Association of Mother’s Handwashing Practices and Pediatric Diarrhea: Evidence from a Multi-Country Study on Community Oriented Interventions


Pediatric Diarrhea
Community Health Workers
Health Promotion
Social Accountability



Improved hand hygiene in contexts with high levels of diarrheal diseases has shown to reduce diarrheal episodes in children under five years. A quasi-experimental multi-country study with matched comparisons was conducted in four rural districts/sub districts in Cambodia, Guatemala, Kenya and Zambia.


Community oriented interventions including health promotion for appropriate hand washing was implemented in the intervention sites, through community health workers (CHW) and social accountability mechanisms. Community councils were strengthened/established in all study sites. Using household surveys, information on mother’s handwashing practices and diarrhea incidence of children 2 weeks preceding the study was obtained.   

Results and Conclusion

Access to safe drinking water was reportedly higher for communities in Guatemala and Zambia (>80%), than those in Cambodia and Kenya (<63%), with significantly higher levels in intervention sites for Guatemala and Kenya. Improved sanitation was low (<10%), for Kenya and Zambia, compared to Cambodia and Guatemala (>40%); intervention sites reporting significantly higher levels, except for Zambia. Hand washing index; hand washing before food preparation, after defecation, attending to a child after defecation, and before feeding children was significantly higher for intervention sites in Cambodia, Guatemala and Kenya (Cambodia, 2.4 vs 2.2, p<0.001, Guatemala, 3.0 vs 2.5, p<0.001, Kenya, 2.6 vs 2.3, p<0.001). Factors significantly associated with lower odds of diarrhea were; mother’s marital status, higher educational status, one or more handwashing practices, wealthier quintiles, older (>24m), and female children. The findings suggest that caretaker handwashing with soap or ash has a protective effect on prevalence of diarrhea in children.


Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R. Global, regional, and national causes of child mortality in 2008: a systematic analysis. The lancet. 2010;375(9730).

World Health Organization. Diarrheal disease 2018 [Available from: on 10/26/2018

Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn J, Rudan I, Campbell H, Cibulskis R, Li M. Child Health Epidemiology Reference Group of WHO and UNICEF Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832).

Alkema L, New J, Pedersen J, You D. UN Inter-agency Group for Child Mortality Estimation; Technical Advisory Group. Child mortality estimation 2013: An overview of updates in estimation methods by the United Nations Inter-agency group for child mortality estimation. PLoS One. 2014;9(7).

Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. The Cochrane database of systematic reviews. 2015(9).

Iyer P SJ, Curtis V, Scott B, Cardosi J. The Handwashing Handbook: A guide for developing a hygiene promotion program to increase handwashing with soap. The World Bank. 2005.

Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS medicine. 2011;8(6).

Arnold B, Arana B, Mäusezahl D, Hubbard A, Colford Jr JM. Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. International Journal of Epidemiology. 2009;38(6).

Hoque BA, Briend A. A comparison of local handwashing agents in Bangladesh. Tropical Medicine & International Health. 1991;94(1).

Scott B, Curtis V, Rabie T, Garbrah-Aidoo N. Health in our hands, but not in our heads: understanding hygiene motivation in Ghana. Health Policy and Planning. 2007;22(4).

Curtis VA, Danquah LO, Aunger RV. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health education research. 2009;24(4).

Schaaf M, Topp SM, Ngulube M. From favours to entitlements: community voice and action and health service quality in Zambia. Health policy and planning. 2017;32(6).

Global Fund. Community systems strengthening framework. Geneva: The Global Fund. 2010.

Demographic Health Survey. DHS Overview 2015 [Available from: Accessed on 10/26/2018

StataCorp. Stata 14. 14.2 ed. Texas, USA2015.

Kawakatsu Y, Tanaka J, Ogawa K, Ogendo K, Honda S. Community unit performance: factors associated with childhood diarrhea and appropriate treatment in Nyanza Province, Kenya. BMC public health. 2017;17(1).

Edward A, F Sanchez J, Chhorvann C, Bowles C, Malama S, Chege J. Impact of community oriented interventions on pediatric care-seeking practices- A multi-country study in Cambodia, Guatemala, Kenya And Zambia. Prev ed Commun Health. 2018.

Vásquez WF, Aksan A-M. Water, sanitation, and diarrhea incidence among children: evidence from Guatemala. Water Policy. 2015;17(5).

Waddington H, Snilstveit B. Effectiveness and sustainability of water, sanitation, and hygiene interventions in combating diarrhoea. Journal of development effectiveness. 2009;1(3).

Cairncross S, Valdmanis V. Water supply, sanitation and hygiene promotion (Chapter 41). 2006.

Anteneh ZA, Andargie K, Tarekegn M. Prevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan District, Northwest Ethiopia, 2014. BMC public health. 2017;17(1).

Cousens S, Kanki B, Toure S, Diallo I, Curtis V. Reactivity and repeatability of hygiene behaviour: structured observations from Burkina Faso. Social science & medicine. 1996;43(9).

Aluisio AR, Maroof Z, Chandramohan D, Bruce J, Masher MI, Manaseki-Holland S, Ensink JH. Risk factors associated with recurrent diarrheal illnesses among children in Kabul, Afghanistan: a prospective cohort study. PLoS One. 2015;10(2).

Peletz R, Simuyandi M, Sarenje K, Baisley K, Kelly P, Filteau S, Clasen T. Drinking water quality, feeding practices, and diarrhea among children under 2 years of HIV-positive mothers in peri-urban Zambia. The American journal of tropical medicine and hygiene. 2011;85(2).

Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics. 2001;108(4).

Brhane G, Regassa N. Nutritional status of children under five years of age in Shire Indaselassie, North Ethiopia: Examining the prevalence and risk factors. Kontakt. 2014;16(3).

Etiler N, Velipasaoglu S, Aktekin M. Risk factors for overall and persistent diarrhoea in infancy in Antalya, Turkey: a cohort study. Public Health. 2004;118(1).

Quick RE, Venczel L, Mintz E, Soleto L, Aparicio J, Gironaz M, Hutwagner L, Greene K, Bopp C, Maloney K. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiology & Infection. 1999;122(1).

Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra RM, Olson CA, Baier KG, Keswick BH, Luby SP. A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhea prevention in rural Guatemala. The American Journal of Tropical Medicine and Hygiene. 2003;69(4).

World Health Organization UNCsF. Progress on sanitation and drinking-water, 2010 update: World Health Organization Geneva; 2010.