 5 times a day across the districts (Supplementary material, Appendix 2). At the same time, frequency of handwashing was positively associated with higher educational levels and higher economic groups (Table 4).
Percent distribution of frequency of handwashing and ratio of HWWS practice and knowledge indices by socio-economic characteristics
. | Frequency of handwashing in a day excluding bathing . | Frequency of handwashing in a day with soap and water excluding bathing . | Ratio of practice and knowledge index . |
---|---|---|---|
Sex of the respondent | |||
Male | 6 | 3 | 0.5 |
Female | 7 | 4 | 0.57 |
Age of the respondent | |||
<30 years | 7 | 4 | 0.57 |
30–44 years | 6 | 4 | 0.67 |
45–59 years | 7 | 4 | 0.57 |
>60 years | 7 | 4 | 0.57 |
Highest educational level | |||
No education | 6 | 3 | 0.50 |
Primary | 7 | 3 | 0.43 |
Secondary | 7 | 4 | 0.57 |
Higher Secondary | 7 | 4 | 0.57 |
Religion | |||
Hindu | 7 | 4 | 0.57 |
Muslim | 7 | 4 | 0.57 |
Others | 6 | 4 | 0.67 |
Social category | |||
Scheduled Caste | 7 | 4 | 0.57 |
Scheduled Tribe | 6 | 3 | 0.50 |
Other backward classes | 7 | 4 | 0.57 |
Others | 7 | 4 | 0.57 |
MPCE | |||
Below INR 3,000 | 6 | 3 | 0.50 |
INR 3,000–5,000 | 6 | 3 | 0.50 |
INR 5,000–10,000 | 7 | 4 | 0.57 |
Above INR 10,000 | 8 | 4 | 0.5 |
. | Frequency of handwashing in a day excluding bathing . | Frequency of handwashing in a day with soap and water excluding bathing . | Ratio of practice and knowledge index . |
---|---|---|---|
Sex of the respondent | |||
Male | 6 | 3 | 0.5 |
Female | 7 | 4 | 0.57 |
Age of the respondent | |||
<30 years | 7 | 4 | 0.57 |
30–44 years | 6 | 4 | 0.67 |
45–59 years | 7 | 4 | 0.57 |
>60 years | 7 | 4 | 0.57 |
Highest educational level | |||
No education | 6 | 3 | 0.50 |
Primary | 7 | 3 | 0.43 |
Secondary | 7 | 4 | 0.57 |
Higher Secondary | 7 | 4 | 0.57 |
Religion | |||
Hindu | 7 | 4 | 0.57 |
Muslim | 7 | 4 | 0.57 |
Others | 6 | 4 | 0.67 |
Social category | |||
Scheduled Caste | 7 | 4 | 0.57 |
Scheduled Tribe | 6 | 3 | 0.50 |
Other backward classes | 7 | 4 | 0.57 |
Others | 7 | 4 | 0.57 |
MPCE | |||
Below INR 3,000 | 6 | 3 | 0.50 |
INR 3,000–5,000 | 6 | 3 | 0.50 |
INR 5,000–10,000 | 7 | 4 | 0.57 |
Above INR 10,000 | 8 | 4 | 0.5 |
The majority of the respondents (61%) washed their hands for more than 30 s – varying from 77% in Assam to 49% in West Bengal. Washing hands for more than 30 s varied from 83.3% in Rayagada in Odisha and 16% in Nashik in Maharashtra across the districts. About one-fifth of the respondents washed their hands for 10 s, varying from 56% in Maharashtra to 8% in Assam. Across the districts, this varied from 63.8% in Nashik, 44.1% in Palghar in Maharashtra to less than 10% in Chittoor, Barpeta, Rayagada and Puruliya.
Handwashing at extended critical times
To ascertain whether the respondents washed their hands at different extended critical times in the last 24 h, they were asked about what they used to wash their hands in the last 24 h preceding the survey. Almost all the respondents stated that they washed their hands in the last 24 h at all the extended critical times (barring one-third of the respondents who did not wash their hands after sneezing/coughing) and it varied somewhat by the sex of the respondents. Females were more likely to practice handwashing at critical times of handwashing, particularly those critical times involving children and cleaning/serving food (Table 5). However, handwashing at certain critical times varied widely across the states – after returning home from outside, children washing hands after returning home from outside, after coming in contact with a sick person, after cleaning children and after sneezing. The largest difference in the handwashing practice across the states was observed in the case of after sneezing/coughing – 34% in Odisha, 44.5% in Maharashtra to more than 60% on the remaining states (Supplementary material, Appendix 3).
Percent distribution of timings and handwashing practices at extended critical times by socio-economic characteristics
Independent variables . | More than 30 s invested for handwashing per occasion (%) . | Handwashing at extended critical times (%) . | ||||||
---|---|---|---|---|---|---|---|---|
Before cooking food . | Before serving food . | Before feeding children . | After cleaning children . | Returning home from outside-Children . | Contact with a sick person . | After sneezing/coughing . | ||
Sex of the respondent | ||||||||
Male | 64.2 | 93.5 | 95.2 | 97.8 | 86.4 | 93.9 | 90 | 64.2 |
Female | 59.5 | 98.1 | 97 | 98.2 | 96 | 95.8 | 93 | 65.7 |
Age of the respondent | ||||||||
< 30 years | 61.0 | 98.2 | 96 | 98.5 | 93.4 | 97.1 | 90.7 | 62.1 |
30–44 years | 57.7 | 98.1 | 96 | 98.3 | 98.1 | 97.2 | 91 | 61.2 |
45–59 years | 62.0 | 97.4 | 98 | 98 | – | 96.7 | 93.1 | 69.1 |
> 60 years | 69.1 | 96.2 | 100 | – | – | 95.2 | 95.1 | 73.5 |
Highest educational level | ||||||||
No education | 60.2 | 97.9 | 96.7 | 97.8 | 92.5 | 94.4 | 90.9 | 63 |
Primary | 61.6 | 96.4 | 97 | 96 | 94.3 | 96.3 | 87.7 | 54.8 |
Secondary | 59.2 | 98.3 | 97.3 | 99.3 | 93.9 | 95.9 | 95.4 | 65.6 |
Higher Secondary | 65.3 | 98.3 | 95.4 | 98.5 | 100 | 98.6 | 92.2 | 83.5 |
Religion | ||||||||
Hindu | 59.2 | 98 | 96.6 | 97.7 | 93.9 | 96.3 | 90.5 | 61.5 |
Muslim | 70.6 | 96.1 | 98.9 | – | 96.7 | 92.4 | 98.8 | 78.1 |
Others | 66.1 | 98.5 | 97.6 | – | – | 100 | 100 | 89.5 |
Social category | ||||||||
Scheduled Caste | 60.6 | 98.3 | 98.6 | 96.5 | 94.4 | 95.2 | 86.9 | 58.8 |
Scheduled Tribe | 436 | 98.5 | 96.9 | 100 | 92.3 | 99.2 | 90.3 | 70.9 |
Other backward classes | 62.6 | 96.5 | 95 | 98.2 | – | 94.5 | 88.1 | 70.8 |
Others | 65.3 | 97.3 | 97.3 | 98.5 | 98 | 96.1 | 99.4 | 80.3 |
MPCE | ||||||||
Below INR 3,000 | 70.1 | 95.7 | 98.6 | 100 | 93.3 | 98.2 | 96.5 | 58.4 |
INR 3,000–5,000 | 61.9 | 98.4 | 96 | 98.3 | 94.2 | 96.6 | 94 | 63.7 |
INR 5,000–10,000 | 56.7 | 98 | 97.3 | 97.2 | 95.2 | 95 | 89.8 | 69.3 |
Above INR 10,000 | 50.4 | 97.8 | 94.7 | 100 | – | 94.1 | 88.2 | 70.8 |
Independent variables . | More than 30 s invested for handwashing per occasion (%) . | Handwashing at extended critical times (%) . | ||||||
---|---|---|---|---|---|---|---|---|
Before cooking food . | Before serving food . | Before feeding children . | After cleaning children . | Returning home from outside-Children . | Contact with a sick person . | After sneezing/coughing . | ||
Sex of the respondent | ||||||||
Male | 64.2 | 93.5 | 95.2 | 97.8 | 86.4 | 93.9 | 90 | 64.2 |
Female | 59.5 | 98.1 | 97 | 98.2 | 96 | 95.8 | 93 | 65.7 |
Age of the respondent | ||||||||
< 30 years | 61.0 | 98.2 | 96 | 98.5 | 93.4 | 97.1 | 90.7 | 62.1 |
30–44 years | 57.7 | 98.1 | 96 | 98.3 | 98.1 | 97.2 | 91 | 61.2 |
45–59 years | 62.0 | 97.4 | 98 | 98 | – | 96.7 | 93.1 | 69.1 |
> 60 years | 69.1 | 96.2 | 100 | – | – | 95.2 | 95.1 | 73.5 |
Highest educational level | ||||||||
No education | 60.2 | 97.9 | 96.7 | 97.8 | 92.5 | 94.4 | 90.9 | 63 |
Primary | 61.6 | 96.4 | 97 | 96 | 94.3 | 96.3 | 87.7 | 54.8 |
Secondary | 59.2 | 98.3 | 97.3 | 99.3 | 93.9 | 95.9 | 95.4 | 65.6 |
Higher Secondary | 65.3 | 98.3 | 95.4 | 98.5 | 100 | 98.6 | 92.2 | 83.5 |
Religion | ||||||||
Hindu | 59.2 | 98 | 96.6 | 97.7 | 93.9 | 96.3 | 90.5 | 61.5 |
Muslim | 70.6 | 96.1 | 98.9 | – | 96.7 | 92.4 | 98.8 | 78.1 |
Others | 66.1 | 98.5 | 97.6 | – | – | 100 | 100 | 89.5 |
Social category | ||||||||
Scheduled Caste | 60.6 | 98.3 | 98.6 | 96.5 | 94.4 | 95.2 | 86.9 | 58.8 |
Scheduled Tribe | 436 | 98.5 | 96.9 | 100 | 92.3 | 99.2 | 90.3 | 70.9 |
Other backward classes | 62.6 | 96.5 | 95 | 98.2 | – | 94.5 | 88.1 | 70.8 |
Others | 65.3 | 97.3 | 97.3 | 98.5 | 98 | 96.1 | 99.4 | 80.3 |
MPCE | ||||||||
Below INR 3,000 | 70.1 | 95.7 | 98.6 | 100 | 93.3 | 98.2 | 96.5 | 58.4 |
INR 3,000–5,000 | 61.9 | 98.4 | 96 | 98.3 | 94.2 | 96.6 | 94 | 63.7 |
INR 5,000–10,000 | 56.7 | 98 | 97.3 | 97.2 | 95.2 | 95 | 89.8 | 69.3 |
Above INR 10,000 | 50.4 | 97.8 | 94.7 | 100 | – | 94.1 | 88.2 | 70.8 |
Handwashing with soap and water
Percent distribution of handwashing substance used for handwashing at critical times in the last 24 h.
Percent distribution of handwashing substance used for handwashing at critical times in the last 24 h.
The proportion of respondents who used soap and water at different critical times in the last 24 h preceding the survey differed widely across the states (Supplementary material, Appendix 4). For illustration, three-fourths of the respondents in Andhra Pradesh washed their hands with soap and water before serving food, before and after eating meals in contrast to 9.5% in Maharashtra. Before feeding the children, one-fourth of the respondents in Maharashtra washed their hands with soap and water while three-fourths of their counterparts in Andhra Pradesh washed their hands with soap and water. It was observed that less than 60% of the respondents washed their hands after returning home from outside in Assam, Maharashtra and West Bengal.
Drying of hands after handwashing
44% of the respondents used a common hanging towel kept at the place of handwashing for drying hands, 28.3% of them used personal handkerchief/towel, 17% of them wiped their hands in worn clothes, 3% used fresh towels, whereas 8% kept as it is. 71.3% of the respondents in Nashik used a common hanging towel for drying hands as compared to 30.3% in Chittoor and Puruliya who used the similar technique for washing hands. Almost half of the respondents from Andhra Pradesh used personal towels for drying their hands. Around two-fifths of the respondents wipe their hands in their worn clothes.
Handwashing (HWWS) knowledge and HWWS practice index
HWWS knowledge index
Gap between knowledge and practice of HWWS at critical times by socio-economic characteristics
Independent variables . | HWWS knowledge index . | HWWS practice index . | Ratio of HWWS practice to knowledge index . | t-test/ANOVA . | Knowledge < Practice . | Knowledge = Practice . | Knowledge > Practice . | χ2 statistic . |
---|---|---|---|---|---|---|---|---|
Sex of the respondent | 0.86 | 35.0*** | ||||||
Male | 0.38 | 0.27 | 0.71 | 0.11 | 14.6 | 38.3 | 47.1 | |
Female | 0.5 | 0.4 | 0.8 | 0.1 | 24.0 | 25.0 | 51.0 | |
Age of the respondent | 3.93*** | 32.3*** | ||||||
< 30 years | 0.49 | 0.43 | 0.88 | 0.06 | 30.1 | 21.4 | 48.0 | |
30–44 years | 0.47 | 0.35 | 0.74 | 0.12 | 19.7 | 29.3 | 50.9 | |
45–59 years | 0.45 | 0.34 | 0.76 | 0.11 | 16.2 | 35.7 | 48.0 | |
> 60 years | 0.43 | 0.31 | 0.72 | 0.12 | 19.4 | 28.1 | 52.6 | |
Highest educational level | 2.31* | 5.9 | ||||||
No education | 0.41 | 0.33 | 0.80 | 0.08 | 23.3 | 28.8 | 47.9 | |
Primary | 0.44 | 0.33 | 0.75 | 0.11 | 18.9 | 29.9 | 51.2 | |
Secondary | 0.5 | 0.38 | 0.76 | 0.12 | 19.5 | 31.4 | 49.1 | |
Higher Secondary | 0.53 | 0.4 | 0.75 | 0.13 | 22.5 | 24.8 | 52.8 | |
Religion | 2.7* | 2.0 | ||||||
Hindu | 0.45 | 0.35 | 0.78 | 0.1 | 21.1 | 29.0 | 49.9 | |
Muslim | 0.51 | 0.36 | 0.71 | 0.15 | 17.6 | 32.4 | 50 | |
Others | 0.61 | 0.51 | 0.84 | 0.1 | 23.7 | 29.0 | 47.4 | |
Social category | 0.8 | 7.6 | ||||||
Scheduled caste | 0.45 | 0.36 | 0.8 | 0.09 | 20.1 | 30.4 | 49.5 | |
Scheduled tribe | 0.41 | 0.3 | 0.73 | 0.11 | 17.7 | 25.8 | 56.5 | |
Other backward classes | 0.48 | 0.36 | 0.75 | 0.12 | 22.8 | 30.7 | 46.5 | |
Others | 0.5 | 0.39 | 0.78 | 0.11 | 22.1 | 30.1 | 47.8 | |
MPCE | 8.55*** | 38.5*** | ||||||
< INR 3,000 | 0.47 | 0.37 | 0.79 | 0.1 | 19.0 | 32.0 | 49.1 | |
INR 3,000–5,000 | 0.48 | 0.33 | 0.69 | 0.15 | 17.3 | 22.8 | 60.0 | |
INR 5,000–10,000 | 0.45 | 0.37 | 0.82 | 0.08 | 21.3 | 32.5 | 46.3 | |
> INR 10,000 | 0.43 | 0.39 | 0.91 | 0.04 | 33.3 | 31.1 | 35.6 | |
Access to basic handwashing facility | 11.2*** | 23.6*** | ||||||
No | 0.42 | 0.27 | 0.64 | 0.15 | 13.4 | 26.9 | 59.7 | |
Yes | 0.48 | 0.39 | 0.81 | 0.09 | 23.3 | 30.2 | 46.6 | |
Total | 0.46 | 0.36 | 0.78 | 14.8*** | 20.9 | 29.4 | 49.7 |
Independent variables . | HWWS knowledge index . | HWWS practice index . | Ratio of HWWS practice to knowledge index . | t-test/ANOVA . | Knowledge < Practice . | Knowledge = Practice . | Knowledge > Practice . | χ2 statistic . |
---|---|---|---|---|---|---|---|---|
Sex of the respondent | 0.86 | 35.0*** | ||||||
Male | 0.38 | 0.27 | 0.71 | 0.11 | 14.6 | 38.3 | 47.1 | |
Female | 0.5 | 0.4 | 0.8 | 0.1 | 24.0 | 25.0 | 51.0 | |
Age of the respondent | 3.93*** | 32.3*** | ||||||
< 30 years | 0.49 | 0.43 | 0.88 | 0.06 | 30.1 | 21.4 | 48.0 | |
30–44 years | 0.47 | 0.35 | 0.74 | 0.12 | 19.7 | 29.3 | 50.9 | |
45–59 years | 0.45 | 0.34 | 0.76 | 0.11 | 16.2 | 35.7 | 48.0 | |
> 60 years | 0.43 | 0.31 | 0.72 | 0.12 | 19.4 | 28.1 | 52.6 | |
Highest educational level | 2.31* | 5.9 | ||||||
No education | 0.41 | 0.33 | 0.80 | 0.08 | 23.3 | 28.8 | 47.9 | |
Primary | 0.44 | 0.33 | 0.75 | 0.11 | 18.9 | 29.9 | 51.2 | |
Secondary | 0.5 | 0.38 | 0.76 | 0.12 | 19.5 | 31.4 | 49.1 | |
Higher Secondary | 0.53 | 0.4 | 0.75 | 0.13 | 22.5 | 24.8 | 52.8 | |
Religion | 2.7* | 2.0 | ||||||
Hindu | 0.45 | 0.35 | 0.78 | 0.1 | 21.1 | 29.0 | 49.9 | |
Muslim | 0.51 | 0.36 | 0.71 | 0.15 | 17.6 | 32.4 | 50 | |
Others | 0.61 | 0.51 | 0.84 | 0.1 | 23.7 | 29.0 | 47.4 | |
Social category | 0.8 | 7.6 | ||||||
Scheduled caste | 0.45 | 0.36 | 0.8 | 0.09 | 20.1 | 30.4 | 49.5 | |
Scheduled tribe | 0.41 | 0.3 | 0.73 | 0.11 | 17.7 | 25.8 | 56.5 | |
Other backward classes | 0.48 | 0.36 | 0.75 | 0.12 | 22.8 | 30.7 | 46.5 | |
Others | 0.5 | 0.39 | 0.78 | 0.11 | 22.1 | 30.1 | 47.8 | |
MPCE | 8.55*** | 38.5*** | ||||||
< INR 3,000 | 0.47 | 0.37 | 0.79 | 0.1 | 19.0 | 32.0 | 49.1 | |
INR 3,000–5,000 | 0.48 | 0.33 | 0.69 | 0.15 | 17.3 | 22.8 | 60.0 | |
INR 5,000–10,000 | 0.45 | 0.37 | 0.82 | 0.08 | 21.3 | 32.5 | 46.3 | |
> INR 10,000 | 0.43 | 0.39 | 0.91 | 0.04 | 33.3 | 31.1 | 35.6 | |
Access to basic handwashing facility | 11.2*** | 23.6*** | ||||||
No | 0.42 | 0.27 | 0.64 | 0.15 | 13.4 | 26.9 | 59.7 | |
Yes | 0.48 | 0.39 | 0.81 | 0.09 | 23.3 | 30.2 | 46.6 | |
Total | 0.46 | 0.36 | 0.78 | 14.8*** | 20.9 | 29.4 | 49.7 |
Note: *** and * denote statistical significance at p < 0.01 and p < 0.1, respectively.
Gap in the HWWS knowledge index and the HWWS practice index by states.
HWWS practice index
Overall, the mean value of the HWWS practice index was estimated as 0.36. The HWWS practice index was highest in Andhra Pradesh (0.46), followed by Assam (0.43), and was lowest in Maharashtra (0.21), followed by West Bengal (0.3) and Odisha (0.39) (Figure 4). Across the districts, it laid between 0.19 in Nashik to 0.52 in Krishna in Andhra Pradesh (Supplementary material, Appendix 6). Furthermore, the HWWS practice index was higher among females (0.4) than the males (0.27). Along the similar lines, it was inversely associated with age and positively associated with higher educational levels (Table 6).
Gap in knowledge and practice of HWWS
The correlation coefficient between the HWWS knowledge index and HWWS practice index was estimated as 0.36 (p < 0.01), suggesting that the translation between the knowledge regarding critical times of handwashing to actual practising was moderate. Overall, the gap between HWWS knowledge and practice indices at critical times was 0.1 (p < 0.01). Among the states, the gap between the knowledge and practice indices was highest in Maharashtra (0.19 in Palghar and 0.18 in Nashik). The HWWS practice index was lower than the HWWS knowledge index for 50% of the sampled households, whereas the HWWS knowledge index and HWWS practice index was equal for 29.4% of the respondents. For the educational categories, although both knowledge and practice were higher among higher educated respondents, results suggested the gap was also positively associated with higher educational levels (Table 6). Similarly, both knowledge and practice indices were higher among the females and households having access to basic handwashing facilities. The practice of handwashing without having knowledge of handwashing was higher in females. However, the gap in handwashing practice and knowledge was higher in females. The HWWS knowledge and practice indices were higher for the younger population along with a lower gap in handwashing practice and knowledge as compared to older ages.
Practice of HWWS at critical times in the last 24 h based on knowledge of extended critical times of handwashing.
Practice of HWWS at critical times in the last 24 h based on knowledge of extended critical times of handwashing.
Table 7 depicts the results of the predicted probabilities of the multiple logistic regression with gap in knowledge and practice of HWWS at critical times as the dependent variable. Findings revealed that the predicted probability of the gap between the HWWS practice index and HWWS knowledge index at critical times was proportionally associated with having a basic handwashing facility present at home. In other words, practice of handwashing was higher in households having basic handwashing facilities available. In fact, the probability of handwashing practice was higher if handwashing infrastructure were readily available for the households. Handwashing practice was higher in instances where the household members had received messages on hand hygiene. A significant sex-differential was noted in the gap between knowledge and practice of HWWS at critical times. The female respondents were less likely to practice handwashing than their male counterparts even if they had knowledge on the importance of HWWS. However, they were more likely to wash their hands with soap and water even in the case of not possessing the proper knowledge of hand hygiene. More highly educated members were less likely to practice handwashing even if they possessed knowledge on hand hygiene. Furthermore, the younger population were more likely to practice handwashing as compared to the older age groups.
Predicted probabilities of multinomial logistic regression with gap between knowledge and practice of HWWS as the dependent variable
Independent variables . | Knowledge < Practice . | Knowledge = Practice . | Knowledge > Practice . |
---|---|---|---|
Sex of the respondent | |||
Male | 0.15*** | 0.38*** | 0.47*** |
Female | 0.23*** | 0.25*** | 0.52*** |
Age of the respondent (in years) | |||
18–29 | 0.31*** | 0.25*** | 0.45*** |
30–44 | 0.18*** | 0.30*** | 0.51*** |
45–59 | 0.16*** | 0.32*** | 0.52*** |
>60 | 0.18*** | 0.25*** | 0.57*** |
Highest educational level of household head | |||
No education | 0.27*** | 0.30*** | 0.43*** |
Primary | 0.21*** | 0.28*** | 0.50*** |
Secondary | 0.17*** | 0.31*** | 0.52*** |
Higher secondary | 0.18*** | 0.22*** | 0.60*** |
Religion | |||
Hindu | 0.21*** | 0.29*** | 0.50*** |
Muslim | 0.14*** | 0.29*** | 0.57*** |
Others | 0.24*** | 0.26*** | 0.49*** |
Social category | |||
Scheduled caste | 0.18*** | 0.32*** | 0.50*** |
Scheduled tribe | 0.20*** | 0.25*** | 0.56*** |
Other backward class | 0.19*** | 0.31*** | 0.50*** |
Others | 0.24*** | 0.28*** | 0.48*** |
MPCE in INR | |||
<3,000 | 0.19*** | 0.35*** | 0.46*** |
3,000–5,000 | 0.19*** | 0.23*** | 0.57*** |
5,000–10,000 | 0.20*** | 0.30*** | 0.50*** |
>10,000 | 0.27*** | 0.32*** | 0.41*** |
Access to basic handwashing facility | |||
No | 0.13*** | 0.26*** | 0.60*** |
Yes | 0.22*** | 0.30*** | 0.48*** |
Received messages on hand hygiene importance | |||
No | 0.24*** | 0.30*** | 0.45*** |
Yes | 0.19*** | 0.29*** | 0.52*** |
Households having under-five children | |||
No | 0.20*** | 0.31*** | 0.49*** |
Yes | 0.22*** | 0.24*** | 0.54*** |
Thinks handwashing is necessary | |||
No | 0.24*** | 0.30*** | 0.45*** |
Yes | 0.19*** | 0.29*** | 0.52*** |
Handwashing infrastructure availability | |||
None | 0.06* | 0.38*** | 0.56*** |
All | 0.32*** | 0.26*** | 0.42*** |
Most | 0.21*** | 0.31*** | 0.49*** |
Some | 0.12*** | 0.30*** | 0.59*** |
Independent variables . | Knowledge < Practice . | Knowledge = Practice . | Knowledge > Practice . |
---|---|---|---|
Sex of the respondent | |||
Male | 0.15*** | 0.38*** | 0.47*** |
Female | 0.23*** | 0.25*** | 0.52*** |
Age of the respondent (in years) | |||
18–29 | 0.31*** | 0.25*** | 0.45*** |
30–44 | 0.18*** | 0.30*** | 0.51*** |
45–59 | 0.16*** | 0.32*** | 0.52*** |
>60 | 0.18*** | 0.25*** | 0.57*** |
Highest educational level of household head | |||
No education | 0.27*** | 0.30*** | 0.43*** |
Primary | 0.21*** | 0.28*** | 0.50*** |
Secondary | 0.17*** | 0.31*** | 0.52*** |
Higher secondary | 0.18*** | 0.22*** | 0.60*** |
Religion | |||
Hindu | 0.21*** | 0.29*** | 0.50*** |
Muslim | 0.14*** | 0.29*** | 0.57*** |
Others | 0.24*** | 0.26*** | 0.49*** |
Social category | |||
Scheduled caste | 0.18*** | 0.32*** | 0.50*** |
Scheduled tribe | 0.20*** | 0.25*** | 0.56*** |
Other backward class | 0.19*** | 0.31*** | 0.50*** |
Others | 0.24*** | 0.28*** | 0.48*** |
MPCE in INR | |||
<3,000 | 0.19*** | 0.35*** | 0.46*** |
3,000–5,000 | 0.19*** | 0.23*** | 0.57*** |
5,000–10,000 | 0.20*** | 0.30*** | 0.50*** |
>10,000 | 0.27*** | 0.32*** | 0.41*** |
Access to basic handwashing facility | |||
No | 0.13*** | 0.26*** | 0.60*** |
Yes | 0.22*** | 0.30*** | 0.48*** |
Received messages on hand hygiene importance | |||
No | 0.24*** | 0.30*** | 0.45*** |
Yes | 0.19*** | 0.29*** | 0.52*** |
Households having under-five children | |||
No | 0.20*** | 0.31*** | 0.49*** |
Yes | 0.22*** | 0.24*** | 0.54*** |
Thinks handwashing is necessary | |||
No | 0.24*** | 0.30*** | 0.45*** |
Yes | 0.19*** | 0.29*** | 0.52*** |
Handwashing infrastructure availability | |||
None | 0.06* | 0.38*** | 0.56*** |
All | 0.32*** | 0.26*** | 0.42*** |
Most | 0.21*** | 0.31*** | 0.49*** |
Some | 0.12*** | 0.30*** | 0.59*** |
Note: *** and * denote statistical significance at p < 0.01 and p < 0.1, respectively.
DISCUSSION
While research on handwashing in communities has expanded in recent times, mostly after the COVID-19 pandemic, there is still a paucity of studies in rural India focusing on the gap in knowledge and practice of hand hygiene. While the illness prevention aspect of hand hygiene was nearly universal, less than one-fourth of the respondents were aware of the time required for handwashing per occasion. Along similar lines, the knowledge of the correct steps of handwashing was also quite low. On one hand, 30% of the respondents could explain all the seven steps of HWWS. On the other hand, around 15% of them could not explain a single step and less than half of them could explain more than any three steps of HWWS. The greater portion of the respondents lacked knowledge on lathering and drying steps. The knowledge of critical times of handwashing was found low. In general, the knowledge related to hand hygiene was better in high FHTC districts than the low FHTC districts.
Considering handwashing at times apart from the WHO-recommended critical times, the respondents were aware of handwashing after returning home from outside (62%), before taking food (77%) and after using the toilet (79%). On the contrary, the knowledge of handwashing related to dealing with feeding and cleaning children was found to be low. This could arise due to lower awareness regarding handwashing before feeding children or after cleaning the child's faeces. Another reason could be that as most of the respondents did not have children under five at home, it was difficult for them to recollect child-related hand hygiene. Broadly, the knowledge of handwashing was better among the younger (<40 years) respondents and females and was also positively associated with higher educational levels.
The inadequacy in the knowledge level is also in accordance with the self-reported practices of the respondents. In fact, previous studies also pointed out that reported knowledge and attitudes regarding hand hygiene do not always necessarily translate into reported practices (Mwesigye et al. 2022). On the whole, the practice of HWWS was worse than the knowledge level. Handwashing with soap and water remained high after toilet use, cleaning home/handling garbage and coming back home from outside. However, half of them used only water to wash their hands after taking meals, before serving food, whenever hands seemed dirty and before eating or cooking. This was in consensus with the recent evidence of handwashing practices with soap and water in rural India which also concluded that practising handwashing varies considerably by socio-economic characteristics and is worse for the socio-economically disadvantaged groups (IIIPS & ICF 2017; MSPI 2018; Pradhan & Mondal 2021; Biswas & Karmakar 2022). As compared to the prior studies, there was an improvement in the HWWS post defaecation and anal cleaning practices (Hoque 2003). However, the frequency of handwashing at most of the critical times did not vary significantly across the states but HWWS varied across the states at the critical times. In fact, many existing studies herald that having a sanitation facility at home improves the handwashing behaviour in the community. For drying hands, two-fifths of the respondents used a common hanging towel kept at the place of handwashing, one-fourth of them used personal handkerchief/towel, whereas 17% of them wiped their hands on worn clothes.
A considerable gap in the knowledge of HWWS existed, particularly in the cases of after sneezing/coughing, before taking meals and before serving meals and before cooking. Similar such studies also outlined that handwashing with only water was more common at most of the occasions as hands visually seeming clean is sufficient for the people to decipher that they are maintaining proper hand hygiene (Halder et al. 2010; Rabbi & Dey 2013; WaterAid India 2017). The gap between the HWWS practice index and HWWS knowledge index was nominal by high and low FHTC districts. Among the states, both the HWWS knowledge index and practice indices were better in Andhra Pradesh and Assam and worse in Maharashtra and West Bengal. The gap in the HWWS practice and knowledge indices was smaller in states with high HWWS practice and knowledge indices. However, the handwashing practice in Odisha was better than the overall knowledge of handwashing. Females were more likely to practice handwashing at the critical times of handwashing, particularly for those critical times involving children and cleaning/serving food. Along similar lines, a substantial gap between knowledge and practice of HWWS was found across socio-economic and demographic characteristics including variations across the districts. For both females and higher educated groups, although the HWWS practice index was higher than their counterparts, the gaps in HWWS practice and knowledge indices were higher for them.
Besides improving the handwashing infrastructure, there is a simultaneous need for triggering behaviour changes through Social and Behavioural Change Communication (SBCC) in the community, which is a long process. This could be done through strengthening the Information, Education & Communication (IEC) component and awareness generation campaigning by the government and the non-government organizations or at a public-private partnership with the help of field-workers such as ASHAs, community level volunteers and anganwadi workers. Innovative ways of spreading messages on hand hygiene, messaging through advertisement in the television, newspaper, social media and radio can also be taken up. The women and children in the family should be targeted to promote hand hygiene in order to make hand hygiene programming sustainable.
CONCLUSION
This is one of the first studies conducted in five states of rural India which attempted to study the gap between handwashing knowledge and practice in the domestic settings. The findings demonstrated that the knowledge of different aspects of hand hygiene and practice of HWWS at critical times varied by socio-economic characteristics of the respondents and varied widely across the districts/states. Most of the respondents were aware of handwashing after using the toilet and before eating – among other WHO-recommended critical times of handwashing. HWWS was mostly restricted to after using the toilet, cleaning garbage and returning home from outside. However, handwashing with only water was more common with children-related activities or before cooking or taking meals. Around two-fourths of the respondents used hanging towels at the place of handwashing after washing their hands. Though the frequency of handwashing excluding bathing in a day was found to be modest, using soap per occasion, particularly at critical times, remained low. The gap between practice of HWWS and associated knowledge was found moderate. It was higher in higher educated people and women and the gap was lower in younger population.
DATA AVAILABILITY STATEMENT
All relevant data are included in the paper or its Supplementary Information.
CONFLICT OF INTEREST
The authors declare there is no conflict.
Correct demonstration of handwashing with soap and water involves the following steps: wet hands with water, apply soap, lather hands/back of hands/fingers/nails, washing hands and drying hands.