Research Article: Handwashing in 51 Countries: Analysis of Proxy Measures of Handwashing Behavior in Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 2010–2013

Date Published: August 02, 2017

Publisher: The American Society of Tropical Medicine and Hygiene

Author(s): Swapna Kumar, Libbet Loughnan, Rolf Luyendijk, Orlando Hernandez, Merri Weinger, Fred Arnold, Pavani K. Ram.


In 2009, a common set of questions addressing handwashing behavior was introduced into nationally representative Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), providing large amounts of comparable data from numerous countries worldwide. The objective of this analysis is to describe global handwashing patterns using two proxy indicators for handwashing behavior from 51 DHS and MICS surveys conducted in 2010–2013: availability of soap anywhere in the dwelling and access to a handwashing place with soap and water. Data were also examined across geographic regions, wealth quintiles, and rural versus urban settings. We found large disparities for both indicators across regions, and even among countries within the same World Health Organization region. Within countries, households in lower wealth quintiles and in rural areas were less likely to have soap anywhere in the dwelling and at designated handwashing locations than households in higher wealth quintiles and urban areas. In addition, disparities existed among various geographic regions within countries. This analysis demonstrates the need to promote access to handwashing materials and placement at handwashing locations in the dwelling, particularly in poorer, rural areas where children are more vulnerable to handwashing-preventable syndromes such as pneumonia and diarrhea.

Partial Text

Pneumonia and diarrheal disease are leading causes of postneonatal child mortality, accounting for approximately 1.6 million child deaths worldwide in 2013.1,2 Even as mortality due to both diseases has been declining, morbidity remains high, with an estimated 1.7 billion episodes of diarrhea and 120 million episodes of pneumonia among children less than 5 years old in 2010.3 These illnesses lead not only to preventable mortality but also to health-care seeking, financial costs for families, and lost caloric intake for children. Repeated episodes of diarrhea have been associated with poor growth outcomes and neurocognitive deficits.4–6 Recent evidence suggests that children living in households with relatively poor environmental conditions are more likely to have signs consistent with environmental enteropathy and growth faltering.7 Handwashing with soap can reduce the risk of diarrhea episodes by 30–47% and respiratory infections by 23%.8–12 The available evidence using structured observation methods in households in several low- and middle-income countries suggests that handwashing behavior must be improved substantially.13,14 However, in most countries where high child morbidity results from handwashing-preventable infections, there is little data on handwashing behavior. Though studies of household handwashing behavior have been conducted sporadically worldwide, there has been no systematic method of data collection to allow for comparison of handwashing behavior across regions, and identification of national and subnational populations where child mortality and morbidity remain high and where particular need exists with respect to handwashing promotion.15 Without meaningful and globally comparable data, it is difficult for governments and international organizations to prioritize handwashing as a public health tool.

In household MICS and DHS surveys, interviewers recorded the presence of soap and water at a place for handwashing by asking the respondent to “Please show me where members of your household most often wash their hands.” For households in which a place for handwashing was observed, interviewers recorded the presence of soap (soap or detergent in a bar, liquid, powder, or paste form), other cleansing agents (such as ash, mud, or sand), and water. If a handwashing place could not be observed, interviewers recorded the reason for the nonobservation, including whether the household refused permission to observe the place. In households in which soap was not observed at a place for handwashing, interviewers in MICS surveys assessed the availability of soap anywhere in the dwelling by asking the respondent “Do you have any soap or detergent (or other locally used cleansing agent) in your household for washing hands?” If yes, the respondent was asked to show the soap to the interviewer.

Between 2010 and 2013, 28 MICS and 23 DHS with standard handwashing indicators became available for analysis. Of the 51 surveys, three were from the Western Pacific Region, five from the southeast Asian Region, six from the Eastern Mediterranean Region, seven from the European Region, 25 from the Africa Region, and five from the Region of the Americas. We identified seven surveys that were conducted among subpopulations and, thus, were not nationally representative: the Roma population of Serbia (Serbia, Roma), the Roma population of Bosnia and Herzegovina (Bosnia/Herzegovina, Roma), south Madagascar (Madagascar, south), the Nyanza Province of Kenya (Kenya, Nyanza), mid and far western Nepal (Nepal, mid and far western), the Balochistan Region of Pakistan (Pakistan, Balochistan), and the Punjab Region of Pakistan (Pakistan, Punjab). The total number of households in nationally representative surveys ranged from 4,223 in Equatorial Guinea to 43,852 in Indonesia, whereas the total number of households in subpopulation surveys ranged from 1,544 in the Roma population of Bosnia and Herzegovina to 95,238 in the Punjab Region of Pakistan (Table 1).

Our analyses of proxy measures of handwashing from 51 DHS and MICS household surveys, together with information from an analysis of 42 studies demonstrating that only 19% of people wash their hands after fecal contact when observed,14 highlight the need to improve handwashing with soap globally to reduce the continued high burden of diarrhea and pneumonia morbidity and mortality. The overwhelming majority of under-five deaths occur in low- and middle-income countries, with about three-quarters of all child deaths occurring in sub-Saharan Africa and South Asia.30 Under-five mortality is highest in rural areas and among poorer and less educated communities.31 In particular, children in sub-Saharan Africa are nearly 14 times as likely to die before the age of five as children in high-income countries.30 A sizable proportion of these deaths are due to preventable causes including diarrhea and pneumonia, both of which can be reduced by handwashing with soap.1 The DHS and MICS surveys indicate that soap for handwashing is least likely to be found in households in the Africa Region. Moreover, fixed handwashing places with soap and water were infrequently observed in most African countries, along with some countries in southeast Asia, Western Pacific, and the Americas, indicating that promotion of handwashing as a preventive measure is not only necessary for lower-income countries, but also in higher-income countries where disparities still exist and could also have adverse sequelae.

Handwashing with soap can substantially reduce the prevalence of pneumonia and diarrhea, two leading causes of child morbidity and mortality worldwide. Our analysis of data from 51 recent household surveys worldwide indicates a substantial need to increase availability of soap for handwashing, and to promote placement of soap and water at fixed handwashing places for many households to increase handwashing with soap. The need is particularly pressing among poorer households and households in rural areas where children may be at greatest risk for preventable mortality. However, this analysis also shows that disparities persist even in higher-income countries. The preventive potential of handwashing with soap was not addressed in the Millennium Development Goals, which expired in 2015. With their focus on equity and the incorporation of handwashing into Sustainable Development Goal target 6.2, the post-2015 Sustainable Development Goals have the potential to substantively level the access to preventive measures, such as soap for handwashing, to promote child survival, health, and growth.41




Leave a Reply

Your email address will not be published.