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R E S E A R C H A R T I C L E Open Access
Designing a handwashing station for
infrastructure-restricted communities in
Bangladesh using the integrated behavioural
model for water, sanitation and hygiene
interventions (IBM-WASH)
Kristyna RS Hulland
1
, Elli Leontsini
1
, Robert Dreibelbis
1*
, Leanne Unicomb
2
, Aasma Afroz
2
, Notan Chandra Dutta
2
,
Fosiul Alam Nizame
2
, Stephen P Luby
2,4
, Pavani K Ram
3
and Peter J Winch
1
Abstract
Background: In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and
mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted
settings remain low. Handwashing stations –a dedicated, convenient location where both soap and water are
available for handwashing –are associated with improved handwashing practices. Our aim was to identify a locally
feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized
trials testing the health effects of this behaviour.
Methods: We conducted formative research in the form of household trials of improved practices in urban and rural
Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two
iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits
over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and
Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the
IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific
handwashing station designs.
Results: Factors that influenced selection of candidate designs were market availability of low cost, durable materials
that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity,
ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific
handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a
handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and
detergent powder for pilot testing in preparation for the subsequent randomized trials.
(Continued on next page)
* Correspondence: rdreibel@jhsph.edu
1
Social and Behavioral Interventions Program, Department of International
Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,
USA
Full list of author information is available at the end of the article
© 2013 Hulland et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Hulland et al. BMC Public Health 2013, 13:877
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(Continued from previous page)
Conclusions: A number of contextual, psychosocial and technological factors influence use of handwashing stations at
five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent
handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household
are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-
WASH helped guide the research and research in-turn helped validate the framework.
Keywords: formative research, Qualitative methods, Trials of improved practices, Handwashing, Hygiene behaviour,
Behaviour change, Behavioural model, Handwashing technology, Enabling technology, Handwashing station, Soapy
water, Feasibility, Acceptability
Background
Introduction
Poor water quality and hygiene are major contributors
to the spread of diarrhoeal disease and acute respira-
tory infections (ARI). Estimates suggest that in 2011
there were 1.3 million ARI-related deaths and 700,000
diarrhoea-related deaths among children under the age
of five [1]. Handwashing with soap has been shown to
significantlyreducetheincidenceofbothrespiratory
infections and diarrhoea. In a meta-analysis of three
systematic reviews, handwashing with soap was shown
to reduce risk of diarrhoeal disease by 48 per cent [2],
and another meta-analysis showed reduced risk of res-
piratory infections by 21 per cent [3].
Based on a review of formative research activities
from eleven countries, Curtis et al. organized factors
that affect handwashing behaviour into two categories:
environmental and “brain”factors [4]. Environmental
factors include social, physical and biological influences
that shape handwashing behaviours. Physical factors, in
particular, include the cost of soap, water, and access to
handwashing stands [4,5]. In Kenya, Schmidt et al. [6]
found that “structural constraints”–such as access to
water inside, rather than outside, the home - influences
the likelihood of handwashing at key times. Findings
from Zimbabwe suggest that altering norms and com-
munity structures in support of positive hygiene beha-
viours can have a positive impact on behavioural
outcomes [7].
The “brain”–or cognitive –factors that influence be-
haviours include an individual’s habits, planning and
motivation for behavioural change [4]. Research in
Kenya found that study participants reporting a higher
degree of handwashing habit and past experience with
handwashing had improved handwashing practices du-
ring structured observations compared to those who
reported less-developed habits [8]. Past behaviours
along with motivational factors such as disgust, social
concerns, and feelings of being a good mother were
found to influence individual handwashing practices
in Ghana [9]. Planned behaviours –those behaviours
intended to avoid a specific negative health outcome –
are often associated with health and disease knowledge.
Studies have demonstrated an increase in handwashing
practices with improved knowledge of key moments for
handwashing [10].
A handwashing station may facilitate behaviour by
providing soap and water together in an established
location convenient to the behaviour, such as near a
toilet or in a food preparation area [5,11]. In addition to
establishing a designated place for handwashing, the
design of the handwashing station influences use. The
Water and Sanitation Program’s (WSP) Global Scaling
Up Handwashing Project has compiled a database of
handwashing station designs and enabling technologies
[12] and links the physical attributes of products to
behaviour [13]. Devine reported that characteristics,
such as tap design, soap presentation, and container
parameters, influenced acceptability of the handwashing
station in Vietnam [14].
The purpose of this study was to inform the design of
a handwashing station for two subsequent randomized-
controlled trials (RCTs) in Bangladesh testing the health
effects of handwashing. Data on handwashing and
hygiene practices in the country showed that there was
considerable room for improvement: in a population-
based, cross-sectional survey, only 14% of people washed
both hands with soap after defecation during five hours
of structured observation [15]. In a sample of over 1,000
villages in rural Bangladesh, 72% of households had
access to water after using the toilet, yet only 42% had
access to soap as well [11]. Having both soap and water
available at the place for handwashing after toileting
was associated with a two-fold increase in handwashing
with soap after faecal contact [16].
Methods
Guiding theoretical framework
The Integrated Behavioural Model for Water, Sanitation
and Hygiene interventions or IBM-WASH [17], outlined
in Figure 1, presents a synthesis of behavioural models
related to water, sanitation, and hygiene (WASH) and
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organizes factors that affect behaviour in an ecological
framework. The IBM-WASH identifies three dimensions
Contextual Factors (e.g., access to water and soap),
Psychosocial Factors (e.g., disgust related to contact with
unclean objects, perceived risk of disease, pre-existing
habit, etc.), and Technological Factors (i.e., related to the
physical hardware storing soap and water) –each of
which function at five aggregate levels: habitual, indivi-
dual, interpersonal/household, community and societal/
structural [17].
We used the factors outlined in the IBM-WASH to
guide selection of candidate designs and qualitative data
analysis. Factors represented in the IBM-WASH frame-
work informed thematic coding of interview transcripts,
and contextualized feasibility and acceptability of spe-
cific handwashing station designs. In turn, the results of
this research process helped validate the application of
the IBM-WASH framework to a specific technology-
supported behavioural outcome.
Definition and selection of candidate handwashing
technologies and soap formulations
We defined a handwashing station as a dedicated, con-
venient location where both soap and water are available
for handwashing. We considered the contextual factors
at the societal/structural and community levels of the
IBM-WASH framework during technology selection
(Figure 1). Because the subsequent intervention was
intended for use in resource-constrained settings, can-
didate handwashing stations were low-cost (between
USD 0.07 and 6.50), simple technologies made with few
moving parts, self-contained, and did not require electri-
city for operation. Parts and supplies needed to be easily
replaceable from existing materials in the household or
easily purchased locally.
Soap was valuable, scarce, and often stored far away
from the water to ration its use. During initial direct ob-
servations/transect walks in potential study areas, we ob-
served that some households were using soapy water in
a bottle placed near their water source instead of bar
soap, in order to minimize waste and prevent soap theft.
Soapy water was therefore included as a candidate soap
formulation, either as part of a handwashing station de-
sign, or to convert the household’s water source into a
complete handwashing station when placed nearby.
We tested a total of seven handwashing station designs
in two phases (see Trials of improved practices below for
details on phases). Details on each of the following de-
signs are presented in Figure 2:
Phase 1 designs:
30 Litre drum with tap and soap container
2.25 Litre Bodna (pot with spout traditionally used
for anal cleansing after toileting) with soap cup
2 Litre Bottle (water only) with a valve cap and soap
container
1.5 Litre Soapy water bottle with a hole in the cap
for dispensing (placed at the water source)
Phase 2 designs:
1.5 Litre Soapy water bottle with pump (placed at
the water source)
40 Litre Bucket with tap, 10 L basin, stool used as a
stand, and soapy water bottle
Levels Contextual
Factors
Psychosocial
Factors
Technology
Factors
Societal/
Structural
Policy and regulations, climate and
geography
Leadership/advocacy, cultural
identity
Manufacturing, financing, and
distribution of the product; current
and past national policies and
promotion of products
Community
Access to markets, access to
resources, built and physical
environment
Shared values, collective efficacy,
social integration, stigma
Location, access, availability,
individual vs. collective
ownership/access, and maintenance
of the product
Interpersonal/
Household
Roles and responsibilities, household
structure, division of labour,
available space
Injunctive norms, descriptive norms,
aspirations, shame, nurture
Sharing of access to product,
modelling/demonstration of use of
product
Individual Wealth, age, education, gender,
livelihoods/employment
Self-efficacy, knowledge, disgust,
perceived threat
Perceived cost, value, convenience,
and other strengths and weaknesses
of the product
Habitual
Favourable environment for habit
formation, opportunity for and
barriers to repetition of behaviour
Existing water and sanitation habits,
outcome expectations
Ease/Effectiveness of routine use of
product
Figure 1 Integrated behavioural model for water, sanitation and hygiene (IBM-WASH). The IBM-WASH outlines key factors that influence
behaviours in water, sanitation and hygiene interventions. These behavioural factors are organized by cell, suggesting the level and domain
(Contextual, Psychosocial, Technology) in which factors operate (Dreibelbis et al. submitted for publication).
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Photo Name
(Capacity)
Description of design
Drum
(30 L)
The drum is a plastic barrel with a turn-handle water-dispensing
spout. A plastic soap container encases a standard sized bar of
soap (0.28 USD). This technology was selected because running
water from the tap allows for washing of both hands and
approximates the functionality of a sink with running water. This
design did not have a waste water receptacle.
Bodna
(2.25 L)
A bodna is a round-bottomed, wide mouthed vessel with a spout,
commonly used in Bangladesh for cleansing after defecation.
Similar vessels are referred to as lota in Pakistan and India. A
plastic soap cup covered the mouth of the bodna and held a
standard sized bar of soap. We tested the bodna because it is a
commonly available, low-cost household item that is familiar to
most Bangladeshis.
Bottle
with valve
(2 L)
The bottles used for this technology are reclaimed 2 litre plastic
soda bottles with a plastic and rubber valve cap. Water is dispensed
from the inverted bottle when the rubber valve is pushed up. The
bottle was installed in a metal holster which also held a standard
sized bar of soap. The purpose of this design was to use locally
available materials for compact, urban handwashing stations.
Soapy
water
bottle
(1.5 L)
Consists of reclaimed 1.5-liter water bottles. In the top of each
Single-load packets of detergent powder ( ~0.03 USD) were mixed
with water to make soapy water for handwashing. This
bottle’s original cap a small hole is drilled to dispense the liquid.
combination was tested because it provides soap and water in a
single package, produced with low-cost local materials.
Soapy
water
bottle with
pump
(1.5 L)
Modification of soapy water bottle (Design #4 above). A
translucent 1.5 litre bottle of more durable plastic replaced the
bottle in Design #4. Instead of a twist-on cap with a hole, a plastic
pump topped the bottle. The same, single load detergent packets
were used to make soapy water.
40L
Bucket (40
L)
Designs #6 and #7are similar. Developed in response to the success
of the drum (Design #1). Consists of a plastic bucket with a lid, a
plastic turn-handle spout, a plastic stool for the bucket to stand on,
and a plastic receptacle for used water. The soapy water bottle
(Design #4) is included.
Kitchen
bucket
(15 L)
This design is a smaller version of design #6 to fit in food
preparation and other areas which lack space for a 40 L
handwashing station. The soapy water bottle (Design #4) is
included.
c
Figure 2 Evaluated handwashing technology designs.
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15 Litre Kitchen bucket with tap, 8 L basin, stand,
and soapy water bottle
Of the seven candidate designs, five were tested in the
urban field site, five in the rural field site, and three de-
signs were tested at both sites.
Study area
Mohammadpur, a sub-district (thana)ofmetropolitan
Dhaka, served as our urban field site. The population re-
sided in densely populated compounds (bashas) consisting
of ten or more families in semi-permanent brick wall
rooms with tin roofs. Households did not necessarily share
familial ties and often shared access to cooking areas,
outside water sources, and sanitation facilities with neigh-
bouring households. The rural study site included house-
holds from Kishoreganj, a district in central Bangladesh
northeast of Dhaka. Households that shared familial rela-
tions were clustered into compounds (baris). Households
typically shared a common courtyard with access to out-
side water source and latrines and usually had their own
cooking facilities. Each site was selected as representative
of infrastructure-restricted, low-income, urban or rural
residence with no or minimal household-level water and
sanitation access.
Selection of study households
In both study sites we prepared a list of all compounds
within each study area. In the urban site (Mohammadpur),
we selected ten compounds through a systematic sample
of every fifth compound (with a random start) to mini-
mize intervention contamination. Within selected com-
pounds, we recruited households with at least one child
under the age of five for participation in the trials. We
identified an average of five households per compound
that met our selection criteria for a total of 50 parti-
cipating households. In the rural site (Kishoreganj), we
identified three clusters of compounds from different geo-
graphic areas of the village to minimize intervention
contamination. Each cluster had ten compounds and an
average of one household per compound that met our
selection criteria of having a child under the age of five for
a total of 29 participating households. A socio-economic
and demographic profile of the study participants is pro-
vided in Table 1.
Trials of improved practices
We tested candidate handwashing stations using trials of
improved practices (TIPs), a formative research metho-
dology. TIPs are used to assess the feasibility and accept-
ability of candidate improved behaviours [18]. The TIPs
methodology has been used to inform a range of beha-
vioural interventions including the development of in-
fant feeding schemes [19], increased bed net usage [20],
and improved corrals and corralling practices to reduce
transmission of diarrhoeal disease associated with do-
mestic animal husbandry [21].
Candidate technologies were assessed in two phases
(Table 2). Phase 1 was characterized by an iterative testing
and design adjustment [14] in which four technologies
were tested: drum with tap and soap container, bodna
with soap, bottle (water only) with valve cap and soap con-
tainer, and soapy water bottle with cap and hole placed by
the water source. Forty of the recruited households in the
urban site participated in Phase 1. Based on preliminary
feedback on the bottle with valve cap, this design was not
tested in the rural areas and all 30 recruited households
participated in Phase 1. Households selected handwashing
station options by lottery whereby household represen-
tatives selected their preferred design in the order in
which names were drawn. After ten households selected a
design, the design was removed from the list of available
options. Following design selection, field research officers
visited the corresponding households and installed it at a
Table 1 Demographic and socio-economic profile of
study participants by site
Urban Rural
n = 50* n = 29
Age
≤25 years 20 10
26-34 years 14 7
35-44 years 7 4
45 to 5 8
Sex
Male 7 6
Female 39 29
Educational level
Illiterate 10 6
Can sign 2 5
≤Grade 5 18 5
Grade6-10 15 12
Upper grade 10 1 1
# of HH members
≤53316
5> 13 13
Profession
Housewife 33 22
Agriculture - 6
Small business 4 -
Service 2 -
Maid/servant 3 -
Other 4 1
* Data could not be obtained for 4 urban households.
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suitable location in consultation with the family. Research
officers demonstrated the design’s use and maintenance
and informed about future visits to seek the family’son-
going consultation with regard to feasibility and accep-
tability based on experience with actual use.
During Phase 1, follow-up semi-structured, qualitative
interviews were completed with the participants within
the week of installing the handwashing station, and then
at days 7, 15, 30 and 45. Interview guides included ques-
tions about handwashing (when and where the behav-
iour was taking place), use of the handwashing station
(where the station was located, how often it was used,
and preferences toward the design) and barriers or facili-
tators to use (see Table 3). In addition, participants were
consulted on technical issues with the new technology,
such as placement of the handwashing station in the
compound or household, maintenance, tap functionality,
and potential leakage.
Findings from Phase 1 were used to inform the im-
proved designs tried in Phase 2. During Phase 2, the
remaining ten recruited urban households which had
not yet tested a design were assigned the soapy water
bottle with a pump. In the rural site, 19 of the participa-
ting households from Phase 1 were assigned either the
40 L bucket with a tap, stand, basin and soapy water bot-
tle with pump, or the 15 L version (Table 2). There was
no lottery in Phase 2. Data collection procedures were
similar during Phase 2, however, there were fewer
follow-up visits and shorter follow-up periods: two
follow-up visits in the urban area over a two week
period, and three or four follow-up visits in the rural
area over a three week period.
Data analysis
Qualitative data from interview transcripts were translated
from Bengali to English. Responses from each household
were compiled for each question in the interview guides,
and then sorted according to each handwashing station
design and study location.
In our analysis we sought to identify key factors making
use of a given handwashing station acceptable and fea-
sible. We defined acceptability to include appropriateness
Table 2 Sites and phases of testing for handwashing
station designs
Study site Phase Handwashing
technology
# households
evaluating
the design
#of
follow-up
visits per
household
Mohammadpur
(urban)
50 households*
1 Drum with tap
and soap
container
10 5
Bodna with
soap cup
10 5
Bottle with
valve cap
10 5
Bottle with
soapy water
10 4
2 Soapy water
bottle with
pump
10 2
Kishoreganj
(rural) 29
households**
1 Drum with
soap container
10 5
Bodna with
soap cup
10 5
Bottle with
soapy water
95
2 15 L Kitchen
bucket with
tap
93
40 Litre bucket
with tap
10 4
* total number of interviews for the urban site: ~210.
** total number of interviews for the rural site: ~220.
Table 3 Interview guide
Question type Sub-question
General questions regarding
handwashing knowledge and
practices
1. Describe your
handwashing practices?
Where and when do you
generally wash hands?
2. Before receiving this
handwashing station how
did you wash your hands?
Questions relating to
handwashing station design
1. What is your reaction to
this handwashing station?
Does it help to wash your
hands? Describe the
advantages?
2. Do you use X
handwashing station? After
what activities are you most
likely to use it?
3. Do all members of your
household wash their hands
with handwashing station?
Who in the household uses
the handwashing station the
most and why?
4. How did your neighbours
react to this hand washing
station? Were they
interested? Did they want
one for their own?
5. Does the handwashing
station help your family
members? Do they like using
it?
Questions identifying issues
surrounding use of the
handwashing station
1. What problems have you
had with the hand washing
station?
2. Was the hand washing
station moved from the place
it was installation?
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and satisfaction with the handwashing station, including
an agreement to install, maintain, and use it to regularly
wash hands. Feasibility referred to whether a handwashing
station design could physically withstand frequent use and
that component parts were replaceable, low-cost and
locally available.
We analysed interview data according to the three main
dimensions (Contextual, Psychosocial, and Technology)
and the five levels of the IBM-WASH framework.
In order to code the qualitative data, four researchers
analysed a subset each of the compiled responses and
coded the transcripts line-by-line to identify key emergent
themes. We compared these initial codes to determinants
in an early iteration of the IBM-WASH framework.
Details of this process of model development and revision
are described in Dreibelbis et al. [17]. Using the refined
constructs from the final iteration of IBM-WASH, we
developed a final codebook for analysis of the interview
data. All compiled responses were coded with the IBM-
WASH-based codebook using Atlas.ti Version 5.2.
Although the iterative phases were informative for
intervention design, we structure our study findings by
the IBM-WASH framework, rather than presenting
results by phase, to emphasize influential behavioural
determinants.
Informed consent
Informed consent was obtained from adult participants
from each household. The study protocol was reviewed
and approved by Ethical Review Committee of icddr,b
(International Centre for Diarrhoeal Disease Research,
Bangladesh).
Results
We first present key factors of the Technology dimen-
sion of the IBM-WASH in detail. We then present key
factors of the Psychosocial and Contextual dimensions.
Following these results, we present the designs finally
selected for use in the subsequent RCTs.
Technology dimension at the habitual level
At the Habitual level, the two most significant factors af-
fecting routine use of the handwashing stations were ease
of use and visual cues. All participants were capable of
using their handwashing stations. However, some partici-
pants specifically noted aspects of the handwashing tech-
nology that made them easy to use. For some, turning a
tap and running water over both hands, as opposed to
pouring water from one hand to the other, made washing
both hands easy. The drum, kitchen bucket and 40 Litre
bucket were especially easy to use because the tap created
a continuous stream of water while washing.
A few participants expressed that children or elderly
members of the household might have difficulty with
using the bottle with valve and the bodna. A few partici-
pants described that pushing or lifting the vessel with
one hand to wash the other hand was difficult, especially
for young children. If the handwashing station was too
difficult to use, caretakers became responsible for hel-
ping the old and young to wash hands.
Several of the handwashing stations served at the same
time as visual cues or reminders for people to wash
hands. Several participants said that seeing the hand-
washing station at certain times, such as after defecation
or before preparing meals, reminded them to wash their
hands. One participant mentioned, “The drum is a re-
minder to wash hands because it is installed near the
toilet”. And another said, “This station (bottle with valve
cap) acts as reminder for us to wash our hands because
it is always in front of us.”
Placement of the handwashing station influenced the
ability of the device to provide visual cues. In most
households, keeping the handwashing device at the toilet
was too far removed from other household activities to
serve as a reminder to wash hands before cooking or
eating. In order to address this problem and to provide
easy access for handwashing inside the house, we tested
the kitchen bucket for use while cleaning, cooking and
eating in the home. One rural participant expressed that
this increased her handwashing practice, saying,
When I am busy with other work, I would not
regularly go to the tubewell [located outside of the
house] to clean my hands before food preparation
because it is placed far away from where I cook. But
now I wash regularly with the kitchen handwashing
station before cooking.
Technology dimension at the individual level
Operating at the Individual level were reactions to the
handwashing station, such as attractiveness and qual-
ity. Participants testing the bottle with metal valve
viewed the reclaimed 2 litre plastic bottle and metal
holster as lacking durability and that the design would
not withstand frequent use. For others, appearance and
perceived value contributed to the acceptability of a
handwashing station in the household. Both the
40-litre bucket and the kitchen bucket were brightly
coloured, and installed complete with a water recep-
tacle and a stool to place the bucket upon. Users re-
ported that these features made these handwashing
stations attractive. Some noted that the water recep-
tacle kept the area surrounding the handwashing sta-
tion clean and dry, and the stool added stability. For
example, one participant said,“All of my family likes
the bucket handwashing station because after washing
hands the waste water is stored in the bowl, and the
handwashing station doesn’t get muddy underneath.”
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Technology dimension at the interpersonal / household level
Operating at the Interpersonal / Household level were
factors influencing how a handwashing station was used
and shared by households and their neighbours.
Because handwashing station designs needed to be
refilled with water and soap, the frequency of regular
maintenance influenced acceptability of the designs.
Handwashing technologies with smaller capacity such as
the bottle with valve, bodna, or soapy water bottle when
used by a large number of people, required frequent
refilling and were not conducive to repeated use through-
out the day. One participant said, “The size of the bottle
[with pump] is small so we need to refill it frequently, but
sometimes we forget.”Most participants using hand-
washing stations with small storage capacities acknow-
ledged that it was not feasible to use the handwashing
station at all key times—after defecation or cleaning a
child’s bottom, and before food preparation or feeding
children.
In the urban field site, several participants mentioned
concerns regarding shared access to a handwashing sta-
tion placed next to a shared latrine and the implications
this had on maintenance among sharing households.
Even with the large storage capacity of the drum, one
urban participant said,
In the last few days, when water and soap have run
out, I have managed to refill it. But our compound
environment is not good. After some time the renters
change, so who will take responsibility? Taking care of
the soap and water is not possible for everybody. There
is no good place to install the drum…[and it] can be
broken. Then, quarrels arise. So, single ownership is
better.
Not only was use and maintenance difficult to nego-
tiate when the handwashing station was accessible to
multiple unrelated households, but theft and damage
were also concerns. Several participants using the bodna,
40 L bucket, and kitchen bucket said they moved the
handwashing station inside at night, so that it would not
be stolen. In both urban and rural sites, the large size of
the soapy water bottle and the use of inexpensive deter-
gent in the mixture was advantageous compared to bar
soap because it was not attractive to steal and was less
likely to be misplaced by children.
Psychosocial dimension
At the Habitual level, past handwashing experiences
influenced current attitudes and practices. Many of our
participants shared that they were not habituated to
using soap and water for handwashing during all key
times. However, some participants noted that their newly
acquired experience of a designated handwashing station
facilitated habit formation. One participant described
how her household’s frequent use of the drum changed
how they felt about handwashing, “In the last few days
we are becoming habituated to hand washing, and now
if we don’t wash our hands then we feel bad.”Several
participants mentioned that though they had past ex-
perience with washing hands after defecation, routine
use of the handwashing station increased their hygiene
habits to include handwashing before cooking and
eating.
At the Individual level, knowledge of handwashing sta-
tion use, self-efficacy, and attitudes toward threats did not
significantly distinguish between handwashing station de-
signs, nor seemed to influence handwashing practice. All
participants knew how to use their handwashing station.
They were fully capable of using the handwashing stations
and soap, indicative of self-efficacy. However, some hand-
washing station designs and locations were preferred or
avoided due to feelings of disgust related of defecation. Be-
cause bodnas are traditionally used for anal cleansing after
defecation, using it as a multipurpose handwashing station
rendered this design unacceptable in both urban and rural
sites. Similarly, placing other handwashing station designs
too close to latrines elicited feelings of disgust when used
for handwashing prior to food preparation, eating, or fee-
ding a child. This was particularly pronounced in those
cases where the handwashing station was in a location
accessible to multiple households.
At the Interpersonal / Household level, participants
explained how different members of the family interacted
with the handwashing stations designs. For example,
mothers often described how their children learned to use
the handwashing station, suggesting that handwashing
was part of a parent’s nurturing role. In addition, partici-
pants in both urban and rural sites alluded to descriptive
norms for handwashing. Though many lacked established
handwashing routines, several participants stated, “Every-
body should wash their hands regularly,”indicating that
some level of hygiene was expected.
Contextual dimension
Age was an important factor in use of the handwashing
station because age often indicated who was in the home
and how easy a handwashing station was to use. A child’s
age and developmental stage was extremely important in
determining acceptability and feasibility. The drum had
low acceptability for some participants because children
might leave the tap running and muddy the floor. Many
participants expressed concerns about children using the
soapy water bottle [Phase 1] because it was too heavy for
young children to lift and they preferred the modified
design with a pump [Phase 2] instead.
At the Interpersonal / Household level, gender roles
and responsibilities of household members played a
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large part in determining handwashing station use and
maintenance. Women came in more frequent contact
with soap and water for household chores than their
male counterparts, were more likely to be in charge of
teaching children to wash hands, and were primarily res-
ponsible for refilling and maintaining the handwashing
station. In both urban and rural sites, several partici-
pants noted that men worked and socialized outside of
the home, so they did not have access to a handwashing
station throughout the day, and their role in main-
tenance was limited.
At the Community level interviews with participants
revealed that the built environment shaped response to
handwashing designs. Access to water had a critical im-
pact on functionality of the handwashing station, espe-
cially in designs with small water storage capacity. In the
urban site, access to water was shared and determined
by electrical pumps drawing from a low pressure and
intermittent municipal supply. One participant described
this problem saying,
“In a slum, our hands become dirty the whole day.
Moreover, electricity is absent, so water is not
available…Water from the bodna is finished after one
person washes his or her hands.”
In the urban site, living quarters were small and
densely arranged. Finding a convenient location to
install a large handwashing station was difficult because
living space was at a premium. One participant noted,
“Our mobility inside the room was interrupted due to
the installation of the handwashing station because it is
congested inside the room.”This was another reason to
test the smaller kitchen bucket.
Lastly, urban households were more likely to be engaged
in income generating activities, and have more access to
urban markets than rural households. Participants in the
urban site often assessed the handwashing station design
they had received in terms of availability of replacement
parts at the market. One participant said that the soapy
water bottle with a pump was not a good option because,
“If it is stolen, we won’t be able to replace it because the
pumper is not available.”Another participant commented
on the feasibility of stocking a handwashing station with
soap if not provided through the study, saying that soap
was expensive and rare in their household.
Selection of the final handwashing station designs for
RCT Pilot testing
Some of the candidate handwashing station designs were
eliminated due to significant factors effecting feasibility
and acceptability. The bottle with valve was not durable
and held small amounts of water; the bodna was asso-
ciated with disgust related to defecation and was deemed
inappropriate for other handwashing purposes; and the
drum was not very attractive, less stable, and left the
area surrounding the handwashing station a muddied
mess. Due to the numerous advantages that the soapy
water bottle designs presented over bar soap —low cost,
easy to make, and not easily stolen, —we included the
soapy water bottle as the method of soap delivery for
use in our final handwashing station designs.
The bucket handwashing stations were also incorpo-
rated into our final handwashing station designs (Figure 3).
They were attractive, had adequate water storage capacity,
and were easy to use. The stand and wastewater receptacle
included added to the handwashing stations’quality. Ac-
cess to more than one handwashing stations was foreseen
as an option for the pilot phase households, in order to
facilitate convenience as well as to overcome the problem
of disgust associated with any station used for toilet-
related handwashing. The 40 litre version was suitable for
outdoor use and large indoor spaces associated more with
locations near a latrine. The 15 litre version was more
suitable for food preparation areas and other tighter
spaces.
Discussion
The study explored factors influencing the feasibility and
acceptability of candidate handwashing station designs
in two infrastructure-restricted settings in Bangladesh,
using the IBM-WASH framework. An acceptable and
Figure 3 Attributes of a successful handwashing station.
Hulland et al. BMC Public Health 2013, 13:877 Page 9 of 12
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feasible handwashing station in our case required more
than the presence of soap and water. Instead, attributes
specific to the handwashing station technology, such as
water storage capacity, durability, and maintenance re-
quirements; contextual factors such as consistent access
to water, the physical location of the technology within a
household’s daily workflow; and psychosocial factors
such as disgust, all contributed to how a handwashing
station facilitated or inhibited handwashing at key times.
Ease of use the physical act of operating the hand-
washing station facilitates habit formation [22], and this
proved an important technology-associated factor in our
case. For women who maintain the home and care for
children, adequate capacity was a major determinant in
acceptability. Attributes specific to handwashing station
technologies have been recognized in programmatic
literature [13,23], and how the design of an acceptable
handwashing station may take several iterations in order
to address context-specific user requirements suc-
cessfully [14]. This was the case in this study as well.
However, in our view, behavioural models on water and
sanitation do an imperfect job of acknowledging factors
associated with the technology, and IBM-WASH [17]
was especially useful in informing the full range of
technology-related influential factors.
The development of the IBM-WASH was concurrent
with this formative research in which we were able to
develop operational definitions of factors and examine in-
teractions between dimensions of the IBM-WASH. Some
of the factors related to the technology and contextual di-
mensions were organized in the framework based on the
data in this paper [17]. In that sense this formative research
in-turn helped validate the IBM-WASH framework.
Regarding contextual factors, provision of a soapy water
bottle without a water storage vessel helped to convert an
existing tube well or hand pump to a handwashing station
where the former provided reliable water access. However,
this did not address the convenience of a second station at
the food preparation area. It soon became evident that
more than one handwashing stations might be required.
This eventuality was not originally anticipated.
Psychosocial factors such as disgust towards faeces has
been described in the literature as a motivator to
handwash [4,24]. In this study, disgust towards faeces
was found to be a barrier to food-related handwashing
when the same handwashing station and soap was used
for faeces-related handwashing. Furthermore, disgust
was found to be a barrier to faeces-related handwashing
if same tap, water, and soap were shared with and
touched by toilet users from other households. Other
psychosocial motivators such as knowledge and self-
efficacy are acknowledged by many behavioural models
[23,25], yet these motivators did not help distinguish
between designs.
Physical attributes of the handwashing station included
in the IBM-WASH and other models [23,24] are essential
to understanding and promoting handwashing with soap
because the behaviour is facilitated by specific products.
For women who maintain the home and care for children,
an adequate capacity was a major determinant in accept-
ability. Previous studies have demonstrated how access to
water influences hygiene practices [26,27], and facilitates
convenient access throughout the day. Though outside
the scope of our intervention, we identified water access
as an important community level factor. Most urban
residents relied on electricity for water access and faced
rolling blackouts each day. In this type of setting, the
ability to store water may underlie the success or failure of
a handwashing station. Expanding these findings to dif-
ferent contexts may also result in similar preference for
water storage capacity. Involving women in the selection
of an acceptable handwashing station in this study helped
to identify some of the barriers to successful handwashing
while underscoring the importance of water access and
convenience to users [28].
Additionally, our findings suggest that handwashing
station components must coexist with the surrounding
household environment. Figueroa and Kincaid discuss
how attitudes toward a product can positively or nega-
tively influence use [29]. Furthermore, Devine found that
a human-centred design process helped to identify bar-
riers and facilitators to frequent use [14]. In this setting,
we found an acceptable and feasible handwashing station
must be delivered as a complete system. The kitchen
bucket and 40 Litre bucket handwashing station designs
included a stool and basin for this reason, and were
highly acceptable.
We focused our analysis on factors occurring in the
Habitual, Behavioural, Individual and Interpersonal/
Household Levels of IBM-WASH for two reasons. First,
Community and Societal/Structural factors shaping the
feasibility and acceptability of handwashing station
designs were already considered in selecting candidate
designs. Second, the subsequent RCTs were to measure
the effects of handwashing that occurs in the household,
hence our formative research had the most direct rele-
vance to the Behavioural, Individual, and Household
Levels of our conceptual framework.
Limitations
This research focused largely on the acceptability and
feasibility of different handwashing station designs.
Another study is necessary to measure the effectiveness
of a chosen handwashing station on actual handwashing
practice. Because handwashing stations were provided
free of charge, there was likely a positive bias toward
handwashing hardware, and in particular to the more
costly designs. Likewise, the study did not include
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measures for desirability or market value. However, in
the urban site, there were references to perceived prod-
uct value, indicating that such measures would be benefi-
cial. Specific questions targeting factors at the Community
level, such as access to markets and resources and shared
community values surrounding hygiene, may have pro-
vided greater context for selecting a handwashing station
design for programmatic use, beyond a randomized trial.
Conclusions
A number of contextual, psychosocial and technological
factors influence use of handwashing stations at five ag-
gregate levels, from habitual to societal. In interventions
that require a handwashing station to facilitate frequent
handwashing with soap, elements of the technology,
such as capacity, durability and location(s) within the
household are key to high feasibility and acceptability.
Access to water, convenience, and disgust towards
faeces-related handwashing stations may require more
than one handwashing station per household.
Using constructs outlined in IBM-WASH may help
identify key components of a behavioural intervention
and key multi-level determinants influencing behaviour
change in specific settings. Though the findings from
this research were used to directly inform an interven-
tion for subsequent research, this methodology may be
used to develop successful interventions for both pro-
grammatic and research purposes.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
KRSH conducted qualitative data analysis, the synthesis and interpretation of
results and was the primary author of the final manuscript. PJW provided
conceptual guidance for data analysis and manuscript development. PJW, EL,
LU, FN, PK, AA and SL conceived of the study design and provided support
for field trials and data collection. PJW, EL, RD and KRSH contributed to the
development of the IBM-WASH-structured analytical approach. AA and NCD
provided detailed information on study methods and lead the qualitative
field research team. All authors provided feedback and read and approved
the final manuscript.
Acknowledgements
The authors wish to thank Debashish Biswas and Dalia Yeasmin and
members of the handwashing qualitative research team at icddr,b. The Bill
and Melinda Gates Foundation provided funding for all research activities.
Author details
1
Social and Behavioral Interventions Program, Department of International
Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,
USA.
2
Water, Sanitation and Hygiene Research Group, Centre for
Communicable Disease, International Centre for Diarrhoeal Disease Research
Bangladesh, Dhaka, Bangladesh.
3
Department of Social and Preventive
Medicine, School of Public Health and Health Professions, University at
Buffalo, Buffalo, USA.
4
Woods Institute for the Environment, Stanford
University, Stanford, USA.
Received: 20 September 2012 Accepted: 13 September 2013
Published: 23 September 2013
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doi:10.1186/1471-2458-13-877
Cite this article as: Hulland et al.:Designing a handwashing station for
infrastructure-restricted communities in Bangladesh using the
integrated behavioural model for water, sanitation and hygiene
interventions (IBM-WASH). BMC Public Health 2013 13:877.
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