With this paper, we aim to describe handwashing worldwide, as measured in Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS) in low- and middle-income countries between 1985 and 2008, and to explain the strengths, weaknesses and evolution of this data collection to inform future survey development.
We searched reports of DHS and MICS conducted before 2009 and analysed data on handwashing measurements. We examined data according to geographic region, as well as demographic characteristics such as wealth quintile, education of the household head, and rural/urban location.
Before 2009, eight MICS and 40 DHS included handwashing-related measurements, using a variety of self-reports and rapid observations. Internal triangulation of findings from surveys that collected multiple types of measurement shows that self-reports to closed questions overestimate behaviour. Observation-based data suggest low handwashing rates in many low- and middle-income countries with high prevalence of water and sanitation-related diseases, and high inter- and intra-country disparities. However, due to the widely disparate nature of the pre-2009 handwashing-related measurements, much of the data cannot be compared between countries, and only an incomplete picture of global rates can be formed.
Efforts to increase the prevalence of handwashing with soap and water need to be strengthened in many low- and middle-income countries, especially among poorer, rural populations and where the household head has less formal education. Closed questions asking for self-reports of handwashing behaviour should be avoided. Findings support instead the inclusion of uniform observation-based measurements, as were integrated as core modules of MICS and DHS in 2009.

Aiello, A.E., Coulborn, R.M., Perez, V. and Larson, E.L. (2008) ‘Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis’, American Journal of Public Health, 98 (8): 1372–81 <http://dx.doi.org/10.2105/AJPH.2007.124610>.

Danquah, L. (2010) ‘Measuring hand washing behaviour: methodological and validity issues’, presented at the South Asia Hygiene Practitioners Workshop, Dhaka, Bangladesh, 1–4 February <http://www.ircwash.org/resources/measuring-hand-washing-behaviour-methodological-and-validity-issues-paper-presented-south> [accessed 9 September 2015].

Halder, A.K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R. and Luby, S.P. (2010) ‘Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh’, BMC Public Health 10: 545 <http://dx.doi.org/10.1186/1471-2458-10-545>.

Liu, L., Johnson, H.L., Cousens, S., Perin, J., Scott, S., Lawn, J.E., et al. (2012) ‘Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000’, The Lancet 379 (9832): 2151–61 <http://dx.doi.org/10.1016/S0140-6736(12)60560-1>.

Luby, S.P. and Halder, A.K. (2008) ‘Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh’, Tropical Medicine & International Health 13 (6): 835–44 <http://dx.doi.org/10.1111/j.1365-3156.2008.02074.x>.

Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet, 366 (9481): 225–33 <http://dx.doi.org/10.1016/S0140-6736(05)66912-7>.

Luby, S.P., Halder, A.K., Huda, T.M., Unicomb, L. and Johnston, R.B. (2011) ‘Using child health outcomes to identify effective measures of handwashing’, The American Journal of Tropical Medicine and Hygiene 85 (5): 882–92 <http://dx.doi.org/10.4269/ajtmh.2011.11-0142>.

Ram, P. (2013) ‘Practical guidance for measuring handwashing behavior: 2013 update’, Working Paper, New York: World Bank Water and Sanitation Program.

Ram, P., Halder, A.K., Granger, S.P., Jones, T., Hall, P., et al. (2011) ‘Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation’, The American Journal of Tropical Medicine and Hygiene 83 (5): 1070–76 <http://dx.doi.org/10.4269/ajtmh.2010.09-0763>.

Rhee, V., Mullany, L.C., Khatry, S.K., Katz, J., LeClerq, S.C., Darmstadt, G.L. and Tielsch, J.M. (2008) ‘Maternal and birth attendant hand washing and neonatal mortality in southern Nepal’, Archives of Pediatrics & Adolescent Medicine 162 (7): 603–8 <http://dx.doi.org/10.1001/archpedi.162.7.603>.

United Nations Children’s Fund (UNICEF) (2012) The State of the World’s Children 2012: Children in an Urban World, New York: UNICEF <www.unicef.org/sowc2012> [accessed 20 June 2015].

UN Inter-Agency Group For Child Mortality Estimation (2012) Levels & Trends in Child Mortality: Report 2012, New York, NY: UNICEF.

All accessed 20 June 2015.

DHS <www.dhsprogram.com/What-We-Do/Survey-Search.cfm>

MICS <www.mics.unicef.org/surveys> Monitoring Group of the Public Private Partnership on Handwashing <www.globalhandwashing.org>

Aiello, A.E., Coulborn, R.M., Perez, V. and Larson, E.L. (2008) ‘Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis’, American Journal of Public Health, 98 (8): 1372–81 <http://dx.doi.org/10.2105/AJPH.2007.124610>.

Danquah, L. (2010) ‘Measuring hand washing behaviour: methodological and validity issues’, presented at the South Asia Hygiene Practitioners Workshop, Dhaka, Bangladesh, 1–4 February <http://www.ircwash.org/resources/measuring-hand-washing-behaviour-methodological-and-validity-issues-paper-presented-south> [accessed 9 September 2015].

Halder, A.K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R. and Luby, S.P. (2010) ‘Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh’, BMC Public Health 10: 545 <http://dx.doi.org/10.1186/1471-2458-10-545>.

Liu, L., Johnson, H.L., Cousens, S., Perin, J., Scott, S., Lawn, J.E., et al. (2012) ‘Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000’, The Lancet 379 (9832): 2151–61 <http://dx.doi.org/10.1016/S0140-6736(12)60560-1>.

Luby, S.P. and Halder, A.K. (2008) ‘Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh’, Tropical Medicine & International Health 13 (6): 835–44 <http://dx.doi.org/10.1111/j.1365-3156.2008.02074.x>.

Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet, 366 (9481): 225–33 <http://dx.doi.org/10.1016/S0140-6736(05)66912-7>.

Luby, S.P., Halder, A.K., Huda, T.M., Unicomb, L. and Johnston, R.B. (2011) ‘Using child health outcomes to identify effective measures of handwashing’, The American Journal of Tropical Medicine and Hygiene 85 (5): 882–92 <http://dx.doi.org/10.4269/ajtmh.2011.11-0142>.

Ram, P. (2013) ‘Practical guidance for measuring handwashing behavior: 2013 update’, Working Paper, New York: World Bank Water and Sanitation Program.

Ram, P., Halder, A.K., Granger, S.P., Jones, T., Hall, P., et al. (2011) ‘Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation’, The American Journal of Tropical Medicine and Hygiene 83 (5): 1070–76 <http://dx.doi.org/10.4269/ajtmh.2010.09-0763>.

Rhee, V., Mullany, L.C., Khatry, S.K., Katz, J., LeClerq, S.C., Darmstadt, G.L. and Tielsch, J.M. (2008) ‘Maternal and birth attendant hand washing and neonatal mortality in southern Nepal’, Archives of Pediatrics & Adolescent Medicine 162 (7): 603–8 <http://dx.doi.org/10.1001/archpedi.162.7.603>.

United Nations Children’s Fund (UNICEF) (2012) The State of the World’s Children 2012: Children in an Urban World, New York: UNICEF <www.unicef.org/sowc2012> [accessed 20 June 2015].

UN Inter-Agency Group For Child Mortality Estimation (2012) Levels & Trends in Child Mortality: Report 2012, New York, NY: UNICEF.

All accessed 20 June 2015.

DHS <www.dhsprogram.com/What-We-Do/Survey-Search.cfm>

MICS <www.mics.unicef.org/surveys> Monitoring Group of the Public Private Partnership on Handwashing <www.globalhandwashing.org>

Aiello, A.E., Coulborn, R.M., Perez, V. and Larson, E.L. (2008) ‘Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis’, American Journal of Public Health, 98 (8): 1372–81 <http://dx.doi.org/10.2105/AJPH.2007.124610>.

Danquah, L. (2010) ‘Measuring hand washing behaviour: methodological and validity issues’, presented at the South Asia Hygiene Practitioners Workshop, Dhaka, Bangladesh, 1–4 February <http://www.ircwash.org/resources/measuring-hand-washing-behaviour-methodological-and-validity-issues-paper-presented-south> [accessed 9 September 2015].

Halder, A.K., Tronchet, C., Akhter, S., Bhuiya, A., Johnston, R. and Luby, S.P. (2010) ‘Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh’, BMC Public Health 10: 545 <http://dx.doi.org/10.1186/1471-2458-10-545>.

Liu, L., Johnson, H.L., Cousens, S., Perin, J., Scott, S., Lawn, J.E., et al. (2012) ‘Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000’, The Lancet 379 (9832): 2151–61 <http://dx.doi.org/10.1016/S0140-6736(12)60560-1>.

Luby, S.P. and Halder, A.K. (2008) ‘Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh’, Tropical Medicine & International Health 13 (6): 835–44 <http://dx.doi.org/10.1111/j.1365-3156.2008.02074.x>.

Luby, S.P., Agboatwalla, M., Feikin, D.R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R.M. (2005) ‘Effect of handwashing on child health: a randomised controlled trial’, The Lancet, 366 (9481): 225–33 <http://dx.doi.org/10.1016/S0140-6736(05)66912-7>.

Luby, S.P., Halder, A.K., Huda, T.M., Unicomb, L. and Johnston, R.B. (2011) ‘Using child health outcomes to identify effective measures of handwashing’, The American Journal of Tropical Medicine and Hygiene 85 (5): 882–92 <http://dx.doi.org/10.4269/ajtmh.2011.11-0142>.

Ram, P. (2013) ‘Practical guidance for measuring handwashing behavior: 2013 update’, Working Paper, New York: World Bank Water and Sanitation Program.

Ram, P., Halder, A.K., Granger, S.P., Jones, T., Hall, P., et al. (2011) ‘Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation’, The American Journal of Tropical Medicine and Hygiene 83 (5): 1070–76 <http://dx.doi.org/10.4269/ajtmh.2010.09-0763>.

Rhee, V., Mullany, L.C., Khatry, S.K., Katz, J., LeClerq, S.C., Darmstadt, G.L. and Tielsch, J.M. (2008) ‘Maternal and birth attendant hand washing and neonatal mortality in southern Nepal’, Archives of Pediatrics & Adolescent Medicine 162 (7): 603–8 <http://dx.doi.org/10.1001/archpedi.162.7.603>.

United Nations Children’s Fund (UNICEF) (2012) The State of the World’s Children 2012: Children in an Urban World, New York: UNICEF <www.unicef.org/sowc2012> [accessed 20 June 2015].

UN Inter-Agency Group For Child Mortality Estimation (2012) Levels & Trends in Child Mortality: Report 2012, New York, NY: UNICEF.

All accessed 20 June 2015.

DHS <www.dhsprogram.com/What-We-Do/Survey-Search.cfm>

MICS <www.mics.unicef.org/surveys> Monitoring Group of the Public Private Partnership on Handwashing <www.globalhandwashing.org>