Barriers to and motivators of handwashing behavior among mothers of neonates in rural Bangladesh.

BACKGROUND: To design a maternal handwashing intervention for the newborn period, this qualitative study explored drivers of handwashing among mothers and other caregivers of neonates and infants in two rural areas of Bangladesh. METHODS: We conducted 40 semi-structured observation sessions to observe handwashing behaviors of primiparous and multiparous mothers of neonates, and to understand the contextual factors that facilitated or hampered those behaviors. We then conducted 64 interviews with mothers of neonates and mothers of infants and 6 group discussions with mothers of infants, other female caregivers and fathers to explore perceptions, beliefs, and practices related to handwashing in the neonatal period. Based on a conceptual model and the Theory of Reasoned Action/Theory of Planned Behavior, we developed a conceptual model a priori, we performed thematic analysis to explain determinants of maternal handwashing behaviors. RESULTS: We conducted 200 h of observation among mothers of neonates. The age range of participating mothers varied between 17 and 25 years and their maximum education was up to 10th grade of schooling. Mothers, other female caregivers and fathers perceived a need to wash hands with or without soap before eating or before feeding a child by hand to prevent diarrhea. Mothers expressed the importance of washing their hands before holding a baby but were rarely observed doing so. All respondents prioritized using soap for visible dirt or feces; otherwise, water alone was considered sufficient. Lack of family support, social norms of infrequent handwashing, perceptions of frequent contact with water as a health threat and mothers' restricted movement during first 40 days of neonate's life, and childcare and household responsibilities adversely impacted handwashing behavior. CONCLUSIONS: Addressing emotive drivers of handwashing within existing social norms by engaging family members, ensuring handwashing facilities and clarifying neonatal health threats may improve maternal handwashing behavior in the neonatal period.

Is pregnancy a teachable moment to promote handwashing with soap among primiparous women in rural Bangladesh? Follow-up of a randomised controlled trial.

OBJECTIVE: Promoting handwashing with soap to mothers of young children can significantly reduce diarrhoea and pneumonia morbidity among children, but studies that measured long-term behaviour after interventions rarely found improvements in handwashing habits. Expecting mothers may experience emotional and social changes that create a unique environment that may encourage adoption of improved handwashing habits. The objective of this study was to determine whether exposure to an intensive handwashing intervention in the perinatal period (perinatal arm) was associated with improved maternal handwashing behaviour vs. exposure to the same intervention after the end of the perinatal period (post-neonatal arm). METHODS: We identified primiparous women previously enrolled a randomised controlled handwashing intervention trial (November 2010-December 2011) and observed handwashing behaviours at the home 1-14 months after completion of the RCT (January-May 2012). We observed maternal handwashing and estimated the prevalence ratio (PR) of maternal handwashing using log-binomial regression. RESULTS: We enrolled 107 mothers in the perinatal arm and 105 mothers in the post-neonatal arm. Handwashing with soap at recommended times was low overall (4.6%) and comparable between arms (PR = 0.9, 95% CI 0.5, 1.5). CONCLUSIONS: This handwashing intervention was unable to develop and establish improved handwashing practices in primiparous women in rural Bangladesh. While pregnancy may present an opportunity and motivation to do so, further studies should assess whether social, individual and environmental influences overcome this motivation and prevent handwashing with soap among new mothers.