Hand hygiene behaviours and water, sanitation, and hygiene (WASH) conditions in urban, low-resource communities of Maputo, Mozambique

Diarrhoeal diseases are a leading cause of mortality in children under 5 in low- and middle-income countries. Within domestic settings, transmission of diarrhoeal pathogens occur through a variety of pathways, including via caregivers’ hands. While handwashing with soap (HWWS) effectively disrupts hand-mediated pathogen spread, barriers such as limited access to soap and water, competing household activities, and lack of knowledge of handwashing benefits can reduce its practice and protective effect. The purpose of this study was to describe the hand hygiene practices of caregivers of young children living in low-income neighbourhoods of Maputo, Mozambique and how these practices vary with access to water, sanitation, and hygiene (WASH) facilities and water insecurity. We conducted structured observations of caregiver hand hygiene behaviours in households with a child ≤2 years old. Observations focused on five opportunities for hand hygiene: after child faeces management, after caregiver toilet use, after caregiver respiratory events (e.g., coughing or sneezing), before preparing food, and before feeding the child. WASH indicator data were comprised of handwashing facility access, presence of soap and water, drinking water source, sanitation access, self-reported hand hygiene practices, and the individual water insecurity experiences (iWISE) scale. We observed 76 caregivers for an average of 3.8 hours each, capturing 691 hand hygiene opportunities. Observed handwashing with soap was rare, with only 2 instances documented over the 286.2 observation hours. Across all hand hygiene opportunities, caregiver self-reported hygiene actions – including washing with water only –were substantially higher than enumerator-observed hand hygiene actions. Most households had access to piped water (84%; 61/73) and low water insecurity (mean IWISE score: 2.9; SD: 3.7), but only 23% of households were observed to have a hand hygiene facility (17/73). Among households with a handwashing facility, soap and water were infrequently observed (31%; 4/13; data unavailable for 4 households). No differences in hand hygiene practices were found across households with and without access to a handwashing facility, access to an improved sanitation facility, and water security. High levels of pathogen exposure previously documented in these communities, coupled with the low rates of caregiver handwashing observed here, underscore the potentially important contribution of hand-mediated pathogen transmission. Lack of access to a designated handwashing facility with soap and water may be key barriers to caregiver handwashing in these low-resource Maputo households. Future work should evaluate pathogen levels on caregivers’ hands and assess hygiene interventions tailored to caregivers’ needs in this setting.