Rural and peri-urban households’ handwashing behaviour before the COVID-19 pandemic: Implications for managing it in North-western Ghana

Abstract

Good hygiene and handwashing remain important in public health, particularly in localities with low or no basic water and sanitation facilities. Using the Integrated Behavioural Model for water and hygiene, this study analysed key factors that shape handwashing behaviour and practices and the implications for managing the COVID-19 pandemic. The study was conducted using 20 rural and peri-urban communities in Ghana. Data gathered from 332 households and 20 focus group discussions indicated respondents have considerable knowledge of the significance of effective handwashing with soap, especially at critical moments. Although the practice of handwashing has been promoted in all the study communities, none of the households had a handwashing station. The respondents however argued that the absence of a handwashing station does not imply they do not wash their hands, especially at critical moments. Access to water, ability to buy soap, gender, and long hours of staying on distant farms shaped handwashing behaviour and practices. Although the study was conducted prior to the COVID-19 pandemic, the findings have substantial implications for the fight against the pandemic. Given that households are knowledgeable of the importance of handwashing, re-iterating the practice and intensifying advocacy on behavioural change, especially in the COVID-19 pandemic will reinvigorate handwashing.

Keywords:

• Critical handwashing moments
• handwashing behaviour
• COVID-19 pandemic
• Ghana
• Integrated behavioural model

1. Introduction

Hygienic practices, particularly handwashing, are irreplaceable in the improvement of public health (Prüss‐ustün et al., 2014). Hygiene of the hands is among the most effective and inexpensive ways of reducing the spread of infectious diseases such as pneumonia and diarrhoea, the two leading causes of child morbidity and mortality globally (Kenney et al., 2020; Kumar et al., 2017). Hand hygiene is recognized to reduce diarrheal infection by 30–47%, respiratory infections by 16%, and reduces the risk of gastrointestinal and respiratory diseases (Ejemot-Nwadiaro et al., 2021). It is identified as a primary measure to minimise healthcare-associated infections and up to 30% of infections can be reduced through excellent hand hygiene practices (Ataiyero et al., 2023; Weston, 2013). Results from a systematic review show that frequent handwashing has a large and significant protective effect against pandemic influenza and frequent handwashing is linked to lower rates of hospitalisation during influenza season (Howard et al., 2020; (Saunders-Hastings et al., 2017). However, the lack of appropriate hygiene practices continues to be the third-largest contributor to the global burden of diseases (Global Handwashing Partnership, 2017). Good hygiene and handwashing, in particular, are important in regions with low or lack of basic sanitation (Hirai et al., 2016).

It is in this regard that the United Nations Sustainable Development Goals (UN SDGs), specifically target 6.2 places emphasis on hygiene, especially handwashing with soap (Adane et al., 2018). Despite the significance of handwashing in reducing hygiene-related diseases and minimising transmission of infection, its compliance is minimal, particularly low in sub-Saharan Africa (Adane et al., 2018; Srigley et al., 2015). Additionally, the availability of handwashing facilities is higher in urban than in rural areas (WHO/UNICEF, 2019). To promote handwashing, the installation of handwashing facilities is argued for as a measure to increase the practice of handwashing among households (Wolf et al., 2019). However, based on a review of handwashing practices and facilities availability and using 115 data points from 77 countries, Wolf et al. (2019) found that one in four persons does not have designated handwashing facilities, and even where there are facilities, 51% were observed to have practised handwashing.

Studies have also established that although handwashing appears to be a simple task, its practice is high in households with higher income and socioeconomic status, higher educational levels, females, and access to water (Hirai et al., 2016; Schmidt et al., 2009). Poverty, a particular household income indicator, is directly linked to handwashing behaviour (Adane et al., 2018). Low-income households often use soap cautiously to save money for other household expenses (Luby et al., 2011). The link between poverty, the educational level of households, and handwashing practices has implications for poverty-ridden areas in Ghana. Poverty in Ghana is mainly a rural phenomenon and the rural Upper West Region has the highest poverty index, with a Palma index of 2.22 (Ghana Statistical Service, 2018). This suggests that rural and peri-urban households may be more vulnerable to hygiene-related risks.

In Ghana, organisations (both non-state and state agencies) have been promoting handwashing practices. Although over 50% of households in Ghana have assigned places for handwashing and other related practices, less than 20% have water and other materials for cleansing (UNICEF, 2019). In recent times, so much has been researched into handwashing behaviours in urban settings and public places (commercial centres, schools, and health facilities) where the population is concentrated (Fianko & Akosua Gawu, 2020; Fielmua et al., 2021; Kweku et al., 2020; Labi et al., 2019; Prah et al., 2018; Yawson & Hesse, 2013). This creates a handwashing behaviour knowledge gap in rural and peri-urban areas, especially in deprived regions of Ghana. This study presents a nuanced perspective of household hand hygiene services and practices in rural and peri-urban communities in the Upper West Region where livelihoods are still poor and the poverty level remains highest (70.9%) (Ghana Statistical Service, 2018). Although the study was conducted before the COVID-19 pandemic, the findings have substantial implications for the fight against the COVID-19 pandemic.

2. Integrated behavioural model for water, sanitation, and hygiene

Handwashing is a behavioural issue in many settings and, as such, the presence of a handwashing facility or station can shape handwashing behaviour and practices. To examine hand washing behaviours in rural areas, a behavioural model that considers the technology of the phenomenon is required. As such, this study employed the Integrated Behavioural Model for water, sanitation, and hygiene (IBM-WASH) to examine handwashing services and behaviours in the communities. To better situate the IBM in handwashing, we define a hand washing facility or station as a dedicated device located at a strategic and convenient area with soap and water available for handwashing. The global indicator for hygiene in household settings is access to handwashing station with soap and water on the premises (UNICEF, 2020).

The Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) (Dreibelbis et al., 2013) provided a theoretical framework to examine people’s behavioural patterns in WASH. The IBM-WASH model is an interactive matrix framework of three intersecting dimensions: contextual, psychosocial, and technological factors which influence WASH practices and behavioural patterns, operating across five levels of organization: societal/structural, community, interpersonal/household, individual, and habitual (Dreibelbis et al., 2013; Kuhl et al., 2021; Kostas-Polston et al., 2022). These three interacting dimensions describe the mutual interactions between the individual, the behaviour, and the environment in which the behaviour is practised. Household-level technologies such as handwashing stations are meant to instigate hand washing with soap (Dreibelbis et al., 2013).

The IBM-WASH Model was constructed from a synthesis of research on multi-level behavioural change models to identify interrelated factors that contribute to enteric diseases in low-income countries and to develop low-cost technology to prevent/minimize morbidity and mortality (Kuhl et al., 2021; Kostas-Polston et al., 2022). Unlike other behavioural change models and frameworks, the IBM-WASH model distinctly acknowledges the impact of technology as well as the physical and natural environment on hygiene knowledge, behaviours, and outcomes. As stated by the IBM-WASH framework, hand washing with soap requires some level of technology constituent and the characteristics of this hardware can influence behavioural outcomes. However, the location of the technology and access to the hardware such as water and soap, and the convenience in access and use of the technology may either facilitate or hinder hygiene behavioural practice (Dreibelbis et al., 2013; Luby et al., 2009). The study identified, linked, characterized, and operationalized WASH concepts from research findings within the interactive matrix framework of the IBM-WASH model.

3. Study Context

The study was conducted in the Wa Municipality of the Upper West Region of Ghana (see Figure 1). Wa Municipality has a population of 200,672 as of 2021. The average household size of the Municipality was 3.9 with a total of 190,962 households living in 49,500 houses (Ghana Statistical Service, 2021).

Figure 1. Map of the study in regional and national context.

The data for this paper was part of WaterAid Ghana’s formative research on water, sanitation, and hygiene (WASH) behaviours in 20 rural and peri-urban communities in the Wa Municipality. Hence, this paper was carved out of the research that was carried out between January and April 2018. The aim of the research was to understand existing hygiene and sanitation practices and their determinants and to prioritise key hygiene behaviours for addressing them through relevant and appropriate hygiene promotion activities.

4. Materials and methods

4.1. Research design

This study employed a cross-sectional study design. The essence of this design was to ensure a holistic aggregation of data inputs by all households to adequately reflect their current hygiene and handwashing practices. The study was conducted in 20 selected communities. The communities (Figure 1) were purposely selected because they are WASH targeted operational areas of WaterAid Ghana, the organisation that funded the data collection. These communities have also benefited from WASH interventions rolled out by WaterAid Ghana in the Upper West Region. Simple random sampling was used to select the houses in the selected communities. This method was used because the settlements have either a nucleated or dispersed pattern. One household in each house was surveyed through a convenient sampling method—the availability of an adult who is knowledgeable of the household and its water, sanitation, and hygiene behaviour and practices. In the rural areas, there were instances when a house is occupied by one household. The focus of the study was on WASH behaviours in and around houses and as such the sample size was determined using the total number of houses. This was necessary for unearthing households’ perspectives on the subject area since the focus of sanitation and hygiene is often on the house with little emphasis on the household. Thus, the behaviour of a household in terms of sanitation and hygiene is likely to affect the entire house.

4.2. Sampling

The total number of houses in the 20 communities was 1,935. The sample size was determined using a simple sample size formula by Yamane (1967) as follows:

$\mathrm{n}=\frac{N}{1+N{\left(e\right)}^2}$ Where “n” is the sample size, “N” is the total number of houses, and “e” is the level of precision. Using the equation, $\mathrm{n}=\frac{1,935}{1+1,935{\left(0.05\right)}^2}$ Therefore, $\mathrm{n}=332$

The sample size for all the 20 communities is 332. This was distributed to the communities proportionally. The sample size determination was based on the argument by Teigen and Jørgensen (2016) that at 95% confidence interval (CI), there is a high probability of increased precision of results and minimization of variability which allows for generalization of findings. Table 1 shows the population, households and the sample size.

Table 1. Descriptive statistics of the population and sample size

Descriptive	Population of communities	No. of houses	No. of Households	Household size	Sample size
Mean of 20 communities	1057.7368	101.8421	187.2632	6.8158	17.4737
Std. Deviation	754.44519	60.51929	205.96516	2.00340	5.02625
Minimum	193.00	21.00	22.00	3.40	10.00
Maximum	3120.00	232.00	865.00	10.70	29.00

As shown in Table 1, the mean sample size of the communities was 17.4737 with a wide standard deviation. The descriptive statistics showed that there are wide differences in the population, households, and household size among the communities.

4.3. Data collection methods

The main tools for the study were a household questionnaire, a checklist for focus group discussions (FDG) at the community levels, and a checklist for observation of households’ handwashing stations. The households’ perspective, using the survey, was complemented by FGD with community opinion members/leaders, who were not part of the household survey, and observation of handwashing stations and practices. The key areas of the study instrument were: the availability of handwashing facilities; materials used to perform handwashing; frequency of handwashing; knowledge of handwashing moments; and factors that impede handwashing practices. The FGD was conducted in all 20 communities to complement the household survey. All focus groups consisted of between 7 and 12 participants, comprising men, women, and youth and this represents a cross-section of the communities. The participants of every FGD consciously included between 3 and 6 members of the Water and Sanitation (WATSAN) Committees. A WATSAN Committee is a voluntary body established in each community and charged with the responsibilities of devising strategies for operation and maintenance of water and sanitation facilities, and enforcing the community-level rules regarding good hygiene and sanitation practices in the community. It was observed throughout the FGDs that there was no dominance of one age group or gender over the other and all participants freely expressed themselves on the subjects being discussed. Observation of actual handwashing practice was done since it has been established that handwashing recorded during observation is the best means of measuring handwashing behaviours (Wolf et al., 2019). As such, we observed handwashing practices as and when it was practiced, especially during the household survey and focus group discussions. We also observed the availability of handwashing station or evidence of such stations ever existing (remains of broken-down handwashing station). We employed hidden observation (Sarantakos, 2012) in which handwashing practices were observed without the knowledge of the participant (person practising it).

The tools were administered in the local languages (Waali and Dagaare) because the researchers are fluent in the local languages and this was done to ensure detailed and quality data collection. Community and household entry protocols were observed during the study. The community and household entries revealed that the respondent’s level of education was low and could not speak or understand English, hence the use of local languages.

4.4. Data analysis

The administered household questionnaires were cleaned and edited before being entered into the statistical package for social sciences (SPSS version 21) for analysis. Descriptive statistics were used to analyse variables of interest. Thematic analysis was used for the qualitative data which was obtained from the FGDs and the open-ended questions in the household questionnaire. The main themes were as follows: availability of handwashing facilities; knowledge of handwashing materials; and critical handwashing moments. The thematic analysis also helped in identifying pattern in the data (Flick, 2013). In this study, field data (empirically-based pattern) was compared with what has been established in the literature and what is known before the data collection (Yin, 2018). For instance, we pattern-matched the literature on handwashing (Luby et al., 2011) with the field data on handwashing at critical moments. In an explanatory case study, a pattern might relate to the “how and why of the case” (Yin, 2018 p.251). Therefore, based on the COM-B framework, we explained the perspective of the households on the use of soap/ash to wash hands and how often they wash hands. Households’ views on a particular hygiene behaviour were analysed and triangulated with the FGDs on the same handwashing behaviour in order to increase internal validity. We acquired and used high-quality audio recorders for recording the focus group discussion. The audio recordings were transcribed and analysed. Where appropriate, direct quotations from the participants were used to strongly convey their perspective on handwashing. The three constructs of the IBM-WASH framework were applied in the analysis because they are the key factors that influence handwashing behaviours and interventions. Using the IBM-WASH Framework, we did draw implications for the management of WASH-related diseases and the COVID-19 pandemic, especially in rural areas of developing countries.

4.5. Ethical approval

WaterAid takes seriously a responsibility to uphold the dignity of the people they work with. As such, the study went through the ethical protocol of WaterAid. The methodology and tools in particular were reviewed by WaterAid Ghana and WaterAid United Kingdom. A team from the United Kingdom came to the project area and together with WaterAid Ghana and the Consultants thoroughly reviewed the tools before the fieldwork. The consent of the participants was sought and recording only proceeded after the participants orally consented. At the end of the study, a validation workshop was organised involving key stakeholders in WASH, including representatives of some of the communities. The essence of the validation workshop was to ensure that the findings represent the communities and that no findings jeopardise the communities.

5. Results

Households’ handwashing behaviour was analysed in terms of availability of and access to handwashing stations at home; knowledge of materials for handwashing; and critical times and frequency of handwashing. The background of respondents was analysed to better situate handwashing among households.

5.1. Background of household respondents

The background characteristics of the participants include gender, age, marital status, religion, educational level, and main occupation. An understanding of these characteristics is important in appreciating the responses and perspectives of handwashing behaviour in rural and peri-urban settings. Table 2 presents the details of the characteristics.

Table 2. Characteristics of participants

Variable	Definition	Frequency	Percent
Sex	Male	191	57.5
	Female	141	42.5
Age	Less than 20 years	6	1.9
	20-30years	69	20.8
	31-40years	69	20.8
	41-50years	80	24.2
	More than 50years	108	32.4
Marital Status	Married	290	87.4
	Single	16	4.8
	Widowed	26	7.7
Religion	Christian	112	33.8
	Islam	197	59.4
	African Traditional	23	6.8
Education	No formal education	228	68.6
	Primary education	35	10.6
	JSS/Middle School	43	13.0
	Vocational/Technical	5	1.5
	Secondary/O’Level/A’Level	13	4.8
	Tertiary	8	2.4
Main occupation	Agriculture (Farming/Rearing)	306	92.1
	Commerce	7	2.3
	Small Scale industrial activities	7	2.0
	Public/Civil Service	3	1.0
	Artisans	9	2.6

Source: Fieldwork, 2018

The dominant religion is Islam, comprising 59.4% of households’ respondents and this confirms Wa Municipality as a Muslim-dominated municipality in the Upper West Region. The dominance of Islam and Christianity in the Municipality has implications for the design of handwashing communication strategies for behavioural change. The converging points (mosques and churches) of these religious segments can be used as a medium for disseminating handwashing information to households. There is a generally low level of formal education in the communities, with 68.6% of the households’ respondents not attaining any form of formal education. Although 10.6% of the household respondents (Table 2) have had primary education, interaction with all of them indicated that they could not read or write, neither could they speak English fluently nor understand it. As such, any design of hygiene intervention and communication strategy, especially handwashing during the COVID-19 and beyond, has to be based on the local language. Economically, 92.1% of the households were engaged in subsistence farming. In terms of sectors’ contribution to poverty, subsistence farmers are the worst hit in terms of poverty in rural areas in the Upper West Region (Ghana Statistical Service, 2018).

5.2. Availability of handwashing stations at homes

The household survey revealed that none of the households or houses has a handwashing station. However, the focus group discussions in 16 (84.2%) of the communities showed that households were trained on the construction of home-based handwashing stations such as tippy taps. Tippy-taps are locally constructed handwashing devices used in houses or households that are without access to piped water. This was also confirmed through observation during the household survey where it was observed that some households constructed handwashing stations. Although 47.3% of the household respondents mentioned that handwashing facilities were necessary, our observation showed that only 23% of the houses visited had evidence of a handwashing station ever constructed but had broken down. In terms of spatial differences, 45.6% and 51.7% of respondents in rural and peri-urban areas in the study indicated that handwashing facilities are necessary. According to participants of the FGDs, some households did not reconstruct the stations after they collapsed because the households had developed indolence in the use of the handwashing station. Instead, they opted to wash their hands within the yards after toilets or any other activities that require handwashing. The respondents argued that the absence of piped water and handwashing stations does not signify that households do not wash their hands. All the respondents maintained that they fetch water from water storage facilities (containers, pots and poly tanks) to wash their hands after engaging in activities (going to toilet, cleaning children faecal and upon return from social gatherings) that demand hand hygiene. They maintained that households developed the habit of handwashing with soap or ash before the introduction of handwashing stations, especially the tippy taps.

The FGDs further revealed that children tend to waste water and soap at the handwashing stations when they use the facilities unguided. This is because when the handwashing facilities were constructed, they were accessible to all household members, including children. In terms of households’ sources of water, only 1.5% of the households have water connections to their homes (on-premises connections). The remaining 98.5% of the households relied on the community boreholes, public standpipes, and hand-dug wells for water supply for domestic and other uses. This challenged the refilling of tippy taps containers, affecting the sustainability of handwashing stations.

At the household level in the communities, about 85.8% of the respondents hold the view that the presence of a handwashing station does not necessarily incite handwashing habits because handwashing with soap is a habit that cannot be acquired by the mere presence of a handwashing station. The rest (14.2%) rather think that the presence of a handwashing station reminds individuals to wash their hands after certain activities.

5.3. Knowledge of materials for handwashing and emerging challenges

In terms of knowledge of the materials used for handwashing, all the respondents mentioned soap (solid or liquid) and water as materials that should be used to wash hands, especially after certain activities that are likely to expose one to microbes. Only 22% of the household respondents further mentioned ash and water as materials to be used in handwashing. During the FGDs, discussants gave reasons for the use of soap and water to wash hands. These include: to remove dirt/germs; and to be clean and to prevent disease causation. Respondents did not use mud for handwashing activities though they acknowledged it as a material for handwashing activities. A household head in a community said: Mud was used to wash hands but unfortunately, the mud we have these days is contaminated with agrochemicals and mercury used in farming and mining respectively and it may be even more dangerous to use mud than using only water (excerpts from household survey, 2^nd March 2018)

While the conversation suggests that handwashing with mud is no longer practised because of fear of contamination of soils, some households still use ash and water as materials for handwashing.

All the respondents agreed that handwashing is a good practice, but it is extremely difficult to practice handwashing at all times. The households survey and the FGDs revealed that the key determinants of handwashing with soap in a particular household depend on the financial position of households in terms of ability to buy soap and pay for accessing water services; knowledge of good substitutes to soap (ash); and activity cycle in terms of which activities take place outside the home. About 95.8% of the respondents mentioned that soap is expensive; hence many of their household members do not wash their hands with soap regularly. For these respondents, they are unable to buy soap for laundry, washing dishes, bathing, and further providing soap for all household members to practice handwashing before and after certain activities.

In addition to the challenges in accessing soap, 96.1% of the respondents indicated that they undertake many activities outside the home, making it difficult to effectively carry out handwashing with soap, especially after certain activities. About 91.8% of the respondents are peasant farmers and during the rainy season, household members spend much time on the farms and, as such, are required to carry water to the farms. It is practically impossible to carry enough water to farms to be able to meet handwashing requirements, especially at critical times. This reduces handwashing practices on the farm. For example, a member of a FGD indicated that during farming season, it is practically not possible to carry soap to another person’s farm during contract farming just in case one would want to defaecate. Contract farming is peer-support farming whereby a group of individuals supports each other in their farming activities on a rotational basis. Similarly, it is not possible to expect the beneficiary of the contract farming to provide soap on the farm in anticipation of the people wanting to defaecate. Activities of this nature make handwashing with soap difficult to practice at all times.

A participant of a FGD indicated that handwashing with soap cannot be compulsory before eating because individuals’ biological systems vary. Citing himself as an example, he indicated that:

I cannot wash my hands with soap and eat immediately, no matter the quantity of water used and the frequency of rinsing my hands after using soap. Due to the scent of the soap on my hand, if I dare eat, I will throw up. I will have to wait for about 30 minutes after washing with soap before I can eat. I have represented the community in many fora in Wa, especially at In-Service Training Centre (hotel), but I never used soap to wash my hands before eating (Excerpts from FGD, 14^th March 2018).

The above quotation shows that while the respondent is knowledgeable of the significance of handwashing with soap, his human biological system is reactive to soap when used for handwashing before eating.

5.4. Critical handwashing moments and frequency of handwashing

Certain moments are considered critical and, as such, handwashing with soap before or after those moments is necessary. Public health and the WASH sectors have identified five critical times as necessary for handwashing and these times are: (i) after defecating; (ii) after handling a child’s faeces or cleaning a child’s anus; (iii) before preparing food; (iv) before feeding a child; and (v) before eating (Luby et al., 2011). Using an open-ended question, the study sought the views of household respondents and the FGD participants on critical times at which handwashing with soap is necessary. The responses from the household survey and the FGDs were synthesised. Interestingly, the respondents also identified the above five critical moments as necessary for handwashing, suggesting that respondents have good knowledge of hygiene and handwashing. In addition to the five moments, the respondents identified other critical moments that are somewhat peculiar to their socio-economic arena. These moments are: (i) after gathering rubbish or sweeping compound; (ii) before preparing food—some women even take their bath before preparing food; (iii) after cleaning toilet facility; (iv) when one gets in touch with a harmful chemical substance, especially during the farming season when farmers use weedicides, pesticides, and insecticides; and (v) during and after funeral activities—after burying a corpse and after greeting people at funeral ground.

Analysis of the FGDs transcripts showed that funerals activities have become common events in the communities. The varied activities at the funeral ground (playing traditional instruments, shaking hands, touching and burying corpses, food preparation) make handwashing with soap very significant. The activities listed by the respondents revealed that knowledge of handwashing is gaining ground in the communities. However, what is required is an enhanced positive attitude to pave way for enhanced hygiene behaviours in the communities. Gender-wise, opinions from the various FGDs indicated that women are more mindful than men in terms of handwashing because of the nature of women’s activities (including sweeping, cleaning babies’ faeces and food preparation). A FGD participant jokingly said:

… Women are more conscious of handwashing with soap than men. As for many of us (men), the only time soap is used is when we bath … (Excerpts from FGD, 28^th February 2018).

This is to emphasise the fact that women are more hygiene-conscious than men.

Furthermore, household respondents were required to indicate the frequency of handwashing with soap in selected activities. The question was, do all household members wash their hands during the following activities (Table 3) which were listed for participants to select. Table 3 shows the activities and the frequencies (always, sometimes, and never) at which households wash their hands.

Table 3. Frequency of handwashing during certain activities by household members

Activities	Always		Sometimes		Never
	Freq	%	Freq	%	Freq	%
After changing babies’ nappies or cleaning babies’ faeces.	202	60.9	51	15.5	78	23.6
Before handling food and food preparation	282	85.0	50	14.5	2	0.5
Before eating	293	88.4	35	10.6	3	1
After house cleaning, work and/or disposing of rubbish	244	73.4	80	24.6	6	1.9
After a visit to the toilet	274	82.6	47	14.1	11	3.4
Average		78.06		15.86		6.08

The results show that not all respondents washed their hands with soap before the selected activities. That is, the fact that not 100% of the respondents always wash hands with soap before eating, cooking, and managing children’s faeces demonstrates that appropriate authorities (public health and WASH sector players) would have to intensify advocacy and sensitisation for the promotion of handwashing with soap after certain critical activities. In terms of geographical difference, an average of 77% and 80% of the respondents always wash their hands in all five handwashing moments in rural and peri-urban areas respectively. There is no household in peri-urban areas that does not wash hands before handling or preparing food and after cleaning the house. On the contrary, 2.7% of the respondents in rural areas never washed their hands before preparing/handling food and after cleaning the house. Generally, there is a slight improvement in handwashing practices in peri-urban areas than in rural areas, although there are no designated handwashing stations in both rural and peri-urban areas. Therefore, the absence of handwashing stations in these communities reduces the chance of handwashing practices and this is likely to affect efforts to minimise water and sanitation-related diseases and the COVID-19 transmission.

6. Discussion

The focus of the paper is to understand hand hygiene behaviour in rural and peri-urban communities prior to the COVID-19 pandemic and to draw implications for managing hygiene-related diseases, including the COVID-19 pandemic. The study findings were subjected to the IBM-WASH framework to draw out the implications of contextual, psychosocial, and technological factors of handwashing on public health, especially water and sanitation-related disease management.

Geographically, the study was conducted in the Upper West Region of Ghana where the majority of the people who are below the poverty index are subsistence farmers (Ghana Statistical Service, 2018). This suggests that the majority of the respondents might be within this poverty index because a substantial percentage (92.1%) of respondents in this study are engaged in subsistence farming. Although this formative research did not include the income levels of respondents, previous studies have also established that household income level has a bearing on handwashing (Fielmua et al., 2019; Luby et al., 2011; Woode et al., 2018). It was also established that household size and income level affect the ability to buy soap for all uses including handwashing in rural areas (Fielmua et al., 2019; Luby et al., 2011; Woode et al., 2018). This is particularly significant in this study where the average household size is eight with a standard deviation of 2.571. This means that subsistence farmers which constitute the majority of the rural population in the Upper West Region could have financial difficulty in providing handwashing stations for handwashing activities.

A critical contextual factor in handwashing is access to water and the availability of water at the handwashing station (Hulland et al., 2013). All households in the communities have physical access to different sources of water. In eight out of the 20 communities studied, the main source of water is piped borne (limited mechanised borehole) and water is accessed through pay-as-you fetch. Similar to the findings of Foster and Hope (2017), the household survey and the FGDs revealed that pay-as-you fetch restricts access to adequate potable water for multiple uses, including handwashing. While Staddon et al. (2020) acknowledged that lack of access to indoor piped water limits handwashing practice, the 98.5% of the households in the study that relied on point water systems (boreholes with hand pumps) for water supply performed handwashing by fetching water from storage containers. Contextually, handwashing has a gender dimension even in the absence of a handwashing station. Gender-wise, the participants acknowledged that women are more hygienic and conscious of handwashing than their men counterparts. A balance of the gender dimension of handwashing is critical in managing diseases such as COVID-19. Therefore, when implemented appropriately, handwashing with soap has the capacity to fight COVID-19 (UNICEF, 2020).

Effective handwashing goes with the use of soap (Howard et al., 2020; Hulland et al., 2013; Luby et al., 2011). Yet, the cost related to handwashing with soap is high (Woode et al., 2018) as households are required to buy soap for all uses including handwashing. Several studies including Luby et al. (2011) acknowledged that although the cost of soap is less expensive for wealthier households, its affordability remains difficult for poor households. Soap is reported to be expensive by over 66% in Pakistan, 39% in Bangladesh, 62% in Nepal, and 75% in the Aboriginal remote communities in Australia (McDonald et al., 2015; WaterAid, 2020). Therefore, as long as pay-as-you fetch is the mode of accessing water coupled with the cost of accessing soap for all household members continues to exist, the campaign on handwashing under running water as a measure to curb the COVID-19 pandemic and other water and sanitation-related diseases could be compromised in the Municipality and rural communities that practice pay-as-you fetch. Also, although mud is used as a cleansing material (Biran et al., 2008) and is cost effective, it was not mentioned as the main material for handwashing in the study. In addition, handwashing during the farming season becomes difficult especially during contract farming when the beneficiary farmer does not provide materials for handwashing in anticipation that farmers will go for defecation. These findings reaffirm the findings of Hulland et al. (2013), that varied activities of households made the use of the station ineffective as many activities took place outside the home or at different locations.

Structurally, government and NGOs have developed a deeper interest in hand hygiene and WaterAid Ghana, in particular, has been supporting hand hygiene and water services in Ghana. However, as the psychosocial dimension of the IBM-WASH model suggests, the beliefs of the individuals determine their hygiene behavioural practices and can lead to improved handwashing practices (Mosler et al., 2010). Our study established that individuals had the habit of handwashing at certain critical times and this is based on their knowledge of disease infection. As defined by the psychosocial dimension of the IBM-WASH model, pre-existing habits influence hygiene behaviour practices (Dreibelbis et al., 2013). A study in Kenya reported a higher degree of handwashing among respondents with prior handwashing habits than those with less developed habits (Aunger et al., 2010). On the other hand, the fact that some households openly indicated that they never washed their hands after critical activities imply that they are potential carriers of pathogens and this had the potential to threaten the management of the COVID-19 pandemic and other water sanitation-related diseases. Intriguingly, some individuals are knowledgeable of handwashing, yet their biological makeup cannot withstand the scent of soap. As such, some individuals do not wash their hands with soap before eating because they have suffered vomiting after eating due to the scent of the soap. While there are calls for handwashing with soap during the COVID-19 pandemic (WHO, 2020), individuals who cannot wash their hands with soap run the risk of infection.

The sociocultural context of a community also influences WASH behaviours and hygiene behaviour, in particular, is influenced by cultural and social norms (Winter et al., 2019). Socially, funeral rites in the study area involve so much social gathering and laying in state of corpses poses a risk to mourners/sympathisers. As such, respondents identified funerals as a critical activity that requires handwashing but the use of soap cannot be guaranteed. It is striking to note that the list of handwashing moments as mentioned by respondents signifies that the households are knowledgeable of handwashing with soap although they do not have handwashing stations. Despite the knowledge of households on critical times for handwashing, studies showed that handwashing is less likely to occur if a handwashing station is located off-site or water has to be fetched from somewhere for handwashing (Wolf et al., 2019). That aside, there are instances where stations were provided, yet handwashing practices remain limited. For instance, in a study of handwashing behaviour in shopping centres during COVID-19 in the Wa Municipality, it was established that despite the provision of handwashing stations with soap and widespread advocacy to minimise COVID-19 infections, the citizenry, especially the youth, demonstrated poor attitude towards safety measures by not washing hands before entering shops (Fielmua et al., 2021).

The technology factors relate to the availability of soap, the type of water technology, and other handwashing accessories (Dreibelbis et al., 2013). The study demonstrated that handwashing was to a lesser degree constrained by the absence of handwashing stations at the household levels. The households were trained on the use of appropriate technology to construct handwashing stations. Immediately after the training, households constructed tippy taps to use as handwashing stations. In communities where handwashing stations existed or were constructed, the households and the FGDs revealed that they were mostly a four-litre capacity gallon and this requires frequent refilling, especially in households with many children. The stations could not sustain them because of ineffectiveness—constructed but were not serving the objective because the households did not use them. Beyond the physical state of facilities, demographic characteristics of households contextually shape handwashing. According to Hulland et al. (2013), the age of a household member influences the successful usage of the handwashing station. Our study found that children waste water and soap when they use handwashing facilities unguided. This has affected the sustainability of the handwashing stations. Despite the contextual, psychosocial, and technological barriers to handwashing and given that households are knowledgeable of the importance of handwashing, re-iterating it during the COVID-19 pandemic will reinvigorate handwashing with soap.

6.1. Strengths and limitations of the study

This study contributes to knowledge of WASH in sub-Saharan Africa and Ghana in particular by employing multiple methods to explore handwashing with soap behaviours. Significantly, the study was grounded in theory, as it was informed by IBM-WASH. This significantly contributes to the handwashing literature. This paper presented a topical hand hygiene behaviour issue immediately before the COVID-19 pandemic. As formative research that seeks to inform behaviour change communication, intervention would have contributed greatly to managing the COVID-19 pandemic and communication about its spread. The study did not assess the income levels of households and the ability to afford sustainable handwashing facilities including soap and water. Also, the study did not assess the financial cost of accessing water, soap, and construction of handwashing facilities which would have allowed an analysis of willingness and ability to pay for WASH services, especially handwashing stations.

7. Conclusion

This study employed the IBM-WASH Framework to analyse handwashing behaviours in rural and peri-urban areas in the Wa Municipality. The use of the framework enabled us to understand the key factors that shape handwashing practices and draw the implications for the COVID-19 pandemic. The study demonstrated that the availability and functionality of handwashing stations was only one of the contextual, psychological and technological factors influencing handwashing practices in rural and peri-urban areas in Ghana. Substantially, reliable and regular flow of water is critical to maintaining a positive handwashing behaviour. Given that handwashing is critical to the fight against communicable diseases such as COVID-19, there are potentially serious health consequences for the many households in developing countries that do not have a reliable source of water for the households. It has been demonstrated that households have knowledge of, and understand the importance of handwashing with soap, including the construction of handwashing stations but simply do not practise the knowledge. This has implications for the management of communicable diseases such as the COVID-19. Generally, handwashing practices are slightly higher in peri-urban areas than in rural areas, although there are no designated handwashing stations in both rural and peri-urban areas. The limited handwashing practices require communication on behavioural change, especially in the COVID-19 pandemic. As such, handwashing promotion messages can be communicated to households using social gatherings such as mosques and churches under strict COVID-19 protocols. Similarly, children can also be used as change agents in handwashing behaviours through the formation of children’s clubs in schools and at the community level. To sustain the knowledge of handwashing and the construction of handwashing stations amongst vulnerable and poor households, adequate financial support is required for the continuous purchase of soap, water, and handwashing station construction. This will ensure that the WHO and Ghana Health Service recommendations on handwashing with clean water and soap and target 6.2 of the SDG6 are achieved.

Correction

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Acknowledgments

We acknowledge the financial support of WaterAid Ghana in collecting the data. We also acknowledge the Field Assistants support in administering the households’ questionnaire.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The work was supported by the WaterAid Ghana .

Notes on contributors

Nicholas Fielmua

Nicholas Fielmua is a Senior Lecturer with the SDD University of Business and Integrated Development Studies in Ghana. He holds a PhD in Planning, specialising in Water Governance from the University of Reading, United Kingdom. His research areas include water governance in rural and small towns; collective action around natural resource management; irrigation management and livelihood enhancement; and water, sanitation, and hygiene behaviours.

Jennifer Dokbila Mengba

Jennifer Dokbila Mengba holds an Mphil in Planning from the Kwame Nkrumah University of Science and Technology (KNUST), Ghana. Her research covers water resources, gender, mining and local governance.

Enoch Akwasi Kosoe

Enoch Akwasi Kosoe (PhD) is a Senior Lecturer in the Department of Environment and Resource Studies, SDD University of Business and Integrated Development Studies, Ghana, whose research focuses on water, sanitation and environmental health, and environmental resource management. I hold PhD in Social Administration from the University for Development Studies, Tamale, Ghana, MSc in Environmental Resource Management from the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana and BA in Integrated Development Studies from the University for Development Studies, Tamale, Ghana. He has several research articles.