Behavioural determinants of handwashing at critical times among mothers and care givers in Zimbabwe: implications for behaviour change interventions

Abstract

Handwashing with soap has the potential to reduce the occurrence of infectious diseases. However, few studies have systematically analysed the determinants of handwashing with soap among mothers in rural areas of Zimbabwe. This study was conducted in two rural districts of Zimbabwe to assess the behavioural determinants of hand washing with soap at 5 critical times. Results show that doers wash their hands with soap at critical times for health reasons. Difficulties in accessing soap for handwashing was the main barrier mentioned by 60% and 44% doers and non-doers respectively. The availability of handwashing facilities is an important determinant of handwashing. Family, friends, and village health workers approved handwashing with soap at critical times. Interventions that improve access to soap and handwashing facilities should be promoted. Promoting household income generating activities will go a long way in improving income streams to fund the purchase of soap, handwashing containers and construction of handwashing stations. Households should be encouraged to construct handwashing stations, for example, tippy taps and these should be located at convenient sites to encourage handwashing practice. Hygiene promotion plans and interventions should include the participation of family, friends, and village health workers in mobilizing communities to adopt handwashing with soap at critical times.

HIGHLIGHTS

1. Handwashing with soap at five critical times is crucial for hygiene and personal health.

2. Unavailability of soap and handwashing facilities were main barriers of this practice.

3. Village health workers, family and friends approve handwashing with soap.

4. Enhance income earnings to fund purchase of soap, handwashing containers and construction of handwashing stations.

5. Include family, friends, and village health workers in programs to mobilize communities to adopt handwashing with soap at critical times.

IMPACT STATEMENT

Handwashing with soap at critical times is an important public health practice. However, few studies have systematically analysed the determinants of handwashing with soap at 5 critical times among mothers and caregivers of children aged 0-59 months in rural areas of Zimbabwe. Using evidence from two districts, results show doers wash their hands with soap at critical times for health reasons. Difficulties in accessing soap and lack of handwashing facilities were the main barriers to adopt the practice. Family, friends, and village health workers approved this practice. Interventions that improve access to soap and handwashing facilities should be promoted. Improve household incomes to fund the purchase of soap, handwashing containers and construction of handwashing stations. Include the participation of family, friends, and village health workers in hygiene promotion programs to mobilize communities to adopt handwashing with soap at critical times.

Keywords:

• Barrier analysis
• behavioral determinants
• handwashing
• mothers
• behaviour change
• Zimbabwe

REVIEWING EDITOR:

• Joe Thomas
• Institute of Health and Management
• Australia

SUBJECTS:

• Community Health
• Environmental health
• Health Education and Promotion

Introduction

Stunting, anaemia, and diarrhoeal diseases are the main causes of death of children under two years old (Mbuya et al., 2015). Globally, it is estimated that over 500 000 under five children die from diarrhoeal disease every year (Thiam et al., 2017). Yet, a significant proportion of diarrheal disease, other water borne diseases and more recently COVID-19 can be prevented through drinking clean and safe water and practicing proper hygiene and sanitation (Olapeju et al., 2021; World Health Organization, 2014).

Handwashing with soap (HWWS) is one practice being extensively promoted as a proven public health strategy to reduce diarrhoea, other water borne diseases and COVID-19 (Karinja et al., 2020; White et al., 2020; Xiao et al., 2023; Zangana et al., 2020). Evidence show that HWWS has the potential of reducing diarrhoea among children under five by about 47% (Karinja et al., 2020). Despite the importance of handwashing, its practice remains sub-optimal low in many developing countries (Kalam et al., 2021a; Zangana et al., 2020). The practice of washing hands with soap after contact with faecal matter is low and around 20% globally (Zangana et al., 2020). To create awareness on the importance of handwashing with soap to prevent diseases, Zimbabwe and the rest of the world continue to celebrate the Global Handwashing Day every 15^th of October.

Literature has shown that people are fully aware and have knowledge of the importance of handwashing (Kalam et al., 2021a; Olapeju et al., 2021; Zangana et al., 2020). Yet, this knowledge does not always translate to practice. Identification of the knowledge, attitude, and practices with regards to handwashing is therefore prudent. Systematic reviews on the factors contributing to changes in handwashing behaviours have generated mixed results (Ezezika et al., 2023; Watson et al., 2023; White et al., 2020; Wolf et al., 2019). For example, based on meta-analysis, White et al. (2020) found that knowledge, risk, gender, wealth and education, and infrastructure were the key determinants of handwashing. On the other hand, Watson et al. (2023) found that the availability of soap increased HWWS. These findings highlight that a combination of approaches is needed for promoting handwashing.

Furthermore, individual studies have identified several behavioural determinants that affect handwashing with soap ranging from availability of self-efficacy (Seimetz et al., 2017), handwashing facilities, soap and water, social norms (Friedrich et al., 2017; 2017; 2018; Kalam et al., 2021b; White et al., 2020; Xiao et al., 2023; Zangana et al., 2020), policies, religious and cultural factors. Various studies conducted in Zimbabwe have found that the availability of running water, soap, and handwashing station were some of the major determinants of effective handwashing (Friedrich et al., 2017; 2017; 2018; Inauen et al., 2020; Ncube et al., 2020; Seimetz et al., 2017). Friedrich et al. (2017) conclude that availability of handwashing station with water, knowledge of how to wash hands and perceived risks were some of the major determinants of effective handwashing by caregivers in Harare.

Over the past decade, the water sanitation and hygiene (WASH) sector (Global Waters, 2022) is increasingly seeing program staff doing formative research to understand the constraints and motivators of key behaviours including appropriate handwashing. The most common formative barrier analysis research uses the risks, attitudes, norms, abilities, and self-regulation (RANAS) domains (Inauen et al., 2020), to examine barriers and opportunities and identify entry points for implementing appropriate and sustainable sanitation and hygiene interventions (Inauen et al., 2020; Kittle, 2017).

As discussed above, several studies have investigated the determinants of handwashing with soap, globally and in Zimbabwe. However, in Zimbabwe, with the exception of Inauen et al. (2020), most studies are concentrated in the urban area of Harare only. As such little is known about this topic in other areas of the country facing different contexts including other urban areas and rural areas. Using a Barrier Analysis framework developed by Kittle (2017), this article seeks to analyze the key factors influencing handwashing with soap by mothers and caregivers in Mwenezi and Chiredzi districts of Masvingo Province in Zimbabwe.

Barrier analysis

Barrier Analysis (BA) methodology is a well-established analytical technique used for guiding the design of behaviour change interventions, for example handwashing with soap (Davis et al., 2022; Inauen et al., 2020; Kalam et al., 2021a; Kittle, 2017; Zangana et al., 2020). The BA compares the perceptions and experiences of individuals practicing the identified behaviour with those not (Zangana et al., 2020) and identifies the critical factors enable or hinder behaviour. The hand washing practice with soap at five critical times each day targeted mothers and care givers of children aged 0-59 months in the surveyed districts in line with similar work by People in Need (2023) and Zangana et al. (2020). The five critical times considered in the study are: after using the toilet (urination, menstrual hygiene, and defecation; cleaning child’s bottom or changing nappies and diapers; before child feeding; before eating; before or after food preparation of handling raw meat, poultry, or fish. The Barrier Analysis questionnaire was divided into two sections (Davis et al., 2022; Kittle, 2017). The first section screened and classified the participant as into two groups as those practices handwashing with soap (doers) and those not (non-doers) (Kalam et al., 2021a; Kittle, 2017; Zangana et al., 2020). The classification was based on self-reporting of handwashing practice and proxy indicators including observing used soap at handwashing stations. The second section consisted of open and closed-ended questions (Davis et al., 2022) that assessed factors influencing behaviour change (Zangana et al., 2020). In particular, the determinants explored included: perceived social norms, self-efficacy, action efficacy, perceived positive and negative consequences (Kalam et al., 2021a; Kittle, 2017), access to soap, risk, severity, religion, policy, and culture (Zangana et al., 2020). The descriptions of the behavioural determinants are detailed in White et al. (2020) and Zangana et al. (2020).

Methodology

Sampling and data collection

The study was conducted in Chiredzi and Mwenezi districts in Masvingo Province in April 2021 and targeted mothers and caregivers. In each district, wards were clustered into 5 economic zones based agricultural and livelihood options, market infrastructure and road network. At least one ward was purposively selected from each of the economic zones in each district to ensure wider geographical coverage. Five wards were purposively sampled to cover all the economic zones in each district, and this was done by locally based staff from the two Ministries of Health and Agriculture. From each selected ward, a list of mothers and or care givers of children aged 0-59 months was drawn by two Ministries staff and from this list up to 30 mothers and care givers were randomly oversampled and included into the sampling frame. From the sampling frame, the research assistants screened and classified the sample into those practices handwashing with soap (doers) and those not (non-doers). About 5 doers and 5 non-doers were interviewed in each ward. Using this sampling approach, 45 doers and 45 non-doers were randomly selected and interviewed at their homesteads in the two districts to assess determinants of handwashing with soap at 5 critical times. Table 1 show the survey sample.

Table 1. Handwashing doers and non-doers.

Mwenezi (Ward 2, 5, 6, 9 and 12)			Chiredzi (Ward 8, 9, 13, 22 and 25)			Total
Doers	Non-Doers	Total	Doers	Non-Doers	Total	Doers	Non-Doers	Total
22	23	45	23	22	45	45	45	90

Eleven well trained research assistants collected the data after undergoing training and survey pretesting. The Barrier Analysis questionnaires were translated to vernacular language during the training of enumerators before data collection was done. The training included translation of questions from English to Shona. The data was coded, tabulated, and entered the Barrier Analysis spread sheets after the survey.

Data analysis

The data was cleaned and categorized into the identified themes differentiated by doer or non-doer group. Thereafter, the data was entered into the Barrier Analysis tabulation sheet (Zangana et al., 2020). Descriptive statistics using Chi-square tests were conducted to draw inferences and conclusions with computations of odds ratios done using p-values of 0.05 (Kalam et al., 2021a; Zangana et al., 2020).

Ethical considerations

The researchers adhered to all study procedures in accordance with the 1964 Helsinki Declaration (Kalam et al., 2021b) and comparable ethical standards. The study was ethically approved by senior management of the Ministry of Local Government in Masvingo province in consultation with higher leadership who superintend on all international development work. The respondents were informed of the study objectives and gave their written consent before the survey. All respondents voluntarily participated and were free to withdraw from the interview at any time. All identifiers (e.g name and date of birth) were removed from the dataset to ensure confidentiality.

Results

Perceived self-efficacy

All doers reported that they washed their hands with soap at the five critical times (Table 2). About 53% of non-Doers highlighted that they washed their hands at the recommended times, and sadly about 20% said no. When questioned about factors that facilitated easier handwashing, Doers were 5.7 times more likely to report health reasons as the driving force (p = 0.006). The availability handwashing facilities was one of the main determinants of handwashing among non-doers, and they were 9.8 times more inclined to report this (p = 0.004). With regards to reported difficulties, results show the differences between non-doers and doers is non-significant. Doers are 2 times likely to highlight they don’t have any difficulties in washing their hands at five critical times per day (p = 0.045). When asked about what makes it easier for you to wash your hands with soap at critical times, doers had this to say:

Table 2. Perceived self-efficacy.

Determinant	Doers n (%)	Non -Doers n (%)	Difference	Odds Ratio	95% C.I	ERR*	p = 0.05
Do you think based on your knowledge, skills, and resources you can wash your hands at required periods?
Yes	45 (100)	24 (53)	47%				0.000
Possibly	0 (0)	12 (27)	−27%	0.00		0.00	0.000
No	0 (0)	9 (20)	−20%	0.00		0.00	0.001
What makes it easier for you to wash your hands with soap?
For healthy purposes	7 (16)	0 (0)	16%			5.74	0.006
Detergents and knowledge availability	4 (9)	0 (0)	9%			5.39	0.058
Availability of water and detergents	7 (16)	7 (16)	0%	1.00	0.32–3.13	1.00	0.614
Detergents available (soap, ash, sanitizer)	10 (22)	10 (22)	0%	1.00	0.37–2.03	1.00	0.600
Availability of water	5 (11)	8 (18)	−7%	0.58	0.17–1.93	0.64	0.275
Availability of handwashing facilities	1 (2)	10 (22)	−20%	0.08	0.01–0.65	0.10	0.004
Knowledge acquired through training and awareness	7 (16)	3 (7)	9%	2.58	0.62–10.69	2.00	0.157
Water, soap, and knowledge available	1 (2)	0 (0)	2%			5.09	0.500
Fear of contracting COVID-19 and other diseases	3 (7)	0 (0)	7%			5.29	0.121
None	0 (0)	5 (11)	−11%	0.00		0.00	0.028
Set reminders	0 (0)	2 (14)	−4%	0.00		0.00	0.247
What makes it difficult for you to wash your hands with soap?
Detergent’s unavailability (soap, ash, sanitizer)	13 (29)	15 (33)	−4%	0.81	0.33–1.99	0.85	0.410
Unavailability of water and detergents	2 (4)	2 (4)	0%	1.00	0.13–7.43	1.00	0.692
Forgetting to wash hands	5 (11)	6 (13)	−2%	0.81	0.23–2.88	0.84	0.500
None	25 (56)	16 (36)	20%	2.27	0.97–5.29	1.91	0.045
Lack of handwashing facilities	0 (0)	3 (7)	−7%	0.00		0.00	0.121
Unavailability of water	0 (0)	2 (4)	−4%	0.00		0.00	0.247
Lack of knowledge on importance of handwashing	0 (0)	1 (2)	−2%	0.00		0.00	0.500

Notes: *Estimated Relative Risk.

I wash my hands with soap, ash, and sanitizer because I have these detergents and water. I have knowledge on this from our trainings and awareness from health personnel. Discussion with doer - Mwenezi Ward 6.

To emphasize the reasons for handwashing, the doers had this to say:

We wash our hands for health purposes – to keep ourselves clean and safe from diseases including COVID-19 and Diarrhoea. Discussion with doers - Chiredzi.

Perceived positive and negative consequences

The perceived positive and negative consequences of handwashing are shown in Table 3. Most mothers and caregivers among both doers and non-doers reported primary benefit of handwashing with soap as hygienic purposes and prevention of disease outbreaks. They highlighted that handwashing could help in the prevention of COVID-19 and diarrhoea among doers and prevention of waterborne diseases like typhoid and cholera among non-doers. The lower panel of Table 3 show the negative consequences of handwashing. The majority women interviewed highlighted that there were no identified disadvantages of handwashing with soap (doers = 64%, non-doers = 78%). About 20% of doers mentioned that soap was expensive. Only 4 people in each category reported the negative consequences related to skin irritation. When asked about the positive consequences of handwashing, doers said:

Table 3. Positive and negative consequences.

Determinant	Doers n (%)	Non -Doers n (%)	Difference	Odds Ratio	95% C.I	ERR*	p = 0.05
Advantages of washing your hands with soap
Hygienic purposes	17 (38)	13 (29)	9%	1.49	0.62 – 3.61	1.37	0.251
Prevent disease outbreaks	21 (47)	23 (51)	−4%	0.84	0.37 –1.91 0.98	0.87	0.417
Prevent spread of COVID-19, diarrhoea, and hygienic purposes	5 (11)	1 (2)	9%	5.50	0.62 – 49.11	3.00	0.101
Prevent outbreak of water borne disease such as typhoid and cholera	2 (4)	5 (11)	−7%	0.37	0.07 – 2.03	0.43	0.217
None	0 (0)	2 (4)	−4%	0.00		0.00	0.247
Reduction of medical costs incurred after falling sick	0 (0)	1 (2)	−2%	0.00		0.00	0.500
Disadvantages of washing your hands with soap at recommended times
Skin irritation	4 (9)	4 (9)	0%	1.00	0.23 – 4.27	1.00	0.643
Costly (soap is expensive)	9 (20)	4 (9)	11%	2.56	0.73 – 9.03	2.00	0.115
Tiring	3 (7)	2 (4)	2%	1.54	0.24 – 9.66	1.39	0.500
None	29 (64)	35 (78)	−13%	0.52	0.20 – 1.31	0.60	0.122

Notes: * Estimated Relative Risk.

The advantages include hygienic purposes for personal hygiene and health as this prevents infectious diseases such as cholera, typhoid and diseases. Discussion with doers - Chiredzi.

Majority of does and non-doers acknowledged that there are no disadvantages of handwashing with soap and said:

Hapana zvakashata kugeza nesipo – meaning that there are no disadvantages associated with hand washing with soap. Discussion with doers and non-doers – Chiredzi and Mwenezi.

Perceived social norms

The participants perceived social norms are shown in Table 4. Mothers and care givers in the study sites highlighted that most people around them including family, friends and social networks encouraged and approved their washing of hands with water and soap. More specifically, Doers were 2.3 times more inclined to agree that majority of people around them approved their hand washing practice at required frequencies (p = 0.032), while non-Doers were 3.3 times more inclined to say ‘no’ that people around them approved their washing of hands at critical times (p = 0.034). Doers were twice likely to say ‘Village health workers (VHW)’ approve of them washing their hands at needed critical periods (p = 0.041). There were no significant differences with regards to impressions concerning who disapproves handwashing by doers and non-doers. To demonstrate, the most people who approve handwashing, majority of doers acknowledged that:

Table 4. Perceived social norms.

Determinant	Doers n (%)	Non -Doers n (%)	Difference	Odds Ratio	95% C.I	ERR*	p = 0.05
Do most people you know approve this practice
Yes	36 (80)	27 (60)	20%	2.67	1.04 – 6.85	2.25	0.032
Possibly	6 (13)	8 (18)	−4%	0.71	0.23 – 2.25	0.76	0.382
No	3 (7)	10 (22)	−16%	0.25	0.06 – 0.98	0.30	0.034
People that approve this practice
Village Health Worker (VHW)	22 (49)	13 (29)	20%	2.35	0.99 – 5.62	1.95	0.041
Family member	11 (24)	8 (18)	7%	1.50	0.54 – 4.16	1.37	0.303
Ministry of health, NGOS, Community, social media	10 (22)	17 (38)	−16%	0.47	0.19 – 1.19	0.54	0.083
None	2 (4)	7 (16)	−11%	0.25	0.05 – 1.29	0.30	0.079
People that disapprove this practice
Community	5 (11)	6 (13)	−2%	0.81	0.23 – 2.88	0.84	0.500
Those without knowledge	3 (7)	0 (0)	7%			5.29	0.121
None	35 (78)	34 (76)	2%	1.13	0.43 – 3.01	1.11	0.500
Family member	2 (4)	5 (11)	−7%	0.37	0.07 – 2.03	0.43	0.217

Notes: * Estimated Relative Risk.

Village Health Workers approve our washing of hands with soap at the five critical times each day. Discussion with doers – Chiredzi and Mwenezi.

Perceived access and reminders (cues to action)

About 60% and 44% of doers and non-doers acknowledged having somewhat difficulties in acquiring and or accessing soap for handwashing, while 18% of non-doers said it was very difficult (Table 5). Around 40% of both categories of women reported that it was not difficult at all to access soap. We turn to the cues to action. Doers were 2.2 times more inclined to report that it’s not difficult for them to remember washing hands with soap at recommended periods per day (p = 0.026). About 29% and 42% of those practising appropriate handwashing and not respectively highlighted somewhat difficulties in remembering to properly wash hands at required frequencies.

Table 5. Access and Reminders.

Determinant	Doers n (%)	Non -Doers n (%)	Difference	Odds Ratio	95% C.I	ERR*	p = 0.05
Difficulties in having soap to wash your hands
Very difficult	0 (0)	8 (18)	−18%	0.00		0.00	0.003
Somewhat difficult	27 (60)	20 (44)	16%	1.88	0.81 – 4.33	1.65	0.103
Not difficult at all	18 (40)	16 (36)	4%	1.21	0.51 – 2.84	1.16	0.414
Difficulty to remember to wash your hands with soap
Very difficult	0 (0)	4 (9)	−9%	0.00		0.00	0.058
Somewhat difficult	13 (29)	19 (42)	−13%	0.56	0.23 – 1.33	0.62	0.135
Not difficult at all	32 (71)	22 (49)	22%	2.57	1.08 – 6.14	2.15	0.026

Notes: * Estimated Relative Risk.

Risk

Table 6 show caregivers’ perceptions of diarrhoea and belief that handwashing with soap is effective in preventing the transmission of diseases. Doers were 2.2 times highly likely compared to non-doers to say that their children were not likely at all to suffer from diarrhoea in the next months (p-value = 0.023). Non-doers were 2.7 more inclined to say somewhat likely (p-value = 0.032) when asked about action efficacy (Kalam et al., 2021b), while Doers were 3.2 more inclined to report not likely at all that handwashing with soap could reduce disease transmission (p-value = 0.007). With regards to risks, doers and non-doers acknowledged that:

Table 6. Risk.

Determinant	Doers n (%)	Non -Doers n (%)	Difference	Odds Ratio	95% C.I	ERR*	p = 0.05
Likelihood your child has diarrhoea in the next 3 months?
Very likely
Somewhat likely	9 (20)	16 (36)	−16%	0.45	0.17 – 1.17	0.52	0.079
Not likely at all	34 (76)	24 (53)	22%	2.70	1.10 – 6.63	2.26	0.023
Likelihood your child will have diarrhoea if you wash your hands with soap at appropriate times (action efficacy)?
Very likely	1 (2)	4 (9)	−7%	0.23	0.02 – 2.17	0.28	0.180
Somewhat likely	5 (11)	13 (29)	−18%	0.31	0.10 – 0.95	0.37	0.032
Not likely at all	39 (87)	28 (62)	24%	3.95	1.38 – 11.27	3.19	0.007

Notes: * Estimated Relative Risk.

Not likely at all that our children will suffer from diarrhoea if we wash our hands with soap at the five critical times each day’. Discussion with Doer and non-doers – Chiredzi and Mwenezi.

Religion, policy, and culture

Study results highlight that religion, culture and policy had no effect of handwashing practice and there were no differences between the two groups. Most study participants perceived that it was not the will of God that influenced the incidence of diarrhoea among children (91% in Doers and 82% in Non-Doers, p = 0.176). Most participants said that there existed no cultural taboos, laws and rules that prohibit washing of hands.

Discussion and implications for behaviour change strategy

Self-efficacy

With regards to self-efficacy, doers, and non-doers both acknowledged that they could wash their hands. Availability of handwashing stations or facilities is an important driver for nudging the uptake of appropriate handwashing behaviour and frequency. Our results resonate with findings from previous studies (Kalam et al., 2021b; White et al., 2020). All households should be encouraged to construct handwashing stations, for example tippy taps and these should be located at convenient sites that are more likely to encourage handwashing practice, for example near the latrine. Promoting income generating activities at household level will go a long way in improving income streams to fund the construction of handwashing facilities.

Social norms

Family, friends, and social networks approved participants washing of hands with soap at the required times (Zangana et al., 2020), while Village health workers approve doers of washing their hands. Close family members, friends, and Village health workers were identified to be influential in mobilizing communities for handwashing with soap at critical times. As such, there is scope of using family members, friends, and village health workers to promote handwashing behaviour. Other related studies, also confirm the importance of encouraging the participation of family, friends, and health workers in mobilizing communities to adopt good health behaviours (Davis et al., 2022; Zangana et al., 2020). According to the two groups, the benefit of handwashing is linked to hygienic purposes and prevention of disease outbreaks such as COVID-19, diarrhoea, typhoid, and cholera. The implication is that during behaviour change hygiene trainings in care groups and health clubs, the trainers should explain and emphasize how and why hand washing helps prevent diseases.

Access and cues for action

About 60% and 44% of doers and non-doers acknowledged having somewhat difficulties in acquiring and or accessing soap for handwashing. This finding resonates with White et al. (2020) who report similar findings in Bangladesh. Low-cost soaps need to be made available as well as enhancing income generation options for households to purchase soap. Promoting ash as an alternative to soap as it is locally available and cheap should be seen as a viable intervention, especially among the poor and vulnerable households. Doers highlighted that remembering to wash hands with soap (Zangana et al., 2020) at the recommended times was very easy.

Others

The two groups perceived that religion, culture and policies had little influence on handwashing and they all experienced and noted similar difficulties, positive and negative consequences, difficulties, and levels of access to water and soap. This is plausible as both groups are residing in same geographical areas with similar physical resources. These results are in line with other studies in developing countries (Kalam et al., 2021a; Zangana et al., 2020).

Limitations and strengths

This study uses the Barrier analysis methodology developed by Kittle (2017), which is however not flexible to include demographic characteristics of study participants for example, income, age, and household factors which may have confounding effects. The barrier analysis uses a small sample which is not sufficient for heterogenous analysis. Beyond these limitations, our study identified important findings which could be useful for designing behaviour change strategies for increasing the uptake of handwashing with soap.

Conclusion

The study results have important implications for programming. Washing hands with soap when it was available was easy among Doers. However, accessing soap for handwashing was the main barrier mentioned by 60% and 44% doers and non-doers respectively. Interventions that improve access to soap should be promoted as they increase mothers HWWS and potentially reduce the risk of diseases. Promoting and provision of low - cost soap and ash as an alternative to soap as it is locally available and cheap should be seen as a viable intervention, especially among the poor and vulnerable households. In addition, there is need for interventions that enhance income generation options for households to enable mothers and caregivers to purchase soap.

Family, friends, social networks, and village health workers approved mothers and caregivers washing of hands with soap at the required times. There is scope for dissemination of information and reminders on the benefits of regular handwashing with soap through village health workers, family members and social networks. Awareness of the benefits of handwashing with soap should also be promoted during various gatherings including religious, cultural, and social gatherings to enhance wider dissemination and control the spread of diseases such as Cholera. The availability of handwashing facilities was found to be an important determinant of HWWS. The public and private sectors should promote and encourage all households to adequate handwashing facilities. Households should be encouraged to have adequate mobile water containers that are dedicated for handwashing. Furthermore, construction of tippy taps at convenient sites such as latrine entrance that are more likely to encourage handwashing with soap should be intentionally promoted.

Acknowledgments

We are grateful to the research assistants for data collection and the respondents who provided answers to the survey questions. We also acknowledge the Zimbabwe Resilience Building Fund (ZRBF) and its donors (FCDO, EU, Sweden) for funding the resilience project in the two districts through CARE International. The views reported here are of authors only.

Disclosure statement

The authors declare there is no Complete of Interest at this study.

Additional information

Notes on contributors

Conrad Murendo

Conrad Murendo is a Research, Evidence and Learning Manager with Save the Children, Afghanistan. Previous was a Strategic Learning Advisor at Mercy Corps and CARE International. He holds a PhD in Agricultural Economics from the University of Goettingen, Germany. His research experiences are in food security, nutrition, and resilience.

Rungano Benza

Rungano Benza is a Monitoring and Evaluation Specialist with CARE International. Has a Masters in Strategic Management and Corporate Governance from Midlands State University, Zimbabwe.

Nyashadzashe Gudyanga

Nyashadzashe Gudyanga is a Nutrition Officer at CARE International. She has a Master’s in Food Science and Nutrition. Her experiences are in nutrition and resilience.

Brian Velani

Brian Velani is a Project Officer at CARE International. His experiences are in resilience, and gender.

Fungai Gutusa

Fungai Gutusa is a Team Leader at CARE International. Her postgraduate studies are in Public Health and Gender. Her research experiences are in nutrition, gender, water, and sanitation.