Post-defecation handwashing in Bangladesh: practice and efficiency perspectives

Inadequate handwashing after defecation and anal cleaning practices in the Indian subcontinent is an important source of faeco-oral transmission of enteric diseases. To better understand the process as traditionally practised, 90 women in semi-rural Bangladesh were observed washing hands after defecation. Several components of handwashing practices were identified: the cleaning agent, using left or both hands; frequency of rubbing hands, type and amount of water used to wash, and the drying of hands on the wearer's clothes. A subsequent experiment was conducted to assess the effect of currently practised handwashing and drying according to standardised procedure on faecal coliform count of hands. As a rubbing agent, soil was commonly used (40%); soap was used by 19% and was reported unaffordable by about 81% of the non-users. Good handwashing behaviour was positively associated with better social and economic indicators including education of the women observed. Both hands were unacceptably contaminated after traditional handwashing (the geometric mean count of left was 1,995 and right hand was 1,318 faecal coliform units/hand). After standardising the observed components of handwashing procedures the use of any rubbing agent, i.e. soil, ash or soap, produced similar acceptable cleaning. Use of a rubbing agent (e.g. soil, ash or soap), more rubbing (i.e. six times), rinsing with safer water (e.g. 2 litres of tubewell water) and drying with a clean cloth or in the air produced acceptable bacteriological results. Components of traditional handwashing practices were defined through careful observation, and experiments on handwashing with standardised components showed that efficient and affordable options for handwashing can be developed; this knowledge should be helpful in disease control programmes.