Handwashing with soap to improve child health: Observational and experimental studies to estimate behavior and health effects of handwashing with soap in low-resource settings (Doctoral dissertation).

Pneumonia and diarrhea are the two leading causes of death among children <5 years old, and handwashing with soap can prevent these infections. This dissertation will provide insight into measurement of handwashing, design of a handwashing intervention, and the impact of a handwashing program. Knowledge gained from this work will help researchers design and evaluate programs promoting handwashing with soap in low‐income settings. 

Soap and water may be useful surrogate measures of handwashing that can be used in large‐scale studies. We evaluated whether the presence of soap in the home or the presence of a designated handwashing location were associated with diarrhea and acute respiratory infection (ARI) in children <5 years old in Kenya. Soap was associated with a reduced prevalence of diarrhea, but not ARI. A handwashing location was not associated with diarrhea or ARI. Whereas most households had soap in the home, almost none had a designated handwashing station, which may inhibit handwashing at key times of hand contamination. 

Primiparous women may experience changes during the perinatal period that encourages adoption of healthy behaviors. We estimated impact of the timing of exposure to a handwashing intervention (during the perinatal period or after the end of the neonatal period) on maternal handwashing and infant health. Timing of exposure to the handwashing intervention was not associated with maternal handwashing or diarrhea or ARI. Our intervention was unable to take advantage of the potential unique environment of the perinatal period among primiparous women in rural Bangladesh. 

School handwashing programs can reach large numbers of children and improve child health. We evaluated a pilot of a school‐based handwashing program in Kenya. Handwashing with soap after toileting and before eating was rare among students at school and not associated with exposure to the program. Only seven schools, three program schools and four comparison schools, had soap and water available to students for handwashing. Exposure to the school program was not associated with diarrhea or ARI in children <15 years old. A lack of access to soap and water was likely a major barrier to children washing with soap at school.