Comparing the performance of indicators of hand-washing practices in rural Indian households

Summary objective To compare the results obtained from 26 proxy indicators of domestic hand-washingpractices with those obtained from direct, ‘structured’ observation of hand-washing in a sample of 387households and to assess the potential of these indicators for use in the evaluation of hygiene promotioncampaigns.methods Fieldwork in rural India between February 2005 and April 2006. Household-level dataon hand-washing practices and the availability of soap and water were collected by structuredobservation, questionnaire survey, pocket voting, hand-wash demonstration and environmental check.Between them these techniques produced 27 binary indicators of hand-washing practices, each ofwhich was used to classify households as ‘hand-washing’ or ‘non-hand-washing. To assess the extentto which household classification based on each of 26 proxy indicators concurred with classificationbased on observation, we used the kappa statistic. The prevalence of households defined as ‘hand-washing’ according to each indicator was compared statistically with the prevalence according tostructured observations by testing for a significant difference between two proportions.results Agreement between all the proxy indicators and the observation data was poor and all but twoof the indicators produced estimates of hand-washing prevalence that were significantly different fromthat resulting from observation.conclusion Although some interventions may be able to use proxy indicators as a guide to themagnitude and direction of their impact, these indicators do not provide an accurate guide to the actualpractice or prevalence of hand-washing. Structured observation remains the best indicator of thosetested.keywords hygiene, hand-washingIntroductionDiarrhoeal disease is a major public health problem thatwas estimated to have caused 2.2 million child deathsaround the globe in 2000 (Kosek et al. 2003), althoughdiarrhoeal infections can be prevented by the promotion ofsafe hygiene practices (Esrey et al. 1985; Huttly et al.1997). Hand-washing with soap in particular could sub-stantially reduce the risk of diarrhoeal infection (Curtis C Rabie & Curtis 2005).Whilst the promotion of hand-washing in the domesticsetting has nominally figured in public health effortsaround the world for many years, hand-washing ratesremain very low (typically 2–10%; Scott et al. 2003) andthere is a growing realisation that this issue deserves morefocused attention and investment. Programmes such as thePublic-Private Partnership for Hand Washing with Soap(http://www.globalhandwashing.org), the HygieneImprovement Project (http://www.HIP.watsan.net) andwork by UNICEF and others seek to substantially increaserates of hand-washing with soap among child carers,children and their families in poor settings around theworld.However, such programmes have great difficulty inmeasuring the impact they have had on the targetedbehaviours. There is no simple, easily employed andreliable indicator of whether hands have been washed withsoap at critical times or not (Curtis et al. 1993). Self-reports of hand-washing practices in response to verbal