Structured observations of handwashing with IDP populations


The Field Epidemiology Manual provides a set of core training materials reflecting the essential competencies required by intervention epidemiologists.

Structured observations of handwashing with IDP populations

This question is not answered


I am wondering if anyone has any advice on conducting structured observations in sensitive situations.

I am hoping to conduct, as part or some formative research, structured observations of handwashing within households in the IDP camps of Myanmar. However, concerns have been raised about conducting structured observations within the households here. It is thought that as we are working in camps with conservative Muslim populations it is unlikely that the households will agree to a female enumerator entering to conduct observations since cultural norms do not allow a female to be in the presence of an unknown male.

Suggestions were made around using two female enumerators, however this may also be unacceptable.

 I am wondering if you know of any solutions or ideas around this situation, and what alternative and valid methods are used to measure/assess handwashing in this case?

Thank you

All Replies
  • Hi researcher,

    It would be good to know a bit more about the nature of the observations. Does the observator have to watch how the actual hand washing takes place? Or only to observe the place where it happens?

    Would it be an option to ask the families to take a short video with a smartphone? In that way they do not have to invite any strangers to the household. An additional advantage could be to reduce observer bias.

  • Hi researcher,

    this is a situation where you could profit from local anthropologist advise.

    Maybe firstly you can carry interviews with heads of families in a limited pilot sample? Just to have a qualitative "feeling". Is it possible to use local health structures?  

    It seems there is Field epidemiology training program in Myanmar, they may have a couple of hands (or brains) to share.

    Vladimir Prikazsky

  • Hi researcher,

    In any observational/ethnographic research, but particularly in sensitive or private settings, it will be essential for you to have a supportive informant (local health worker?) who can provide introductions and cultural/linguistic interpretation. The female enumerator may have to be accompanied on household visits.

    The smartphone video option suggested by Arnold Bosman is a good one: the video could then be viewed by the enumerator and a (female) household member for description and interpretation.

    Lisa Hansen

  • a nice recent publication using mixed methods to assess IPC compliance:

  • Hello there,

    Thanks very much Lisa for highlighting our recently published article which explains the use of structured observations to assess hand-washing in health facilities during the Ebola outbreak in Sierra Leone. We drew inspiration from this article, which does something very similar in terms of measuring handwashing events among mothers in a shanty town in Peru (and shows the appropriate means of analyzing the data using generalized estimating equations with robust standard errors):

    I understand you are working in the camps (perhaps overlapping in the camps in Rakhine State where IRC works in Myanmar -- if so, feel free to get in touch). The issue of who can remain in the household is a tough one. And additionally, it may not be possible to find a good solution if it's such a distraction in that it influences the behaviours of hand-washers and carries a heavy observer bias. Structured observations are inflexible in that way.

    I would suggest an alternative. In the WASH world, acceleration sensors have been added to soap to monitor use without observations: (a great read)


    This might be a nice alternative if you can budget for it.

    All the best,

    Ruwan Ratnayake

    Epidemiologist, International Rescue Committee

  • Indeed,the rule for a lady not to be with a man (blood unrelated) is well known by most religious groups (Muslim), but the local scholar leaders or Imams should be able to explain the context and altenative approaches to overcome  or address this issue. My  understanding is that, a witness (closely related to the lady or man)  needs to be present. Again the Imam should be able to explain it. The rules are very clear and often very flexible than one can imagine!

    If you decided to use Smart phones, ethical approval will be needed and I don't think that many men will allow the pictures  of their wives to be taken without clear explanation. The men need to be very well informed, and probably be present (if possible). If religious leaders and men (husbands) accepted your research study conditionnally,  the  women (hopefully they will agree) will have the final word.

    My suggestion: you want to interview or observe my wife cooking or washing, let me be (present) with you then you will have no problem!

    Best wishes.

  • Hi Arnold,

    Thanks for your reply.

    The observer will need to observe when hands a washed (e.g. before eating), if soap is used, and if handwashing is independent or aided by a caregiver.

    I would be concerned that the families using a smart phone themselves would mean we would only see when optimal handwashing is practiced and also not document lack of handwashing after key events.

  • Hi everyone,

    Many thanks for all the very helpful responses.

    Indeed, it sounds like a good option would be to use sensors, though I think it may present a budget problem for this project. Do you know the cost of putting sensors inside of soap?

    In terms of the husband being present, this is no problem and if it would mean an accompanied female enumerator could enter then perhaps this is an option..

    We will hopefully have the support/advice of hygiene promoters and I will speak to the community first to understand more of what is and is not acceptable.

  • Dear researcher, thanks a lot for initiating this rich exchange.

    The outcomes of your study will be of interest for most of us. Personally I am working with a group on understanding motivators for hand-washing behaviour better, so that they may be targeted with specific tools such as game based interventions.

    From that perspective, our group is very interested if you will also look at motivation and attitude in your study. Is it possible to share a bit more information about the study questions and expected outcomes / hypotheses?

    Thanks again

  • I'm curious about the rationale for conducting structured observations, versus alternate modes of data collection - interviews, surveys, etc.

    Why does this particular study call for structured observations? Is it to test a hypothesis regarding field methodologies?

    And what is the intent behind studying hand-washing? Is there a hygiene problem leading to high rates of disease transmission within the camps?

    Are there infrastructure barriers - lack of clean water, indoor plumbing, wastewater disposal, etc. - that could better account for the problem? Focusing on hand-washing may inadvertently place blame on household members for infrastructural problems beyond their control.

    The technical solutions seem unnecessary and excessive - a bar of 'digital soap' probably costs more than a week's income for the refugees.

    Recording video in a private space seems highly intrusive and may be objectionable to many as a form of spying on people already suffering from political persecution; it also seems to imply the household members don't know how to properly wash their hands, which may be taken as insulting.

  • Hello,

    Thank you again for the interesting debate.

    We will be trying to understand motivations and attitudes towards child handwashing in this population during the formative research phase of the project and this will shape the handwashing intervention.

    The formative research aims to answer:

    1. What are the current handwashing practices of children 5-12 within households in selected camps

    2. What are the current barriers and enablers to child handwashing with soap (HWWS) within the household

    3. Who is responsible for children HWWS in the household

    After this we will aim to iteratively develop an intervention around a novel soap using 'trial of improved practices' methodology.

    We would ideally like to use structured observations to minimise reporting bias, though if we find this is not possible or acceptable in this population we will have to consider the methods (for which I am seeking advice here).

    This project is funded by a grant from the Humanitarian Innovation Fund and the primary aim of the research is to develop a handwashing intervention for children in emergency populations that is acceptable, feasible and cost-effective.

    There are high rates so childhood diarrhoea in these camps, especially in the rainy season, and with limited funding we can't also address the water and sanitation infrastructure, however, there is good evidence that HWWS reduces diarrhoea and other communicable diseases such as respiratory infections.

  • PS. Apologies for my delayed response, the emails were going to my junk email folder which I have only just realised, so have only just seen your additional messages

  • What about measuring the rate at which the household consumes soap?

    Presumably, the more handwashing, the more soap that gets used up. Are there relatively accurate ways to track inventories in target areas -- perhaps working with the suppliers / distributors -- without needing to enter the households?

    Also, what about availability and accessibility of soap for the study population? Is it sold via retail outlets or distributed through other channels? Are there quotas or other limits on supply? In conditions of extreme poverty, households may view soap as a nonessential purchase compared with food items.

    Could a successful interventional study involve producing statistical evidence of increased soap consumption accompanied by reduction in childhood diarrhoea within the target population?

  • Thank you for reply.

    I think measuring soap consumption would be a good idea as it is low cost and less invasive.

    There is another partner in the project who is planning to conduct a soap market analysis so hopefully this can contribute to our knowledge on the availability and accessibility pf soap for the study population.

    We also hope that if the TIPs study is successful we may seek further funding to do a larger scale intervention study, so in this case looking at childhood diarrhoea rates may be a good indicator of intervention effect