Introduction

Hand washing with soap and water (HWWS) at 5 critical times in an important public health behaviour meant to reduce infectious and water borne diseases.^1-3 Hand washing at 5 critical times includes washing hands with water and soap⁴ before cooking, before eating, before feeding the child, after defecation and cleaning the child’s bottom/perineal care – washing the genital and rectal areas of the body.^1,4-6 The most common indicator used to measure appropriate handwashing is percent of respondents who washed their hands with soap at 5 critical times. Inadequate water supply, limited access to soap, and lack of information are some of the major challenges preventing mothers/caregivers in adopting appropriate hand washing behaviour at all 5 critical times with water and soap in many developing countries.^3,6 Owing to these challenges, most mothers/caregivers in many developing countries partially wash their hands at 5 critical times. To effectively measure partial handwashing behaviour, most development agencies use an additional indicator to measure partial handwashing behaviour. The indicator for partial handwashing behaviour used by many development agencies include percent of respondents who washed their hands with soap or ash in at least 3 out of 5 critical times.⁷

Acute respiratory infections and diarrhoeal diseases are the main causes of mortality and morbidity among children under the age of 5 years in areas lacking adequate sanitation and hygiene⁴ including Afghanistan.^8,9 Mothers/caregivers play a vital role in improving children’s health⁴ through appropriate handwashing provision of clean water, safe disposal of waste and children faecal matter, and use of improved latrine. Poor water, sanitation, and hygiene (WASH) is one of the leading causes of diarrhoea and respiratory diseases.^4,10 According to GBD Diarrhoeal Diseases Collaborators,^11,12 it is estimated that around 500 000 under-5 children die globally from diarrhoea-related diseases every year. Furthermore, about 60%, 13%, 80% of diarrhoea, acute respiratory infections and malaria in low- and medium-income countries is linked to inadequate and poor water, sanitation and hygiene.¹⁰ Yet, a significant proportion of infectious diseases and other water borne diseases can be prevented through adequate water, sanitation and hygiene.^4,13

The major faecal-oral transmission routes through which disease-causing pathogens can reach children have been identified as food, flies, fingers, fluids and fields.⁴ Breaking these faecal-oral transmission routes remains one of the aims of proper WASH interventions. Handwashing with water and soap (HWWS), household hygiene, safe disposal of waste, drinking clean water and use of improved latrine are some of the most effective methods of preventing the spread of these micro-organisms that cause infectious and water borne diseases.^1,5,6,14 Recent meta-analyses evidence show that HWWS has the potential of reducing diarrhoeal diseases by about 40%.¹⁵ Despite handwashing being cost-effective, its practice remains quite low in many developing countries.^1,16,17 For example, washing hands with soap after contact with faecal matter remains relatively low at 22% in low and medium income countries¹⁷ and 19% globally.¹⁵

Infectious diseases including diarrhoea, acute respiratory infections, typhoid, and cholera are a major public health concern in Afghanistan, where nearly three-fifths of child deaths are noted per 1000 live births.¹⁸ According to^8,9diarrhoeal and acute respiratory diseases are the major diseases causing excess morbidity and mortality among children in Afghanistan. As a result, appropriate hand washing behaviour at critical times by mothers/caregivers is crucial to prevent the spread of infectious diseases among children.

In their systematic review,^15,19identified various studies understanding the determinants of appropriate handwashing in South East Asia and Africa, with the bulk drawn from Bangladesh, India and Kenya, and less is explored on this topic in Afghanistan. Some of the major determinants of appropriate handwashing identified in literature include access to handwashing materials and resources including soap and water,^3,4,17,19,20 health education,^19,21 and having younger children in the household.^17,22 Most of these studies on determinants of appropriate handwashing are based on cross-sectional data and less on panel data regression analysis.

To our knowledge there are no or very few studies that have been done to understand the determinants of handwashing behaviour using panel data regression models that provide robust estimates compared to cross section research design. Afghanistan is good case study as it has one of the highest prevalence of infectious diseases including acute respiratory infections and diarrhoea.^8,9 The novelty of this study is that it utilised panel data regression to rigorously estimate the determinants of handwashing at critical times among mothers/caregivers of under-5 children in Afghanistan. In addition, the study used 2 indicators of handwashing behaviour – handwashing at 5 critical times and at least 3 times.^4,7,21 This study aims to fill the gap in the literature, as there is to-date, limited empirical studies that have used panel data analysis methods to examine determinants of appropriate handwashing behaviour in a developing country context. Therefore, the article addresses the following key research questions:

Three hypotheses are formulated for our investigation to answer the research questions, particularly on the factors influencing HWWS. First, we anticipate that access to handwashing materials and resources including soap and water is closely related with handwashing at critical times.^3,4,17,19,20 Second, we expect that mothers/caregivers having younger children adopt appropriate handwashing behaviour given that they are regularly in contact with their children when feeding them and removing faecal matter.^17,22 Finally, we expect that health education is positively associated with HWWS. A strong link between health education and HWWS has been discovered in several studies.^19,21

Methods

Programme interventions

Save the Children, International Medical Corps, and Concern Worldwide implemented the Lifesaving Humanitarian Response Programme in Afghanistan in 2022 funded by USAID. About 1 195 054 beneficiary households received either multi-purpose cash assistance, food assistance, and WASH assistance or a combination in selected districts and villages across 7 provinces (Faryab, Jawzjan, Nangahar, Sar-e-Pul, Balkh, Kandahar, and Badakhshan).

Multipurpose cash assistance (MPCAs): The MPCA transfer amount, set by Afghanistan Cash and Voucher Working Group, ranged between $97 and $125 which was intended to cover approximately 80% of non-food items a 6-person household may need. The MPCA beneficiaries would receive 3 to 4 times transfer. Households were selected to participate in the cash assistance programme based on a pre-set vulnerability targeting criteria. Vulnerability criteria considered for this programme included indicators such as food insecurity, income, asset ownership, and receipt of remittances from abroad. Transfers were given to the head of household.

Unconditional food assistance: The unconditional food assistance was given to vulnerable households especially households headed by women, the elderly, people with disabilities and pregnant and lactating women (PLW) were prioritised.

Water, Sanitation and Hygiene (WASH): Save the Children, International Medical Corps, and Concern Worldwide provided WASH services to vulnerable beneficiary households and communities. The WASH services included water trucking, chlorination and rehabilitation of existing water points, construction of safe water points, distribution of WASH kits and hygiene promotion activities. Hygiene promotion activities focused on COVID-19 misconceptions, other viruses and water borne diseases and rumour management, modes of transmission, hand and surface hygiene, and appropriate prevention measures, including handwashing with soap. Table 1 show the provinces receiving MPCA, Food Assistance, and WASH services. The main hypothesis is that receipt of WASH interventions should translate into appropriate handwashing behaviour.

Table 1.

List of interventions by provinces.

Data source

The data used in this article is drawn from quantitative baseline and endline surveys for the Lifesaving Humanitarian Response Programme funded by USAID in Afghanistan. The baseline data was collected before the interventions in March 2022 and endline survey data was conducted after the interventions were implemented in December 2022. The sample size in each district was calculated based on the population proportions in each district and systematic probability proportional-to-size (PPS) sampling method. Primary caregivers (or mothers) of the children in the household, aged 18 years and above, who were able to respond to the questions about household conditions (WASH, nutrition, and health) and information on their children particularly those below 2 years, maternity diet and access to health care and nutrition services. Each survey targeted around 1208 mothers/caregivers across the 7 provinces (Faryab, Jawzjan, Nangahar, Sar-e-Pol, Balkh, Kandahar, and Badakhshan) drawn from the beneficiary registration lists. The final sample for each province, which provided a 95% confidence interval, and 5% margin of error is shown in Figure 1. This sampling was sufficient and representative of households with infants 0 to 5 months and young children aged below 2 years.

Figure 1.

Sample size per province for baseline and endline survey.

The percentage of the population living in dwellings with a safe source of drinking water (handpump, protected spring and well, public tap/standpipe, piped water into dwellings or into compound) are different across the province. According to Ref.,²³ these include Faryab (43%), Jawzjan (62%), Nangarhar (84%), Sar-e-Pul (26%), Balkh (61%), Kandahar (71%) and Badakhshan (78%).

Results

Descriptive analysis

Table 2 shows the descriptive statistics for sociodemographic factors at baseline and endline. At endline mothers/caregivers washed hands with water and soap at 3.31 critical times and this is significantly higher compared to baseline. At endline, 74% of mothers/caregivers reported practicing at least 3 out of 5 critical times to wash hands, either before eating, after defecation or using toilet, before preparing food, before feeding an infant or after changing or cleaning child’s bottom, compared to 62% at baseline. About 60% of mothers/caregivers reported having access to clean water source at endline and this was significantly higher compared to baseline.

Table 2.

Descriptive statistics for sociodemographic factors at baseline and endline.

Over 2 in 3 households (68.8%) reported receiving hygiene promotion in the past 12 months. Figure 2, show that the most reported promotion activities received by the households were knowledge sharing about COVID-19 misconceptions (41.9%), followed by promotion activities related with appropriate prevention measures including hand washing with soaps (38.3%); information sharing about virus, water sanitation related disease and prevention measure to avoid the spread of diseases (36.9%); information about mode of transmission of diseases (35.4%) and hand and surface hygiene promotion activity (28.1%).

Figure 2.

Proportion of respondents receiving hygiene promotion activities.

At endline, the proportion of mothers/caregivers that reported washing their hands on different critical times had generally increased compared to the baseline, except for ‘after defecation or using the toilet’ which dropped from 85% to 78% (Figure 3). The proportion of mothers/caregivers who highlighted that they washed hands before preparing food increased from 68% at baseline to 82% at endline.

Figure 3.

Critical times of handwashing practiced by mother/caregivers.

There was an increase in the proportion of households reporting having a designated handwashing station. Over half of households (55.5%) had a designated handwashing station at home at endline and this was significantly higher compared to 31.6% at baseline. About 34.8% of households at endline were mentioned that hand washing facility in their homestead that was equipped with water only (without soap), having increased by 11.1% from baseline. At endline, only 22% of households were reported to have a designated hand washing facility that was equipped with water and soap, although it increased slightly from the baseline report (14%).

Econometric analysis

Determinants of handwashing at 5 critical times

Table 3 show the results of factors determining handwashing at 5 critical times using panel poisson regression model. The Hausman test statistic for model selection was 12.55 (P = .403) and not significant and therefore a random effects poisson regression is appropriate over fixed effects model.^24,25 Therefore, the study proceeds and interprets results from the random effects regression (columns 4 and 5). As compared to mothers/caregivers without access to handwashing facility with water and soap, those who had access had 1.20 (IRR = 1.20; 95% CI: 1.13-1.28) times increased likelihood of washing hands at 5 critical times. Mothers/caregivers who sought medical treatment at public health facility were 1.07 (IRR = 1.07; 95% CI: 1.01-1.13) times more likely to wash hands at critical times than those not seeking treatment from these institutions. The odds of washing hands at 5 critical times were higher among mothers/caregiver who had children below 2 years old compared to those who did not have. Mothers/caregivers who had children below 2 years 1.05 (IRR = 1.05; 95% CI: 1.00-1.11) times more likely to wash hands at critical times than those not owning.

Table 3.

Determinants of handwashing at 5 critical times using random effects poisson regression.

Determinants of handwashing at least 3 times

The Hausman test for model selection was 11.86 (P = .457). Given that the Hausman statistic is not significant the random effects panel logit regression is used for estimation (Table 4). The study revealed that mothers/caregivers with access to handwashing facility with water and soap were 1.73 (OR = 1.73; 95% CI: 1.32-2.27) times more likely to practice handwashing at least 3 times compared to those without access. We incorporated time required to get water from source as one of the variables. Accordingly, mothers/caregivers with water sources that were far away based on time were 0.99 less likely to wash their hands at least 3 times (OR = 0.99; 95% CI: 0.98-1.00) compared to counterparts with nearer water sources. Mothers/caregivers that sought medical treatment from public health facilities were 1.49 (OR = 1.49; 95% CI: 1.21-1.83) times more likely to practice handwashing at least 3 times compared to those not seeking medical treatment from these facilities. Having children less than 2 years old was also a significant determinant of handwashing at least 3 times. Mothers/caregivers with children less than 2 years had 1.24 (OR = 1.24; 95% CI: 1.01 -1.52) higher odds of practicing appropriate handwashing behaviour compared to their respective counterparts. The odds of washing hands at least 3 times were lower among mothers/caregiver from households having a member with disability.

Table 4.

Determinants of handwashing at least 3 times using random-effects logit regression.

Does occurrence of infectious diseases predict appropriate handwashing behaviour

According to literature, contracting infectious diseases is one of the major determinants of handwashing behaviours.^26,27 The variables measuring the occurrence of infectious diseases (acute respiratory infection, tuberculosis, diarrhoea, cholera malaria, skin infection and COVID-19) were only collected at endline. Table 5 show the regression estimates on the role of occurrence of infectious diseases on handwashing behaviour using endline data. Respondents who reported contracting infectious diseases in the past 6 months were more likely to practice handwashing at 5 critical times (OR 1.04; 95% CI 1.01–1.07). The article revealed that mothers/caregivers from households with a member who suffered from infectious diseases in the past 6 months were 1.52 (OR = 1.52; 95% CI: 1.31-1.76) times more likely to practice handwashing at least 3 times compared to those not.

Table 5.

Role of infectious diseases on handwashing at 5 critical times and at least 3 times.

Discussion

This study was undertaken, to assess the determinants of handwashing at 5 critical times and at least 3 times among mothers/caregivers of children under-5 years in rural areas of Afghanistan. About 22% of households had a designated hand washing facility equipped with water and soap at endline, suggesting the need for increased hygiene promotion particularly on washing hands with water and soap complemented by promoting greater access to soap and water. The proportion of mothers/caregivers that reported washing their hands on different types of occasions increased at endline compared to baseline, except for ‘after defecation or using the toilet’. Mother/caregivers with access to handwashing facility with water and soap had 1.20 higher odds of washing hands at 5 critical times. Treatment at public facility, an indirect proxy of health education and having children under 2 years was associated with 1.07 and 1.05 higher odds of washing hands at 5 critical times. Access to handwashing with water and soap, treatment at public facility and children under 2 years were significant and robust to alternative specification of handwashing at least 3 times. Mothers/caregivers who reported contracting infectious diseases in the past 6 months had 1.04- and 1.52-times higher odds of handwashing at 5 critical times and at least 3 times respectively.

The study showed that handwashing at 5 critical times among mothers/caregivers of children under-5 years was positively determined by access to handwashing facility with water and soap. This finding is in line with studies that emphasise the importance of access to handwashing materials and resources as the key drivers for handwashing.^3,4,17,19,20 Distance to water source was negatively related with appropriate handwashing behaviour. These results tally with earlier literature that mothers/caregivers who had water supply far away had reduced odds of handwashing at critical times compared to those with water supply nearer their homesteads.^3,6 These findings imply that having reliable water source that is nearer household should be a top priority for promoting handwashing at critical times.

The seeking of treatment at a public health facility was a key driver of handwashing at critical times. Mother/caregivers usually get health and hygiene education on appropriate hand washing and frequency during visits to health facilities.³ This study’s results demonstrate the importance of promoting health and hygiene information and knowledge to influence appropriate handwashing behaviour.¹⁹

Mothers/caregivers with children less than 2 years of age adopted appropriate handwashing behaviour. This finding is in line with similar findings from studies conducted in various countries including Bangladesh, Ethiopia, Nepal and Vietnam.^4-6,17,22 The logic being that when mothers/caregivers have younger children, they potentially contact them on a regular basis when feeding them and conducting perineal care which subsequently increases the likelihood of handwashing at and hygiene practices.

The study’s results indicate that mothers/caregivers who contracted infectious diseases were more likely to adopt appropriate handwashing behaviours at critical times. These findings resonate with recent literature that individuals susceptible to contracting infectious diseases were more likely to wash their hands at appropriate times.^26-28 For example, some studies found that individuals that contracted influenza and or COVID-19 frequently washed their hands.^27,28

The manuscript’s implication is that it contributes to achievement of Sustainable Development Goal (SDG)-6 of ensuring clean water and sanitation, and in particular outcome target of achieving adequate and equitable sanitation and hygiene for all by 20230. This is achieved by promoting hygiene education for mothers/caregivers with children under-5. Promoting appropriate handwashing behaviour by mothers is one of the cost-effective options for reducing the burden of infectious diseases, and subsequently contribute to SDG-3 (good health and wellbeing) by improving the health and well-being of children under-5 and reducing under-5 mortality rates.

Conclusion

The average hand washing practice of mothers/caregivers was 3.3 out of 5 during critical times associated with good hygiene practices. The main determinants that positively influenced appropriate handwashing behaviour were access to handwashing facilities with soap and water, treatment at public facility, infectious diseases, and children under 2 years. These findings suggest that the public sector and development agencies should promote interventions that improve access to handwashing facilities, water, and soap. Households should be encouraged to construct handwashing stations, for example, tippy taps and these should be located at convenient sites to encourage handwashing practice. Hygiene education should be done to nudge mothers/caregivers to adopt appropriate handwashing behaviour at critical times. The policy and programming implications of this study creates a juxtapose for the comparison and dissemination of findings to guide international health providers and aid agencies operating within developing nations with similar contexts. In addition, the public sector and development agencies need to promote remunerative, entrepreneurial activities that increase disposable income to assist households to purchase soap and handwashing facilities, enhance the public health strategy to educate the population on good hand hygiene and finally, to construct clean water sources including handpump, protected spring and well, public tap/standpipe, piped water into dwellings or into compound. These water sources should be constructed within the geographical confines of these rural communities. Furthermore, there is need to promote healthcare seeking behaviour for mothers/caregivers to access medical treatment and health hygiene education at public facilities vital for prevention of infectious diseases.