Communal bowl hand-rinsing before meals: Co-developing and testing a culturally sensitive intervention to reduce pathogen transmission in Ghana

Diarrhoea is the second leading cause of death among children in Africa. Hands are the most common mode of diarrhoea transmission and other significant infections for all ages. This study tackles an important cause of the spread of infections in Africa, that has previously attracted little attention: the practice of Communal-Bowl Hand-Rinsing (CB-HR). CB-HR refers to more than one person washing their hands in one shared container of water, without soap and without changing the water between individuals. Common before meals at homes, schools, and social gatherings across sub-Saharan Africa (SSA), CB-HR is sometimes performed according to age, often with children being the last to wash in the water bowl, putting them at higher risk. Additionally, mothers continue to hand-feed their children after CB-HR, facilitating the transfer of infection to children. CB-HR can be a response to water scarcity, but is habitual, persisting where water is available, despite decades of general and outbreaks-related hand-hygiene education (such as for cholera, Ebola, and COVID-19). Summary of research, and my 2022 survey of WaterAid and Save-the-Children hygiene experts from 15 offices in SSA (including Ghana), showed that CB-HR occurs in all 15 countries, with no known targeted interventions at academic, non-governmental organisation (NGO), United Nations or governmental levels. Research including during outbreaks of disease and microbiological tests on hand-swabs show that stool and other germs spread during CB-HR as the water bowl becomes contaminated and serves as a transmission medium (including a study in Ghana). My recent research in Mali, and preliminary CB-HR studies I am leading in Ghana, have identified culturally-sensitive and acceptable intervention options targeting social norms to curb CB-HR. My research aims to work with communities and stakeholders in Northern region, Ghana to jointly-develop a culturally acceptable, low-cost pre-meal family-handwashing alternative behaviour option that includes soap and not using a shared water-basin, and its scalable delivery/implementation strategy to drive behaviour change beyond awareness-raising. This will be achieved using contextual information from the community, observations and discussions, plus workshops with communities and stakeholders. Intervention implementation, while focussing on mothers and household-heads, will target whole communities recognising the crucial role of group behaviours. Community members (community/religious leaders, African drummers/actors, school-teachers, women and Water-and-hygiene village committee members and volunteers) at multiple village locations will be involved in delivery of activities. Activities will be engaging, fun and novel, learning from behaviour-change theories, former research, experts such as in WaterAid, and my experience of working in Mali and Ghanaian communities. Specific objectives are to Conduct qualitative formative research to better understand the motivations and context for CB-HR in Northern Ghana where CB-HR is common. Work with community members and stakeholders to identify culturally acceptable alternative-behaviours (solutions) to CB-HR at homes, and strategies for their delivery/implementation. Test the effectiveness of the intervention (solution and their delivery strategy) in a 12-village randomised controlled trial. Benefits/Impacts: An immediate benefit could be improved food hygiene and possibly diarrhoea reduction outcomes. If the proposed intervention is effective, it can be scaled nationally or adapted for other SSA countries, the impact on reducing the spread of infection in cases of diarrhoea, and outbreaks affected by handwashing (e.g. cholera, hepatitis, Covid-like and other organisms) can be significant. Given that diarrhoea is a leading cause of under-5 year illness and death, scaling of the intervention could impact related United Nations Sustainable Development Goals.