Development of a handwashing with soap intervention in low-income settlements of Mombasa, Kenya

Interventions to improve handwashing with soap have shown mixed effects on behaviour which may be due to contextual differences in different settings. Low-income settings have complex socio-economic conditions which requires local contextual adaptation to support intervention adoption. Detailing the development of an intervention can inform other researchers and practitioners on best practices, and it enables replicability and scalability.

This study adopted the Trials of Improved Practices (TIPs) approach and incorporated co-creation and co-design of interventions with stakeholders. A total of 56 participants were randomly selected and an initial survey was conducted. The development process entailed stakeholder engagements and educational activities. Educational activities were delivered through household-level visits and community dialogue sessions. Qualitative data were collected throughout the process using in-depth interviews. A survey was conducted after the educational activities to assess availability of handwashing facilities and handwashing with soap practices. Logistic regression was used to estimate the effect of independent variables on availability of handwashing facilities and on handwashing with soap, and McNemar's test was used to evaluate if the interventions improved handwashing practices. Qualitative data were analysed thematically, and the findings explained the process and the effect of the interventions.

Initial survey results showed that 59% of handwashing facilities were not at a fixed location, and only 21% of respondents reported handwashing with soap. Households with a fixed handwashing facility had 5.3 times higher odds of handwashing with soap compared to households with mobile handwashing facilities (P = 0.02 CI 1.32-21.23). Participating households made improvements by designating handwashing facilities at the compound level and separate handwashing facilities at the household level. Access to fixed handwashing facilities increased from 10 to 77%, and reported handwashing with soap among respondents significantly increased from 21 to 64% after the education activities (McNemar's X²(1) = 12.46; P = 0.00). This improvement in handwashing was attributed to the educational visits and practical demonstrations and was motivated by improved hygiene conditions in the households.

Households can improve reported handwashing with soap if they are provided with the necessary skills for making improvements. This approach could serve as a model for future public health initiatives aimed at improving hygiene practices in similar settings.