“To mark one era of the Global Handwashing Day, let’s wash hands with soap frequently and stop spreading the virus with clean hands” — certainly a warm invitation. However, we must think about the feasibility of doing so properly in the context of a developing country like Bangladesh.
Handwashing has been promoted as a preventive measure against many diseases for many years – the coronavirus pandemic has brought it into the spotlight. Handwashing is one of the three feasible preventive measures against the virus, as advised by experts; using face masks and maintaining physical distance are the other two measures. To help people adopt these behaviours, BRAC has been implementing a project under Hygiene and Behaviour Change Coalition (HBCC), jointly funded by Foreign, Commonwealth, and Development Office (FCDO) and Unilever. BRAC Institute of Governance and Development (BIGD), in collaboration with Behavioural Insights Team (BIT) is working with BRAC on this project to design and disseminate behaviourally-informed messages for effective behavioural change. To this end, BIGD recently conducted a study to capture people’s knowledge, practices, and barriers to COVID-19 preventive practices.
Research Experience at the Heart of Coronavirus Pandemic
Like other countries, Bangladesh has restricted and limited social mobility to control the infection. Traditional applied qualitative techniques have become irrelevant in this new context. To comply with the public health guidelines to combat COVID-19, the research team adopted an alternative methodological approach.
There are two-fold challenges to adopt traditional anthropological research techniques and tools in this new normal environment—fear of community transmission and ethical dilemma as the researcher and respondents may have different mitigation capabilities.
So, we customized and contextualized the data collection process by using appropriate qualitative tools, particularly in-depth telephone interviews (IDIs), visual¹ and shadow² observations, and focus group discussions (FGDs) using virtual video communication platforms. Respondents were connected through telephones and often through live video, which allowed the researchers to collect observational data. This “new modality” of qualitative fieldwork is an innovative experience that has been emerging in the context of “COVID-19”.
Structural and Personal Barriers to Handwashing During COVID-19 Pandemic
BIGD research found that people already know about the importance of conventional practices of handwashing, e.g. before and after taking a meal and after using toilets and are also aware of the new practices in the corona context. However, the actual handwashing practices are diverse during the pandemic crisis. While some people are compliant, many others are reluctant to follow the guideline of frequent handwashing.
Economic, social, cultural, and even individual behavioural barriers prevent people from following the handwashing health guidelines properly. We can broadly categorize the barriers in two groups: personal (e.g. personal belief of no necessity of handwashing, habitual traits, and so on) and structural (insolvency of purchasing soap regularly, lack of access to handwashing facilities at home, and so on).
Structural barriers are often obvious, especially for a context like Bangladesh. Many people in peri-urban and urban slum areas use a shared handwashing facility. We found that many of them cannot afford to buy soap regularly and those who can afford, are not ready to share the soap. At workplaces, they do not have handwashing facilities. One respondent stated, “I don’t use hand sanitizer. Usually, I don’t wash my hand when I am outside. There are no handwashing facilities where I work. We also don’t wear masks at my workplace, to tell you the truth.”
Personal barriers are not always obvious, yet are all too important. Often they emerge from their personal beliefs, knowledge, behaviors and perceptions that result in different handwashing practices. In the following section, we focus on the identified personal barriers, particularly on the knowledge, awareness and practice (KAP) and community perception about handwashing.
Personal Barriers to Proper Handwashing Practice During the Pandemic
As mentioned earlier, overall, people seem to be aware of the health safety guidelines and the importance of handwashing. However, there are a variety of personal barriers.
We got many different perceptions from the diverse community of respondents; for example, a male respondent noted, “There is a fear in our minds of getting infected by the virus, which is why we are careful to stay protected from this deadly infection.” A female respondent also shared similar thoughts – that everybody would die one day, but dying from the Coronavirus would be an ill-fated demise, “I want just one thing from God: please do not give me ‘কু–মরা’ (bad death)” she said, “I want ‘সু–মরা’ (good death). That’s why I try to stay safe and wash my hands regularly. It was rather annoying to do so in the beginning, but now I am used to it.” The perception of ‘কু–মরা’ emerged from the newly adapted funeral practices for COVID deaths, where not even close family members, relatives, neighbours can attend the funeral. This is deemed unfortunate for an individual from the socio-emotional perspective.
But the majority of respondents informed that people are not as scared or worried about getting infected by the Coronavirus as they were at the beginning of the outbreak. As a result, reluctance to comply with the national health guidelines is increasing. This reluctance is stronger and more visible among rural people compared to the urban population. Our research found that people unequivocally agreed that the initial importance of handwashing at the outset of the pandemic is going down in their localities.
Many come up with their own rationale for not following the guidelines. For example, one respondent said “I don’t think it is possible to maintain 20 seconds of handwashing with soap all the time. I wash hands with water frequently and as I don’t go outside my house all that often, so it’s okay to sometimes skip handwashing with soap.” Many respondents also reported that they forget to wash their hands with soap. They also said that they cannot restrain themselves from regular practices such as picking noses or rubbing eyes – which means that personal traits determine compliance.
In addition, although people have ideas about the health guideline for coronavirus, they do not have clear knowledge about the concept of germs. As stated by a respondent, “Sneezing, cough and hand-touch of corona patients can spread corona germs. To be honest, I don’t have a proper idea about germs, but I think proper cleanliness can minimize the risk of exposure to many diseases.” Another respondent quoted, “Dirt and waste cause different kinds of diseases; for example, diarrhoea is caused by germs and germs are spread through the dirt.” The lack of clarity about germs also plays a role in preventing people from following health guidelines.
Another respondent said that there is no initiative from local administration to monitor or remind us whether we are washing hands. It indicates that people expect support from others to shape their behaviours.
It is clear that only providing handwashing facilities will not be enough, a well-structured behavioural change communication (BCC) strategy to change people’s knowledge, awareness, behaviours and community perceptions is needed to ensure that people adopt appropriate handwashing behaviour.
The Programmatic intervention of BRAC
To address these barriers, BRAC has taken an ambitious initiative. BRAC Communications team has been disseminating video messages to make people habituated with the practice of washing their hands with soap. Under this initiative, BRAC WASH programme aims to install 1,000 Hand Washing Stations (HWS) in public places across 20 sub-districts of Dhaka, Mymensingh, and Khulna divisions by the end of this year, and motivate people to wash hands with soap regularly. There are two-fold objectives – to begin with, people will have handwashing facilities outside their homes, and secondly, this will nudge people to develop handwashing habits at home.
However, since we are talking about behaviour change, it is better to integrate the interventions within existing good practices. Behaviours are hard to change – the adoption of entirely new behaviour is even harder. Adding nudges within the existing practices is one way of achieving this objective. For example, making soaps available in mosques and shared handwashing facilities, and conducting in-person demonstrations on handwashing using Behavioral Communication Change (BCC) materials in these facilities may inspire people to wash hands more frequently and accurately.
¹ Respondents were requested to capture some pictures and videos of their daily COVID-19 experiences and then asked them to send those visual contents to the researcher team using virtual social platforms.
² This study used some shadow observations through which we wanted to get some insights from BRAC field workers’ observation and perception.
Sonia Afrin and Tanvir Shatil are Research Associates and Atiya Rahman is a Senior Research Associate at the Economic Growth and Development team at BIGD, Brac University.
