The tradition of washing hands in a common bowl before eating: a qualitative study of the practice of communal bowl hand rinsing before mealtimes, in rural and urban Mali 

The tradition of washing hands in a common bowl before eating: a qualitative study of the practice of communal bowl hand rinsing before mealtimes, in rural and urban Mali | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The tradition of washing hands in a common bowl before eating: a qualitative study of the practice of communal bowl hand rinsing before mealtimes, in rural and urban Mali Evans Atiah Asamane, Rachel L Adams, Chloe Poole, Cheick Sidibe, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4999129/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Diarrhoeal disease is a leading cause of death in children under 5 years old globally, despite being largely preventable. It is widely known that individual handwashing with soap is key in preventing transmission of enteric pathogens. Communal bowl hand rinsing (CB-HR) is the act of two or more people washing hands in a shared bowl of water without the use of soap, and without changing the water between individuals; this remains a commonplace cultural practice in many African countries. It occurs before household mealtimes, at gatherings and in schools. Evidence demonstrates that communal water provides a reservoir for communicable diseases, however there is limited evidence about the motivations including the social and cultural norms underpinning its continued practice. The aim of this study was to gain a better understanding of public perspectives on CB-HR, identifying the reasoning and exploring the beliefs behind the practice and determining factors preventing the improvement of hand hygiene. Methods We recorded 59 semi-structured interviews and 26 focus groups, in the local language of Bambara, across both rural and urban communities in Mali. Participants included mothers, fathers, grandmothers and grandfathers. Recordings were transcribed into French, translated into English and analysed using thematic analysis. Results CB-HR was commonplace amongst our participants, they confirmed that CB-HR was rooted in tradition for the purposes of social cohesion and family unity. The exact way in which CB-HR was practised varied. There was wide awareness of the infection-related risks associated with CB-HR. Various reasons were given for not practising and maintaining individual handwashing with soap. Ways of combining CB-HR and individual handwashing with soap were described, including the need for role models to maintain motivation. Conclusion CB-HR was widespread in our rural & urban sample despite knowledge of its health risks, and access to running water and handwashing equipment (vessels and soap) because of the belief that it maintained social cohesion. Programmes aimed at improving infection control need to address the social and cultural drivers of CB-HR, or to adapt interventions in ways that are not perceived to threaten family unity. handwashing communicable diseases common/communal bowl shared bowl infection control hygiene sanitation social norms. Figures Figure 1 Figure 2 Figure 3 Background Diarrhoeal disease has a large global health burden, leading to 1.8 billion deaths per year with the largest proportion of these occurring in children under 5 years old [ 1 ]. As well as contributing to mortality, diarrhoeal disease also plays a role in childhood malnutrition and developmental delays [ 2 , 3 ]. Individual handwashing with soap is proven to be the single best and most cost-effective way to prevent transmission of diarrhoeal pathogens [ 4 , 5 ]. The recommended technique is to wet the hands with running water, rub with soap for at least 20 seconds and then rinse with running water [ 4 , 6 ]. Handwashing is also promoted as a key intervention for the prevention of diseases such as COVID-19, Cholera and Ebola [ 7 ]. However, UNICEF estimate that almost 3 billion people worldwide do not have access to soap and water at home [ 6 ]. Globally, the frequency of recommended handwashing techniques at key interventional moments (e.g. after using the toilet and prior to mealtimes) is especially low but is thought to be as low as 5–22% in sub-Saharan Africa (SSA) [ 7 ]. It is estimated that 75% of cases of diarrhoea can be attributed to poor handwashing techniques and lack of effective food hygiene methods [ 1 ]. Communal bowl hand rinsing (CB-HR) from a shared water bowl, usually without soap, is a common practice in many African countries before mealtimes, in schools, and at funerals [ 8 ]. Members of the same household or community group rinse their hands in a shared water container, sometimes from the oldest to youngest, without replenishing the water and usually without the use of soap (see Fig. 1 ). We prefer the term communal bowl hand rinsing (CB-HR) rather than washing to indicate that the same water is shared between individuals, hands are only rinsed for a few seconds, soap is rarely used and therefore washing is scarcely achieved. CB-HR is commonly practiced in SSA and the practice precedes meals that are typically eaten with hands and often from a shared plate, further increasing the risk of ingesting and transmitting pathogens [ 9 – 12 ]. The motivations behind CB-HR are poorly investigated and unclear. CB-HR is thought to have a social function – as a source of community and familial bonding [ 13 , 14 ], and is typically practiced in association with commensality, the culturally significant act of coming together to share meals [ 15 ]. In addition, CB-HR may have a practical function – linked to saving often scarce water resources [ 8 , 13 , 14 ]. Research demonstrates that CB-HR directly increases the transmission of diseases such as cholera [ 12 ], with one paper demonstrating that bacteria, fungi and parasites were all present in the communal bowl water after the practice [ 13 ]. Health education around handwashing practices is included in routine outreach work and focuses on using clean, running water with soap [ 16 , 17 ]. In addition, organisations such as UNICEF, Water Aid and Save the Children have been working for decades in countries across Africa to tackle sanitation issues and increase health education in both rural and urban communities [ 16 , 18 ]. Such programmes are often referred to as WA ter, S anitation and H ygiene (WASH) programmes, that is, any programme concerned with all 3 of these components. Handwashing kits are often introduced as part of these programmes and take a range of forms. The kit most typically used in Mali can be seen in Fig. 2 . Following the COVID-19 pandemic, governmental strategies to reduce viral transmission in African countries included promotion of social distancing and the wearing of face masks in confined spaces. However, recommended handwashing practices were not given equal promotion, with research demonstrating that prevalence of handwashing instead declined during the pandemic [ 19 ]. In some communities, there was an increase in the accessibility of handwashing equipment in public spaces, but there was no directive to encourage recommended handwashing methods while at home [ 20 ]. Existing literature shows that key determinants for improving hand hygiene and general sanitation in households include economic status of the households, education level of the head of household, type of residency, access to running water, and number of children in the household [ 21 – 24 ]. However, motivators and drivers for this practice and interventions directly targeting this behaviour are lacking in the literature. We found no evidence of interventions that have been developed to directly address this common practice in Africa. In view of this, the aim of the study was to gain a better understanding of CB-HR, identifying the reasoning behind the practice and determining factors preventing recommended handwashing practice in Mali. Such evidence is needed to support the development and implementation of sustainable behaviour change interventions which are sensitive to global, socio-economic contexts. Mali is a large country sharing ethnic groups with many West, Northern and Central African countries, thus enabling our findings to be of greater relevance to other countries in the region. Methods Design We employed a two-phase qualitative study using two complementary methods: focus groups and semi-structured interviews. The focus group study (November 2020 to January 2021) was part of the formative research informing the development of the intervention within the MaaCiwara study: a parallel group, two-arm cluster randomised trial focussing on food safety and hygiene at a community level [ 25 ]. Having identified the practice of CB-HR in the focus groups, a follow-up, nested qualitative study was conducted (August to September 2021). This nested study was part of a feasibility trial testing a simple intervention of introducing soap as part of the practice of communal handwashing to reduce pathogen transmission during CB-HR. Setting Mali is a conflict-affected West African Francophone country where despite outbreaks of cholera, Ebola and despite recent COVID-19 handwashing promotion and existing low-cost low-tech tools to reduce water usage and improve handwashing practices, CB-HR has persisted. Data were collected in Mali’s capital city Bamako and surrounding villages. Specifically, in the urban areas of Banconi and Sabalibougou in Bamako, and 3 rural villages in the Koulikoro region: Dialakoroba, Zantiguila, and Tienfala. Additional focus groups were also conducted in 2 other cities, Segou and Sikasso, in the central and southern regions of Mali, respectively. In urban settings we specifically targeted lower socio-economic areas. Recruitment and Sampling Permissions were obtained from local community leaders to approach community members. For the focus groups, community members were invited to take part in each of the seven locations. Invitations were made by the local community health volunteer. The sampling strategy was purposeful to get a range of community members: mothers, grandmothers and fathers of children aged 6–36 months, and elders (grandfathers who were heads of household) took part in four separate focus groups in each setting. For the interviews, 6 heads of households (fathers or grandfathers), and mothers (with children 6–36 months) were interviewed in each of the 5 communities involved in the feasibility study. Data collection Separate topic guides were developed, tested and iteratively revised for each phase of the study (see Additional 1 and Additional 2). The trial manager in Mali (CS), a medical doctor with qualitative research experience, provided training for and supervision of data collection. Focus groups and interviews lasted 30–60 minutes. Data collection was conducted in Bambara, the national language in Mali, by Malian researchers. The focus groups were facilitated by two sociology graduates (one male, one female). To help develop rapport with local gatekeepers and facilitate the smooth running of the data collection, the fieldworkers arrived at the locations outside of Bamako the day before the focus groups, where they met with local community leaders, health staff and volunteers. Focus groups were typically held in the community’s usual meeting place, such as a community leader’s home or an open space in the centre of the community. The topic guide comprised the following key topic areas – breastfeeding, complementary feeding, food storage, handwashing, play, animal husbandry, information sharing within the community and format for celebrations. This paper reports data that emerged on the topic of CB-HR. In addition to the audio-recordings, field workers kept field notes detailing additional information from each focus group. Interviews were conducted by either a male (CS) or a female (HD) medical doctor experienced in conducting qualitative research in participants’ homes. The topic guide covered understanding of recommended handwashing techniques, usual handwashing practice, practices related to and reasons for CB-HR, feelings about hand washing in relation to infant feeding and attitudes towards soap. Data analysis Data collection, synthesis and analysis were conducted concurrently to allow for improvement of the process, tools and approach in the proceeding interviews [ 26 ]. Bambara is not commonly a written language and so the local practice is to speak in Bambara and write in French; therefore, the digital recordings were transcribed into French by another Mali team member who then translated them into English to share with the wider team [ 27 ]. Thematic analysis [ 28 ] was used to analyse the data, using NVivo v.12 software. Both data sets were analysed together. Two UK-based researchers (MY & MB) repeatedly went through the transcripts to gain an in-depth insight into the content and produced a draft coding framework. Subsequently, initial codes were identified, and differences discussed with the supervising qualitative team (NG, EAA & SMH). Two researchers (EAA & CS) independently coded 10% of the transcripts using this framework. Differences were discussed in the group and the codes modified before applying the framework to the remaining transcripts. The analysis was then reviewed (CP & SS), and themes identified and discussed with the qualitative team. Results In total, 168 participants contributed to 28 focus groups, with each focus group containing 6–7 participants, and 59 interviews were conducted (see Table 1 . Participants have been anonymised following the key in Fig. 2 . Table 1 Rural/Urban split for number of (a) individual interviews and (b) focus groups (a) Interviews Rural Urban Total Mothers 18 12 30 Fathers/Heads of Household 19 10 29 59 (b) Focus groups Rural Urban Total Mothers 2 3 5 Fathers 3 4 7 Elders 3 4 7 Grandmothers 3 4 7 26 Themes We found that CB-HR was a part of everyday life for most of our participants, with only a handful of rural and urban interviewees stating that they did not practice CB-HR. We identified 4 themes with 13 subthemes which helped us understand why CB-HR is practised and what the scope for change is (see Fig. 3 ). 1. The practice of CB-HR The key driver of CB-HR was building and maintaining social cohesion between families and the wider community, with the scarcity of water a secondary, but also relevant, reason. Nonetheless, there were important variations in the perceptions and interpretations of the importance of the practice. 1.1 Unity, solidarity, and tradition The practice of CB-HR was described as something that had been passed down through the generations as a means of improving and preserving family unity and generational links. Our elders used to say that when we all washed our hands together, we each took something from the other and this contributed to social cohesion. (rural grandfather) This links to commensality, which is also a practice that aims to strengthen familial relationships and contribute to unification of the household. [CB-HR] is better than each one washing his hands separately because if each one washes his hands separately there will be no agreement between people, it creates affection between the members of a family (urban father) One participant added that the act of CB-HR demonstrated to visitors that their household was strongly unified. It is about cohesion between family members… when you wash your hands in the same container when a foreigner comes, he would know that you are united and well educated (rural head of household) Some men also explained that hand washing with soap was believed to wash away wealth. Actually, if we estimate the percentage of those who wash their hands with soap here in the general population, I would say it is 10%. Because in our opinion, even washing with soap is not good for our traditions, it is said that a person who washes all the time with soap cannot save money … We wash our hands from time to time just to avoid getting sick. You can't do it all the time, it's not easy. … Nowadays, toxic products such as fertilizers that we handle every day, force us to wash our hands with soap to protect ourselves from getting sick and dying (urban, elder FG) However, there were a few interviewees who gave the reasoning for CB-HR in their household, as simply a practice they had grown up with. We learned [to wash our hands in one container] from our parents… They didn’t tell us the reasons (rural father) 1.2 Scarcity of water Whilst maintaining the emphasis on social cohesion as the primary reason for CB-HR, scarcity of water was also mentioned frequently as another reason for its practice. As far as water is concerned, it's because there wasn't enough water... Concerning the washing of the hands together, it was because of the lack of water (rural father) 1.3 Variations While CB-HR is typically performed in order of age from oldest to youngest as a demonstration of respect, examples were given where this was not adhered to. One participant explained that were times when the order of handwashing was adapted to accommodate time constraints. When I'm at home, I [head of household] wash my hands first and then the others, but often when we are in a hurry, it's by order of arrival (urban father). Two participants described CB-HR practices that involved gendered handwashing containers. There is a container for the old women, one for the women and one for the men… we have 3 containers for handwashing (rural mother). Another variation was the practice of drinking the water after it had been used for CB-HR as a means of further strengthening family bonds. It strengthens family ties… It’s meant to strengthen the bond because I drink your filth, you drink mine too (urban father). Further, it was also reported that it had been common to give the water just to the children to drink as it not only strengthened family connections, but also protected them from “spells”, as one participant stated. If everyone finishes washing their hands in the water, I give it to the child because it prevents him from getting sick … It prevents a lot of things because even if someone wants to put a bad spell on him, he will be protected against it (rural mother). 2. Knowledge about individual handwashing with soap 2.1 Links between CB-HR and infection While many participants continued to practice CB-HR, they also stated that they were well informed about the risk of communicable diseases when good hand hygiene is not enforced. It has been explained to us that the old method is no longer adequate and that it can lead to illness, we all agree today that washing our hands in the same utensil and with the same water is harmful to our health (rural father). The role of health workers in this was acknowledged. We rely a lot on our health workers, and we don’t do everything they tell us not to do, but the things that we are used to is little by little that we change our behaviour (rural father). When talking about the reasons why drinking the water from the CB-HR bowl was no longer practised, the transmission of diseases was cited as the reason. Some said that drinking water in which everyone washed their hands brings love between family members, but now there are too many diseases which made people stop (urban mother). Issues with washing dirty hands, especially from children in a communal bowl were also recognised. The adults use the kettle [a plastic kettle-shaped container , Fig. 2 ] to wash their hands with soap and they don't want to wash their hands in the same cup of water as the children because… they play a lot downstairs, and their hands are very dirty (urban father). However, there were also those who acknowledged that even though they knew that CB-HR could have adverse effects, not having had personal experience of such effects was a reason for maintaining the tradition of CB-HR. We use a container for handwashing. This can have consequences, but we have not experienced any consequences in this use (rural head of household). 2.2 Positive attitudes towards soap Almost half of the participants stated that soap was used at least occasionally in their household, while one participant stated that soap use was mandatory in their home. We all must wash our hands with soap after leaving the toilet and before eating… If you don’t wash your hands with soap you don’t eat with us (rural father). However, some participants placed more emphasis on this for certain age groups e.g., children. Before starting to eat we ask the children to go and wash their hands with soap to eat, even I washed my hands with soap powder before eating (urban father). Conversely, another participant explained that villagers believed that the adults were more likely to pass on disease to the children, leading to adults washing their hands separately. It's the adults who can contaminate the children, which is why we demand that the adults wash their hands with soap before feeding the children (rural mother). 3. Responses to recommendations to practice individual handwashing with soap 3.1 Fear of disrupting family bonds Fear was expressed that if family members washed their hands separately then this might lead to segregation and distance within the family unit. The fact of washing hands separately divides the family members that's why we like to wash our hands in the same container (rural mother). So, there will never be an expectation in a family that doesn’t do it because it will become every man for himself (urban father). A small proportion of the participants had adapted their CB-HR techniques to maintain both the traditional values of CB-HR and incorporate the necessary aspects of infection control. The fact that everyone washes their hands in the same container makes the water dirty and it can contain a lot of germs, so we changed strategies… we do a first round by washing all our hands together in the same container, then we do a second round by washing with soap and water from the kettle but this time separately (rural head of household). Everyone washes their hands with soap separately and when they eat, they rinse in a single container (urban father). 3.2 Impact of pandemics Despite this, a few interviewees from both rural and urban locations stated that they had made adaptations to their handwashing practices as a direct response to emerging pandemics, namely Ebola and COVID-19. Since the time of Ebola, I have put the handwashing kit in my house until now I renew it every time it gets bad, and if the soap runs out I buy another one. (rural head of household). However, others described that these pandemics had had no effect on CB-HR in their household as the diseases had not affected their village. We tell ourselves that the disease [COVID-19, Ebola] has not yet arrived in our village, and we have never heard that anyone has had this disease. That’s why we continue to wash our hands together (rural mother). 3.3 Concerns about soap Most participants recognised that public health messaging recommended the use of soap as part of handwashing but some discussed apprehensions regarding its use. The use of soap is not at all appropriate in our society … when you wash your hands with soap to eat it is quite possible that the soap penetrates the belly according to our old parents (rural head of household). I don't like using soap to wash my hands … I don't know what they are made of (rural father). Because in our opinion, even washing with soap is not good for our tradition, it is said that a person who washes all the time with soap cannot save money (rural head of household). Some participants believed plain water was enough to make their hands clean. You see this child here, if you wash his hands in water right away, he will be clean (rural mother). One participant stated that the use of soap was only for those with occupational exposure to communicable diseases, and otherwise members of the household did not use soap. If we do work in which we are in contact with microbes we have our hands with soap with water or there is bleach but if we don’t do work in which we are in contact with microbes we wash our hands with simple water (rural head of household). 3.4 Perceived financial and practical limitations of individual handwashing Some participants raised practical issues preventing them from discontinuing CB-HR, this included the allocation of disposable income to purchase soap and the number of water vessels and bowls needed, plus the need for sufficient water, especially in large families. There is no problem with the use of soap on the side, but… it would require us to multiply the handwashing containers while we have only one handwashing container… it would take a lot of water, you would have to fill it (rural head of household). Concerns were also expressed about purchasing handwashing kits. As we cannot afford to buy the new handwashing kits that is why we keep washing hands in the same container (rural mother). Some participants stated that handwashing kits should be more readily available in order to encourage their use in communities. Handwashing is for our health, if handwashing kits will be given to people with soaps or gels, they will be used in practice (rural grandmother). Similarly, another argued that people outside of the community should provide handwashing resources to motivate households to wash their hands using recommended techniques. You [the interviewer] [should] bring handwashing kits like the ones we have in our health centres with liquid soap and put the same in front of each door (rural mother). However, one participant stated that although the provision of handwashing kits would be beneficial his household would still practice CB-HR as it was quicker than using a handwashing kit. [CB-HR is] easier than washing their hands with soap in a washing kit which takes more time and people will stay waiting for each other I think that's why … it's just easier and faster (rural head of household). Alcohol-based hand gel was also used by a small proportion of participants following the recent COVID-19 pandemic. One participant explained how they tried to incorporate it as part of their handwashing practices, first washing their hands communally before using alcohol gel individually. However, they acknowledged that its use was limited by accessibility and affordability. Washing hands with soap in a container is the first and after using a gel, which you can't find because it's a question of money, it's easier with soap (rural father). 4. Maintaining change 4.1 Failure to maintain change post pandemics Despite the COVID-19 and Ebola pandemics influencing some households to make adaptations, there was evidence that these changes were not necessarily maintained. At one point we were forced to use alcohol gel… now we are not worried anymore (rural head of household). When corona was serious, we used to [wash hands individually] but now it's almost over so we stopped (urban father). 4.2 Motivating reasons for practising individual handwashing with soap One participant recognised that the cost of disease treatment could be high, therefore preventing the emergence of disease was preferential. I would urge good hygiene practice by everyone, even the cold you see with good hygiene practice, the cold will be reduced. I myself hate colds and when I am affected I don't take anyone's hand. I eat alone because contamination is fast. Therefore everyone must ensure that this is practiced in order to maintain good health. If diseases multiply in the family you will not stop spending money (rural head of household). 4.2 The need for role models to drive change Participants explained that in order for change to take place there must be people in the community driving the change forward. We have received information, nobody can say that they have not received information here, but sometimes there must be someone in the community or in the family who takes care of that (rural head of household). Some participants felt this should be the responsibility of the women, as they were in the home most and the primary caregivers. Women … are the ones who are most in contact with the children and they are the ones who are in charge of filling the handwashing kit and putting soap on the kit so… it's the women who must be more courageous so that this gesture is adopted … awareness should be raised at a time when women are most available (rural head of household). However, others felt it should be the head of household’s responsibility to lead by practice. Well, as the head of the family you have to set a good example. The head of the family must wash his hands with soap (rural head of household). Discussion Despite decades of public health interventions none have targeted CB-HR despite its prevalence throughout SSA [ 29 – 33 ], and diarrhoea remains one of the highest causes of death in SSA [ 34 ]. Our data indicate that CB-HR is still widely practised in Mali despite there being some awareness amongst participants of the risks that CB-HR poses to health such as diarrhoea and the spread of pandemic causing infections (e.g. Ebola & COVID-19). The practice of drinking the CB-HR water was rare. We did not see any noticeable difference between the attitudes of people toward CB-HR in urban and rural areas. For the majority, the motivation behind CB-HR was its role in fostering social cohesion, that is, improving and maintaining family unity. Several participants did however describe various adaptations that had been developed to CB-HR e.g. use of soap after CB-HR, individual bowls for handwashing, passing round handwashing kits and pouring clean water from the kettle over each other's hands into the bowl and using soap. Reasons for such adaptations included desire to reduce infection risk, convenience, and personal preference. Use of soap as part of handwashing was generally acceptable to participants and in some cases actively encouraged, with only a few respondents expressing concerns about using soap, or expressing concerns about the affordability of soap and handwashing equipment. Our findings reflect and elaborate on existing literature on CB-HR which has previously identified the primary motivations behind CB-HR in Africa as being linked to social practices around strengthening unity, which participants describe as their “tradition” [ 33 ]. Although scarcity of water was not a major theme in our data, it has been cited as an issue elsewhere [ 20 ]. Affordability was a minor theme in our data, and while handwashing devices and facilities are easily available and relatively cheap (2500cfa = £3.14), not all families prioritise this in limited budgets. When considering potential interventions to reduce the spread of pathogens, it is important to note that participants showed awareness of programmes previously conducted in the region aimed at tackling sanitation issues [ 16 , 18 ]. However, this and other studies [ 30 , 31 , 35 ] show that social and cultural values can supersede such knowledge. Even when participants had the capability in terms of knowledge to stop CB-HR, or the opportunity, that is, resources (water, handwashing vessels and soap), concerns about unity remained the driving motivation [ 36 ], which aligns with other evidence relevant to CB-HR [ 35 , 37 , 38 ]. Our data clearly suggests that it is not lack of knowledge, lack of handwashing facilities or availability of water that is the primary issue to be addressed, but rather the continued practice of CB-HR is motivated by deeply-held beliefs related to the social value of CB-HR, beliefs that in many cases outweigh any health concerns. For instance, our data suggested that the threat of pandemics to health was able to change behaviour in the short term, but not to sustain long-term change once the threat was perceived to have dissipated [ 39 ]. This provides clear evidence that any interventions targeting long-term change to CB-HR will need to be informed by the social and cultural context of people’s lives. The main barrier to stopping CB-HR was fear of disrupting family unity and hierarchies with the resultant social dysfunction. We see parallels between this and commensality where people come together to share food, it is common practice in many parts of the world to share at least one family meal a day together. The sharing of food in this way is widely considered to be important for family unity [ 15 ]. The maintenance of family unity therefore needs to be an essential component of any WASH programme targeted at CB-HR. Such programmes need to incorporate elements orientated towards enhancing family unity. Our data suggests that there is a realistic potential to do this successfully, as some participants had found ways to adapt their practice to incorporate individual handwashing with soap. In addition to the value placed on social and familial cohesion as a primary reason for continuing to practice CB-HR, for some participants there was also scepticism about the relationship between CB-HR, pathogens, and disease. Diarrhoea, common in the communities sampled, has many potential causes, such as poor food hygiene or sanitation, therefore, it can be hard for people to link specific practices, such as CB-HR to consequences, adversely affecting uptake of recommended handwashing practices. There are studies exploring the usefulness of microscopy to demonstrate how water samples, or swabs from hands carry bacteria [ 31 , 40 , 41 ], however, there may be cost barriers to implementing such interventions. Some participants argued that handwashing kits and soap should be provided for free, which likely reflects previous provision of free resources as part of WASH interventions, which could be said to have reduced the sense of individual agency at household level. However, we suggest that there needs to be a more non-disease driven approach that focuses on motivation to change, by targeting social norms within communities. Such change cannot be achieved in isolation, as was echoed by our participants when arguing that role models were needed. A key role in motivating such change needs to be played by key community leaders, both formal and informal (e.g. male and female leaders, elders, religious leaders and wise women). The media and schools can also play important roles in reinforcing such messages [ 31 ]. Strengths and limitations Strengths of this study include the large size and diversity of the qualitative sample which included participants from both rural and urban communities in Mali, across different generations, genders, and social status. We also recognise that the need to translate the spoken data (in Bambara) first into French for transcribing, then English for analysis may have resulted in some nuances being lost in translation. Recommendations Programmes that directly focus on CB-HR are needed. However, these programmes need to be informed by the social and cultural context of CB-HR practices, and evaluations should investigate the impact on social cohesion. Future research Future research in this area should analyse in more depth how the community members key to driving behavioural and social norm change vary from one community to another. Research modelling the cost-benefit to individual households of costs associated with hand washing versus the cost of disease treatment may be helpful. Also, microbiology studies exploring the benefits, or not, of alternative handwashing practices described here e.g. household members passing the handwashing kits around. The benefits of combining interventions that address social cohesion issues with interventions demonstrating the reality of the germ transmission, such as microscope and ‘Glo Germ’ demonstrations may also be of benefit [ 31 , 35 ]. Data currently under analysis (YD) has shown that more than half of people with handwashing kits do not use them for everyday washing, rather they save them for people such as guests. Conclusion We found widespread evidence that the practice of CB-HR was considered usual and desirable across both urban and rural communities, despite the importance of individual handwashing with soap in infection control being understood by many. Our data show that even when participants had knowledge of the health risks of CB-HR, access to running water, and handwashing equipment (vessels and soap) in many cases, they continued a form of CB-HR motivated by the high value assigned to CB-HR as a means of maintaining social cohesion. Programmes aimed at targeting infection control need to address the social and cultural drivers of CB-HR or adapt interventions to preserve elements that contribute to family unity. Abbreviations CB-HR Communal bowl - hand rinsing FG Focus group SSA Sub-Saharan Africa UNICEF United Nations Children's Fund WASH WAter, Sanitation and Hygiene Declarations Competing interests’ statement EAA, RA, CS, YD, HD, OT, KW, NG, SMH and RL’s declare grant funding to their institution for the current manuscript from Medical Research Council (MRC), UK Research and Innovation (UKRI) Global Challenges Research Fund (GCRF) MR/T030011/1. RL and SMH are also supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. The follow up interviews conducted August to September 2021 were funded by The Institute for Global Innovation, University of Birmingham, ID: 4029. MY and MB have no financial or non-financial competing interests to declare. Authors’ contributions SMH was the Chief Investigator for the MaaCiwara project and oversaw all project activities. NG was the qualitative lead for the MaaCiwara project and oversaw all qualitative data collection and analysis. SMH, RL, CS, YD and OT conceived the project and developed the original project plan. CS and HD conducted the interviews, supervised by SC, EAA and SMH. CS supervised translation. MY and MB conducted the initial, descriptive analysis and draft results, CP and RA developed the thematic analysis for this paper, analyses were overseen by NG, EAA and SMH. EAA prepared the first draft of the Introduction and Methods, CP updated and finalised the Introduction, Methods and Results and prepared the first draft of the Discussion, SS supported preparation of the methods and KW provided anthropological insights on the findings. Contributions to the paper were coordinated by RA, and development of the drafts was overseen by RA, EAA, SMH and NG.All authors contributed to and approved the final version of this paper. Acknowledgements We thank the dedicated team of research staff at University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali for managing and co-ordinating the data collection, transcription and translation. In particular we would like to thank K Demba Keita and F Karagodio for facilitating the focus groups and H Sangho and F Keita for translating the data. We especially want to thank the participants in Mali included in the study for their assistance, without whom this project would not have been possible. Data availability The data supporting the findings of this study are available from the corresponding author upon request, subject to completion of a data sharing agreement. References Walker, C.L.F., et al., Global burden of childhood pneumonia and diarrhoea. Lancet, 2013. 381 (9875): p. 1405-1416. Fischer Walker, C.L., et al., Does childhood diarrhea influence cognition beyond the diarrhea-stunting pathway? PLoS One, 2012. 7 (10): p. e47908. Checkley, W., et al., Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol, 2008. 37 (4): p. 816-30. Control, C.f.D., When and How to Wash Your Hands | Handwashing | CDC. 2022. Control, C.f.D., Show me the science - why wash your hands? CDC website, 2020. UNICEF, Handwashing with soap, critical in the fight against coronavirus, is ‘out of reach’ for billions. 2020. Amon-Tanoh, M.A., et al., Effects of a social norm-based handwashing intervention including handwashing stations, and a handwashing station-only intervention on handwashing with soap in urban Côte d'Ivoire: a cluster randomised controlled trial. The Lancet Global Health, 2021. 9 (12): p. e1707-e1718. De Buck, E., et al., Approaches to promote handwashing and sanitation behaviour change in low- and middle-income countries: a mixed method systematic review. Campbell Systematic Reviews, 2017. 13 (1): p. 1-447. Badowski, N., et al., Understanding household behavioral risk factors for diarrheal disease in Dar es Salaam: a photovoice community assessment. J Environ Public Health, 2011. 2011 : p. 130467. Maponga, B.A., et al., Risk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study. BMC Infect Dis, 2013. 13 : p. 567. Midzi, S.M., et al., An outbreak of dysentery in a rural district of Zimbabwe: the role of personal hygiene at public gatherings. Cent Afr J Med, 2000. 46 (6): p. 150-3. Oyugi, E.O., et al., An outbreak of cholera in western Kenya, 2015: a case control study. Pan Afr Med J, 2017. 28 (Suppl 1): p. 12. Tetteh-Quarcoo, P.B., et al., Microbial Content of “Bowl Water” Used for Communal Handwashing in Preschools within Accra Metropolis, Ghana. International Journal of Microbiology, 2016. 2016 : p. 2617473. Enkhbat, M., et al., Handwashing Practice among Elementary Schoolchildren in Urban Setting, Mongolia: A School-Based Cross-Sectional Survey. Journal of Environmental and Public Health, 2022. 2022 : p. 3103241. Jönsson, H., M. Michaud, and N. Neuman, What Is Commensality? A Critical Discussion of an Expanding Research Field. Int J Environ Res Public Health, 2021. 18 (12). UNICEF. Handwashing Promotion- Monitoring and Evaluation Module . 2013 01/05/2024]; Available from: https://www.unicef.org/media/91326/file/Handwashing-MandE-Module.pdf. UNICEF. For children in Mali, hand-washing and safe water save lives . 2012; Available from: https://reliefweb.int/report/mali/children-mali-hand-washing-and-safe-water-save-lives. World Vision International. Mali WASH Capacity statement . 2021 01/05/2024]; Available from: https://www.wvi.org/sites/default/files/2022-10/Mali%20WASH%20Capacity%20Statement%20FINAL.pdf. Olapeju, B., et al., Trends in handwashing behaviours for COVID-19 prevention: Longitudinal evidence from online surveys in 10 sub-Saharan African countries. PLOS Global Public Health, 2021. 1 (11): p. e0000049. Amegah, A.K., Improving handwashing habits and household air quality in Africa after COVID-19. The Lancet Global Health, 2020. 8 (9): p. e1110-e1111. Pickering, A.J., et al., Hands, water, and health: fecal contamination in Tanzanian communities with improved, non-networked water supplies. Environ Sci Technol, 2010. 44 (9): p. 3267-72. Mwakitalima, A., et al., Scaling up rural sanitation in Tanzania: evidence from the National Sanitation Campaign. Journal of Water, Sanitation and Hygiene for Development, 2018. 8 (2): p. 290-306. Kisaakye, P., P. Ndagurwa, and J. Mushomi, An assessment of availability of handwashing facilities in households from four East African countries. Journal of Water, Sanitation and Hygiene for Development, 2020. 11 (1): p. 75-90. Anteneh, Z.A., K. Andargie, and M. Tarekegn, Prevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan District, Northwest Ethiopia, 2014. BMC Public Health, 2017. 17 (1): p. 99. Asamane, E.A., et al., Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022). Trials, 2023. 24 (1): p. 68. Pope, C., S. Ziebland, and N. Mays, Qualitative research in health care: Analysing qualitative data. BMJ: British Medical Journal, 2000. 320 (7227): p. 114. Davidson, C., Transcription: Imperatives for Qualitative Research. International Journal of Qualitative Methods, 2009. 8 (2): p. 35-52. Braun, V. and V. Clarke, Using thematic analysis in psychology. Qualitative research in psychology, 2006. 3 (2): p. 77-101. Chidziwisano, K., et al., Improving complementary food hygiene behaviors using the risk, attitude, norms, ability, and self-regulation approach in rural Malawi. The American Journal of Tropical Medicine and Hygiene, 2020. 102 (5): p. 1104. Gautam, O.P., et al., Trial of a novel intervention to improve multiple food hygiene behaviors in Nepal. The American Journal of Tropical Medicine and Hygiene, 2017. 96 (6): p. 1415. Manjang, B., et al., Promoting hygienic weaning food handling practices through a community-based programme: intervention implementation and baseline characteristics for a cluster randomised controlled trial in rural Gambia. BMJ Open, 2018. 8 (8): p. e017573. Morse, T., et al., Developing a contextually appropriate integrated hygiene intervention to achieve sustained reductions in diarrheal diseases. Sustainability, 2019. 11 (17): p. 4656. Asamane, E., et al., Good Intentions but bad outcomes: Communal-bowl hand-rinsing before meals transmits pathogens and diseases: a systematic review. MedRxiv, 2024: p. 2024.08. 19.24311865. Demissie, G.D., et al., Diarrhea and associated factors among under five children in sub-Saharan Africa: evidence from demographic and health surveys of 34 sub-Saharan countries. Plos One, 2021. 16 (9): p. e0257522. Manaseki-Holland, S., et al., Effects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia. PLoS Medicine, 2021. 18 (1): p. e1003260. Michie, S., et al., Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data). Health Technology Assessment, 2015. 19 (99). Gautam, O.P. and V. Curtis, Food hygiene practices of rural women and microbial risk for children: Formative research in Nepal. The American Journal of Tropical Medicine and Hygiene, 2021. 105 (5): p. 1383. Chidziwisano, K., E. Tilley, and T. Morse, Self-reported versus observed measures: validation of child caregiver food hygiene practices in rural Malawi. International Journal of Environmental Research and Public Health, 2020. 17 (12): p. 4498. Kwasnicka, D., et al., Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychology Review, 2016. 10 (3): p. 277-296. Ogba, O.M., P.E. Asukwo, and I.B. Otu-Bassey, Assessment of bacterial carriage on the hands of primary school children in Calabar municipality, Nigeria. Biomedical Dermatology, 2018. 2 : p. 1-7. Tetteh-Quarcoo, P.B., et al., Microbial content of “bowl water” used for communal handwashing in preschools within Accra Metropolis, Ghana. International Journal of Microbiology, 2016. 2016 (1): p. 2617473. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4999129","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350461192,"identity":"fc1444a9-82d1-4140-86bf-28cc615ef4ca","order_by":0,"name":"Evans Atiah 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16:30:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4999129/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4999129/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67176691,"identity":"fee75272-49cc-4b92-bc89-f15e783e36e8","added_by":"auto","created_at":"2024-10-22 05:06:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":206476,"visible":true,"origin":"","legend":"\u003cp\u003eCommunal bowl hand rinsing before eating in a household in rural Mali (2022).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/867f3ee1878ba657a78f3056.png"},{"id":67176061,"identity":"82b8c56d-6829-40b7-b9c3-a4c87b703c5e","added_by":"auto","created_at":"2024-10-22 04:58:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":817008,"visible":true,"origin":"","legend":"\u003cp\u003eHandwashing kit comprising plastic kettle and bowl frequently seen in Mali (courtesy of: T.K. Naliaka, CC BY-SA 4.0, via Wikimedia Commons)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/4b71e286b6d34d1b8674c97a.png"},{"id":67176062,"identity":"372a04c9-4042-4585-86a0-db6be7821e71","added_by":"auto","created_at":"2024-10-22 04:58:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":61325,"visible":true,"origin":"","legend":"\u003cp\u003eVisual representation of the 4 key themes from this study\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/2af0278cf467407236d82451.png"},{"id":67176700,"identity":"9ee67151-02b1-44bf-9509-db59937e18de","added_by":"auto","created_at":"2024-10-22 05:06:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1965257,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/6ddc295f-15fa-453a-b0df-68db24b1f9ce.pdf"},{"id":67176690,"identity":"ef562941-8315-4689-a970-da13bc2009b5","added_by":"auto","created_at":"2024-10-22 05:06:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":116413,"visible":true,"origin":"","legend":"","description":"","filename":"Additional1TheInterviewTopicGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/b281740a6ff76c8f0a016238.docx"},{"id":67176065,"identity":"e2ad207c-c2fe-4cd9-a122-2a730e86a5ec","added_by":"auto","created_at":"2024-10-22 04:58:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":141148,"visible":true,"origin":"","legend":"","description":"","filename":"Additional2FocusGroupTopicGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-4999129/v1/0bfef9ac03db48ecf526e4c0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The tradition of washing hands in a common bowl before eating: a qualitative study of the practice of communal bowl hand rinsing before mealtimes, in rural and urban Mali ","fulltext":[{"header":"Background","content":"\u003cp\u003eDiarrhoeal disease has a large global health burden, leading to 1.8\u0026nbsp;billion deaths per year with the largest proportion of these occurring in children under 5 years old [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As well as contributing to mortality, diarrhoeal disease also plays a role in childhood malnutrition and developmental delays [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Individual handwashing with soap is proven to be the single best and most cost-effective way to prevent transmission of diarrhoeal pathogens [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The recommended technique is to wet the hands with running water, rub with soap for at least 20 seconds and then rinse with running water [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Handwashing is also promoted as a key intervention for the prevention of diseases such as COVID-19, Cholera and Ebola [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, UNICEF estimate that almost 3\u0026nbsp;billion people worldwide do not have access to soap and water at home [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Globally, the frequency of recommended handwashing techniques at key interventional moments (e.g. after using the toilet and prior to mealtimes) is especially low but is thought to be as low as 5\u0026ndash;22% in sub-Saharan Africa (SSA) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is estimated that 75% of cases of diarrhoea can be attributed to poor handwashing techniques and lack of effective food hygiene methods [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCommunal bowl hand rinsing (CB-HR) from a shared water bowl, usually without soap, is a common practice in many African countries before mealtimes, in schools, and at funerals [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Members of the same household or community group rinse their hands in a shared water container, sometimes from the oldest to youngest, without replenishing the water and usually without the use of soap (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We prefer the term communal bowl hand \u003cem\u003erinsing\u003c/em\u003e (CB-HR) rather than \u003cem\u003ewashing\u003c/em\u003e to indicate that the same water is shared between individuals, hands are only rinsed for a few seconds, soap is rarely used and therefore washing is scarcely achieved. CB-HR is commonly practiced in SSA and the practice precedes meals that are typically eaten with hands and often from a shared plate, further increasing the risk of ingesting and transmitting pathogens [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The motivations behind CB-HR are poorly investigated and unclear. CB-HR is thought to have a social function \u0026ndash; as a source of community and familial bonding [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and is typically practiced in association with commensality, the culturally significant act of coming together to share meals [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, CB-HR may have a practical function \u0026ndash; linked to saving often scarce water resources [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Research demonstrates that CB-HR directly increases the transmission of diseases such as cholera [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], with one paper demonstrating that bacteria, fungi and parasites were all present in the communal bowl water after the practice [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealth education around handwashing practices is included in routine outreach work and focuses on using clean, running water with soap [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, organisations such as UNICEF, Water Aid and Save the Children have been working for decades in countries across Africa to tackle sanitation issues and increase health education in both rural and urban communities [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Such programmes are often referred to as \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWA\u003c/span\u003eter, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eS\u003c/span\u003eanitation and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eH\u003c/span\u003eygiene (WASH) programmes, that is, any programme concerned with all 3 of these components. Handwashing kits are often introduced as part of these programmes and take a range of forms. The kit most typically used in Mali can be seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFollowing the COVID-19 pandemic, governmental strategies to reduce viral transmission in African countries included promotion of social distancing and the wearing of face masks in confined spaces. However, recommended handwashing practices were not given equal promotion, with research demonstrating that prevalence of handwashing instead declined during the pandemic [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In some communities, there was an increase in the accessibility of handwashing equipment in public spaces, but there was no directive to encourage recommended handwashing methods while at home [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Existing literature shows that key determinants for improving hand hygiene and general sanitation in households include economic status of the households, education level of the head of household, type of residency, access to running water, and number of children in the household [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, motivators and drivers for this practice and interventions directly targeting this behaviour are lacking in the literature.\u003c/p\u003e \u003cp\u003eWe found no evidence of interventions that have been developed to directly address this common practice in Africa. In view of this, the aim of the study was to gain a better understanding of CB-HR, identifying the reasoning behind the practice and determining factors preventing recommended handwashing practice in Mali. Such evidence is needed to support the development and implementation of sustainable behaviour change interventions which are sensitive to global, socio-economic contexts. Mali is a large country sharing ethnic groups with many West, Northern and Central African countries, thus enabling our findings to be of greater relevance to other countries in the region.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eWe employed a two-phase qualitative study using two complementary methods: focus groups and semi-structured interviews. The focus group study (November 2020 to January 2021) was part of the formative research informing the development of the intervention within the MaaCiwara study: a parallel group, two-arm cluster randomised trial focussing on food safety and hygiene at a community level [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Having identified the practice of CB-HR in the focus groups, a follow-up, nested qualitative study was conducted (August to September 2021). This nested study was part of a feasibility trial testing a simple intervention of introducing soap as part of the practice of communal handwashing to reduce pathogen transmission during CB-HR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eMali is a conflict-affected West African Francophone country where despite outbreaks of cholera, Ebola and despite recent COVID-19 handwashing promotion and existing low-cost low-tech tools to reduce water usage and improve handwashing practices, CB-HR has persisted. Data were collected in Mali\u0026rsquo;s capital city Bamako and surrounding villages. Specifically, in the urban areas of Banconi and Sabalibougou in Bamako, and 3 rural villages in the Koulikoro region: Dialakoroba, Zantiguila, and Tienfala. Additional focus groups were also conducted in 2 other cities, Segou and Sikasso, in the central and southern regions of Mali, respectively. In urban settings we specifically targeted lower socio-economic areas.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and Sampling\u003c/h2\u003e \u003cp\u003ePermissions were obtained from local community leaders to approach community members. For the focus groups, community members were invited to take part in each of the seven locations. Invitations were made by the local community health volunteer. The sampling strategy was purposeful to get a range of community members: mothers, grandmothers and fathers of children aged 6\u0026ndash;36 months, and elders (grandfathers who were heads of household) took part in four separate focus groups in each setting. For the interviews, 6 heads of households (fathers or grandfathers), and mothers (with children 6\u0026ndash;36 months) were interviewed in each of the 5 communities involved in the feasibility study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eSeparate topic guides were developed, tested and iteratively revised for each phase of the study (see Additional 1 and Additional 2). The trial manager in Mali (CS), a medical doctor with qualitative research experience, provided training for and supervision of data collection. Focus groups and interviews lasted 30\u0026ndash;60 minutes. Data collection was conducted in Bambara, the national language in Mali, by Malian researchers.\u003c/p\u003e \u003cp\u003eThe focus groups were facilitated by two sociology graduates (one male, one female). To help develop rapport with local gatekeepers and facilitate the smooth running of the data collection, the fieldworkers arrived at the locations outside of Bamako the day before the focus groups, where they met with local community leaders, health staff and volunteers. Focus groups were typically held in the community\u0026rsquo;s usual meeting place, such as a community leader\u0026rsquo;s home or an open space in the centre of the community. The topic guide comprised the following key topic areas \u0026ndash; breastfeeding, complementary feeding, food storage, handwashing, play, animal husbandry, information sharing within the community and format for celebrations. This paper reports data that emerged on the topic of CB-HR. In addition to the audio-recordings, field workers kept field notes detailing additional information from each focus group.\u003c/p\u003e \u003cp\u003eInterviews were conducted by either a male (CS) or a female (HD) medical doctor experienced in conducting qualitative research in participants\u0026rsquo; homes. The topic guide covered understanding of recommended handwashing techniques, usual handwashing practice, practices related to and reasons for CB-HR, feelings about hand washing in relation to infant feeding and attitudes towards soap.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData collection, synthesis and analysis were conducted concurrently to allow for improvement of the process, tools and approach in the proceeding interviews [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Bambara is not commonly a written language and so the local practice is to speak in Bambara and write in French; therefore, the digital recordings were transcribed into French by another Mali team member who then translated them into English to share with the wider team [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Thematic analysis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] was used to analyse the data, using NVivo v.12 software. Both data sets were analysed together. Two UK-based researchers (MY \u0026amp; MB) repeatedly went through the transcripts to gain an in-depth insight into the content and produced a draft coding framework. Subsequently, initial codes were identified, and differences discussed with the supervising qualitative team (NG, EAA \u0026amp; SMH). Two researchers (EAA \u0026amp; CS) independently coded 10% of the transcripts using this framework. Differences were discussed in the group and the codes modified before applying the framework to the remaining transcripts. The analysis was then reviewed (CP \u0026amp; SS), and themes identified and discussed with the qualitative team.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 168 participants contributed to 28 focus groups, with each focus group containing 6\u0026ndash;7 participants, and 59 interviews were conducted (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants have been anonymised following the key in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRural/Urban split for number of (a) individual interviews and (b) focus groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(a) Interviews\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFathers/Heads of Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e(b) Focus groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFathers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e26\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eWe found that CB-HR was a part of everyday life for most of our participants, with only a handful of rural and urban interviewees stating that they did not practice CB-HR. We identified 4 themes with 13 subthemes which helped us understand why CB-HR is practised and what the scope for change is (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e1. The practice of CB-HR\u003c/h2\u003e \u003cp\u003eThe key driver of CB-HR was building and maintaining social cohesion between families and the wider community, with the scarcity of water a secondary, but also relevant, reason. Nonetheless, there were important variations in the perceptions and interpretations of the importance of the practice.\u003c/p\u003e \u003cp\u003e1.1 Unity, solidarity, and tradition\u003c/p\u003e \u003cp\u003eThe practice of CB-HR was described as something that had been passed down through the generations as a means of improving and preserving family unity and generational links.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOur elders used to say that when we all washed our hands together, we each took something from the other and this contributed to social cohesion. (rural grandfather)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis links to commensality, which is also a practice that aims to strengthen familial relationships and contribute to unification of the household.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e [CB-HR] is better than each one washing his hands separately because if each one washes his hands separately there will be no agreement between people, it creates affection between the members of a family (urban father)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant added that the act of CB-HR demonstrated to visitors that their household was strongly unified.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt is about cohesion between family members\u0026hellip; when you wash your hands in the same container when a foreigner comes, he would know that you are united and well educated (rural head of household)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome men also explained that hand washing with soap was believed to wash away wealth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eActually, if we estimate the percentage of those who wash their hands with soap here in the general population, I would say it is 10%. Because in our opinion, even washing with soap is not good for our traditions, it is said that a person who washes all the time with soap cannot save money \u0026hellip; We wash our hands from time to time just to avoid getting sick. You can't do it all the time, it's not easy. \u0026hellip; Nowadays, toxic products such as fertilizers that we handle every day, force us to wash our hands with soap to protect ourselves from getting sick and dying (urban, elder FG)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, there were a few interviewees who gave the reasoning for CB-HR in their household, as simply a practice they had grown up with.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe learned [to wash our hands in one container] from our parents\u0026hellip; They didn\u0026rsquo;t tell us the reasons (rural father)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e1.2 Scarcity of water\u003c/p\u003e \u003cp\u003eWhilst maintaining the emphasis on social cohesion as the primary reason for CB-HR, scarcity of water was also mentioned frequently as another reason for its practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAs far as water is concerned, it's because there wasn't enough water... Concerning the washing of the hands together, it was because of the lack of water (rural father)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e1.3 Variations\u003c/p\u003e \u003cp\u003eWhile CB-HR is typically performed in order of age from oldest to youngest as a demonstration of respect, examples were given where this was not adhered to. One participant explained that were times when the order of handwashing was adapted to accommodate time constraints.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhen I'm at home, I [head of household] wash my hands first and then the others, but often when we are in a hurry, it's by order of arrival (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Two participants described CB-HR practices that involved gendered handwashing containers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThere is a container for the old women, one for the women and one for the men\u0026hellip; we have 3 containers for handwashing (rural mother).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother variation was the practice of drinking the water after it had been used for CB-HR as a means of further strengthening family bonds.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt strengthens family ties\u0026hellip; It\u0026rsquo;s meant to strengthen the bond because I drink your filth, you drink mine too (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, it was also reported that it had been common to give the water just to the children to drink as it not only strengthened family connections, but also protected them from \u0026ldquo;spells\u0026rdquo;, as one participant stated.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf everyone finishes washing their hands in the water, I give it to the child because it prevents him from getting sick \u0026hellip; It prevents a lot of things because even if someone wants to put a bad spell on him, he will be protected against it (rural mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2. Knowledge about individual handwashing with soap\u003c/h2\u003e \u003cp\u003e2.1 Links between CB-HR and infection\u003c/p\u003e \u003cp\u003eWhile many participants continued to practice CB-HR, they also stated that they were well informed about the risk of communicable diseases when good hand hygiene is not enforced.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt has been explained to us that the old method is no longer adequate and that it can lead to illness, we all agree today that washing our hands in the same utensil and with the same water is harmful to our health (rural father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe role of health workers in this was acknowledged.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe rely a lot on our health workers, and we don\u0026rsquo;t do everything they tell us not to do, but the things that we are used to is little by little that we change our behaviour (rural father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen talking about the reasons why drinking the water from the CB-HR bowl was no longer practised, the transmission of diseases was cited as the reason.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome said that drinking water in which everyone washed their hands brings love between family members, but now there are too many diseases which made people stop (urban mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIssues with washing dirty hands, especially from children in a communal bowl were also recognised.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe adults use the kettle [a plastic kettle-shaped container\u003c/em\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e] to wash their hands with soap and they don't want to wash their hands in the same cup of water as the children because\u0026hellip; they play a lot downstairs, and their hands are very dirty (urban father).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, there were also those who acknowledged that even though they knew that CB-HR could have adverse effects, not having had personal experience of such effects was a reason for maintaining the tradition of CB-HR.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe use a container for handwashing. This can have consequences, but we have not experienced any consequences in this use (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e2.2 Positive attitudes towards soap\u003c/p\u003e \u003cp\u003e Almost half of the participants stated that soap was used at least occasionally in their household, while one participant stated that soap use was mandatory in their home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe all must wash our hands with soap after leaving the toilet and before eating\u0026hellip; If you don\u0026rsquo;t wash your hands with soap you don\u0026rsquo;t eat with us (rural father).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some participants placed more emphasis on this for certain age groups e.g., children.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eBefore starting to eat we ask the children to go and wash their hands with soap to eat, even I washed my hands with soap powder before eating (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, another participant explained that villagers believed that the adults were more likely to pass on disease to the children, leading to adults washing their hands separately.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt's the adults who can contaminate the children, which is why we demand that the adults wash their hands with soap before feeding the children (rural mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3. Responses to recommendations to practice individual handwashing with soap\u003c/h2\u003e \u003cp\u003e3.1 Fear of disrupting family bonds\u003c/p\u003e \u003cp\u003eFear was expressed that if family members washed their hands separately then this might lead to segregation and distance within the family unit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe fact of washing hands separately divides the family members that's why we like to wash our hands in the same container (rural mother).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eSo, there will never be an expectation in a family that doesn\u0026rsquo;t do it because it will become every man for himself (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA small proportion of the participants had adapted their CB-HR techniques to maintain both the traditional values of CB-HR and incorporate the necessary aspects of infection control.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe fact that everyone washes their hands in the same container makes the water dirty and it can contain a lot of germs, so we changed strategies\u0026hellip; we do a first round by washing all our hands together in the same container, then we do a second round by washing with soap and water from the kettle but this time separately (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eEveryone washes their hands with soap separately and when they eat, they rinse in a single container (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e3.2 Impact of pandemics\u003c/p\u003e \u003cp\u003eDespite this, a few interviewees from both rural and urban locations stated that they had made adaptations to their handwashing practices as a direct response to emerging pandemics, namely Ebola and COVID-19.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSince the time of Ebola, I have put the handwashing kit in my house until now I renew it every time it gets bad, and if the soap runs out I buy another one. (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, others described that these pandemics had had no effect on CB-HR in their household as the diseases had not affected their village.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe tell ourselves that the disease [COVID-19, Ebola] has not yet arrived in our village, and we have never heard that anyone has had this disease. That\u0026rsquo;s why we continue to wash our hands together (rural mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e3.3 Concerns about soap\u003c/p\u003e \u003cp\u003e Most participants recognised that public health messaging recommended the use of soap as part of handwashing but some discussed apprehensions regarding its use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e The use of soap is not at all appropriate in our society \u0026hellip; when you wash your hands with soap to eat it is quite possible that the soap penetrates the belly according to our old parents (rural head of household).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI don't like using soap to wash my hands \u0026hellip; I don't know what they are made of (rural father).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eBecause in our opinion, even washing with soap is not good for our tradition, it is said that a person who washes all the time with soap cannot save money (rural head of household).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Some participants believed plain water was enough to make their hands clean.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eYou see this child here, if you wash his hands in water right away, he will be clean (rural mother).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e One participant stated that the use of soap was only for those with occupational exposure to communicable diseases, and otherwise members of the household did not use soap.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIf we do work in which we are in contact with microbes we have our hands with soap with water or there is bleach but if we don\u0026rsquo;t do work in which we are in contact with microbes we wash our hands with simple water (rural head of household).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e3.4 Perceived financial and practical limitations of individual handwashing\u003c/p\u003e \u003cp\u003eSome participants raised practical issues preventing them from discontinuing CB-HR, this included the allocation of disposable income to purchase soap and the number of water vessels and bowls needed, plus the need for sufficient water, especially in large families.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere is no problem with the use of soap on the side, but\u0026hellip; it would require us to multiply the handwashing containers while we have only one handwashing container\u0026hellip; it would take a lot of water, you would have to fill it (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConcerns were also expressed about purchasing handwashing kits.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAs we cannot afford to buy the new handwashing kits that is why we keep washing hands in the same container (rural mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants stated that handwashing kits should be more readily available in order to encourage their use in communities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eHandwashing is for our health, if handwashing kits will be given to people with soaps or gels, they will be used in practice (rural grandmother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, another argued that people outside of the community should provide handwashing resources to motivate households to wash their hands using recommended techniques.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou [the interviewer] [should] bring handwashing kits like the ones we have in our health centres with liquid soap and put the same in front of each door (rural mother).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, one participant stated that although the provision of handwashing kits would be beneficial his household would still practice CB-HR as it was quicker than using a handwashing kit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e[CB-HR is] easier than washing their hands with soap in a washing kit which takes more time and people will stay waiting for each other I think that's why \u0026hellip; it's just easier and faster (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Alcohol-based hand gel was also used by a small proportion of participants following the recent COVID-19 pandemic. One participant explained how they tried to incorporate it as part of their handwashing practices, first washing their hands communally before using alcohol gel individually. However, they acknowledged that its use was limited by accessibility and affordability.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWashing hands with soap in a container is the first and after using a gel, which you can't find because it's a question of money, it's easier with soap (rural father).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4. Maintaining change\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e4.1 Failure to maintain change post pandemics\u003c/h2\u003e \u003cp\u003eDespite the COVID-19 and Ebola pandemics influencing some households to make adaptations, there was evidence that these changes were not necessarily maintained.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAt one point we were forced to use alcohol gel\u0026hellip; now we are not worried anymore (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eWhen corona was serious, we used to [wash hands individually] but now it's almost over so we stopped (urban father).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Motivating reasons for practising individual handwashing with soap\u003c/h2\u003e \u003cp\u003eOne participant recognised that the cost of disease treatment could be high, therefore preventing the emergence of disease was preferential.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI would urge good hygiene practice by everyone, even the cold you see with good hygiene practice, the cold will be reduced. I myself hate colds and when I am affected I don't take anyone's hand. I eat alone because contamination is fast. Therefore everyone must ensure that this is practiced in order to maintain good health. If diseases multiply in the family you will not stop spending money (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The need for role models to drive change\u003c/h2\u003e \u003cp\u003eParticipants explained that in order for change to take place there must be people in the community driving the change forward.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe have received information, nobody can say that they have not received information here, but sometimes there must be someone in the community or in the family who takes care of that (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants felt this should be the responsibility of the women, as they were in the home most and the primary caregivers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWomen \u0026hellip; are the ones who are most in contact with the children and they are the ones who are in charge of filling the handwashing kit and putting soap on the kit so\u0026hellip; it's the women who must be more courageous so that this gesture is adopted \u0026hellip; awareness should be raised at a time when women are most available (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, others felt it should be the head of household\u0026rsquo;s responsibility to lead by practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWell, as the head of the family you have to set a good example. The head of the family must wash his hands with soap (rural head of household).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite decades of public health interventions none have targeted CB-HR despite its prevalence throughout SSA [\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and diarrhoea remains one of the highest causes of death in SSA [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our data indicate that CB-HR is still widely practised in Mali despite there being some awareness amongst participants of the risks that CB-HR poses to health such as diarrhoea and the spread of pandemic causing infections (e.g. Ebola \u0026amp; COVID-19). The practice of drinking the CB-HR water was rare. We did not see any noticeable difference between the attitudes of people toward CB-HR in urban and rural areas. For the majority, the motivation behind CB-HR was its role in fostering social cohesion, that is, improving and maintaining family unity. Several participants did however describe various adaptations that had been developed to CB-HR e.g. use of soap after CB-HR, individual bowls for handwashing, passing round handwashing kits and pouring clean water from the kettle over each other's hands into the bowl and using soap. Reasons for such adaptations included desire to reduce infection risk, convenience, and personal preference. Use of soap as part of handwashing was generally acceptable to participants and in some cases actively encouraged, with only a few respondents expressing concerns about using soap, or expressing concerns about the affordability of soap and handwashing equipment.\u003c/p\u003e \u003cp\u003eOur findings reflect and elaborate on existing literature on CB-HR which has previously identified the primary motivations behind CB-HR in Africa as being linked to social practices around strengthening unity, which participants describe as their \u0026ldquo;tradition\u0026rdquo; [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Although scarcity of water was not a major theme in our data, it has been cited as an issue elsewhere [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Affordability was a minor theme in our data, and while handwashing devices and facilities are easily available and relatively cheap (2500cfa = \u0026pound;3.14), not all families prioritise this in limited budgets.\u003c/p\u003e \u003cp\u003eWhen considering potential interventions to reduce the spread of pathogens, it is important to note that participants showed awareness of programmes previously conducted in the region aimed at tackling sanitation issues [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, this and other studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] show that social and cultural values can supersede such knowledge. Even when participants had the capability in terms of knowledge to stop CB-HR, or the opportunity, that is, resources (water, handwashing vessels and soap), concerns about unity remained the driving motivation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which aligns with other evidence relevant to CB-HR [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur data clearly suggests that it is not lack of knowledge, lack of handwashing facilities or availability of water that is the primary issue to be addressed, but rather the continued practice of CB-HR is motivated by deeply-held beliefs related to the social value of CB-HR, beliefs that in many cases outweigh any health concerns. For instance, our data suggested that the threat of pandemics to health was able to change behaviour in the short term, but not to sustain long-term change once the threat was perceived to have dissipated [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This provides clear evidence that any interventions targeting long-term change to CB-HR will need to be informed by the social and cultural context of people\u0026rsquo;s lives.\u003c/p\u003e \u003cp\u003eThe main barrier to stopping CB-HR was fear of disrupting family unity and hierarchies with the resultant social dysfunction. We see parallels between this and commensality where people come together to share food, it is common practice in many parts of the world to share at least one family meal a day together. The sharing of food in this way is widely considered to be important for family unity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The maintenance of family unity therefore needs to be an essential component of any WASH programme targeted at CB-HR. Such programmes need to incorporate elements orientated towards enhancing family unity. Our data suggests that there is a realistic potential to do this successfully, as some participants had found ways to adapt their practice to incorporate individual handwashing with soap.\u003c/p\u003e \u003cp\u003eIn addition to the value placed on social and familial cohesion as a primary reason for continuing to practice CB-HR, for some participants there was also scepticism about the relationship between CB-HR, pathogens, and disease. Diarrhoea, common in the communities sampled, has many potential causes, such as poor food hygiene or sanitation, therefore, it can be hard for people to link specific practices, such as CB-HR to consequences, adversely affecting uptake of recommended handwashing practices. There are studies exploring the usefulness of microscopy to demonstrate how water samples, or swabs from hands carry bacteria [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], however, there may be cost barriers to implementing such interventions.\u003c/p\u003e \u003cp\u003eSome participants argued that handwashing kits and soap should be provided for free, which likely reflects previous provision of free resources as part of WASH interventions, which could be said to have reduced the sense of individual agency at household level. However, we suggest that there needs to be a more non-disease driven approach that focuses on motivation to change, by targeting social norms within communities. Such change cannot be achieved in isolation, as was echoed by our participants when arguing that role models were needed. A key role in motivating such change needs to be played by key community leaders, both formal and informal (e.g. male and female leaders, elders, religious leaders and wise women). The media and schools can also play important roles in reinforcing such messages [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eStrengths of this study include the large size and diversity of the qualitative sample which included participants from both rural and urban communities in Mali, across different generations, genders, and social status. We also recognise that the need to translate the spoken data (in Bambara) first into French for transcribing, then English for analysis may have resulted in some nuances being lost in translation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eProgrammes that directly focus on CB-HR are needed. However, these programmes need to be informed by the social and cultural context of CB-HR practices, and evaluations should investigate the impact on social cohesion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFuture research\u003c/h2\u003e \u003cp\u003eFuture research in this area should analyse in more depth how the community members key to driving behavioural and social norm change vary from one community to another. Research modelling the cost-benefit to individual households of costs associated with hand washing versus the cost of disease treatment may be helpful. Also, microbiology studies exploring the benefits, or not, of alternative handwashing practices described here e.g. household members passing the handwashing kits around. The benefits of combining interventions that address social cohesion issues with interventions demonstrating the reality of the germ transmission, such as microscope and \u0026lsquo;Glo Germ\u0026rsquo; demonstrations may also be of benefit [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Data currently under analysis (YD) has shown that more than half of people with handwashing kits do not use them for everyday washing, rather they save them for people such as guests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe found widespread evidence that the practice of CB-HR was considered usual and desirable across both urban and rural communities, despite the importance of individual handwashing with soap in infection control being understood by many. Our data show that even when participants had knowledge of the health risks of CB-HR, access to running water, and handwashing equipment (vessels and soap) in many cases, they continued a form of CB-HR motivated by the high value assigned to CB-HR as a means of maintaining social cohesion. Programmes aimed at targeting infection control need to address the social and cultural drivers of CB-HR or adapt interventions to preserve elements that contribute to family unity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCB-HR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCommunal bowl - hand rinsing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eFG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eFocus group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUNICEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUnited Nations Children\u0026apos;s Fund\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eWASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eWAter, Sanitation and Hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests’ statement\u003c/h2\u003e\n\u003cp\u003eEAA, RA, CS, YD, HD, OT, KW, NG, SMH and RL’s\u0026nbsp;declare grant funding to their institution for the current manuscript\u0026nbsp;from Medical Research Council (MRC), UK Research and Innovation (UKRI) Global Challenges Research Fund (GCRF) MR/T030011/1. RL and SMH are also supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands.\u0026nbsp;The follow up interviews conducted August to September 2021 were funded by\u0026nbsp;The Institute for Global Innovation, University of Birmingham, ID: 4029. MY and MB have no financial or non-financial competing interests to declare.\u003c/p\u003e\n\u003ch2\u003eAuthors’ contributions\u003c/h2\u003e\n\u003cp\u003eSMH was the Chief Investigator for the MaaCiwara project and oversaw all project activities. NG was the qualitative lead for the MaaCiwara project and oversaw all qualitative data collection and analysis. SMH, RL, CS, YD and OT conceived the project and developed the original project plan. CS and HD conducted the interviews, supervised by SC, EAA and SMH. CS supervised translation.\u0026nbsp;MY and MB conducted the initial, descriptive analysis and draft results, CP and RA developed the thematic analysis for this paper, analyses were\u0026nbsp;overseen by NG, EAA and SMH. EAA prepared the first draft of the Introduction and Methods, CP updated and finalised the Introduction, Methods and\u0026nbsp;Results and prepared the first draft of the Discussion, SS supported preparation of the methods and KW provided anthropological insights on the findings. Contributions to the paper were coordinated by RA, and development of the drafts was overseen by RA, EAA, SMH and NG.All authors contributed to and approved the final version of this paper.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe thank the dedicated team of research staff at University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali for managing and co-ordinating the data collection, transcription and translation. In particular we would like to thank K Demba Keita and F Karagodio for facilitating the focus groups and H Sangho and F Keita for translating the data. We especially want to thank the participants in Mali included in the study for their assistance, without whom this project would not have been possible.\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon request, subject to completion of a data sharing agreement.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalker, C.L.F., et al., \u003cem\u003eGlobal burden of childhood pneumonia and diarrhoea.\u003c/em\u003e Lancet, 2013. \u003cstrong\u003e381\u003c/strong\u003e(9875): p. 1405-1416.\u003c/li\u003e\n\u003cli\u003eFischer Walker, C.L., et al., \u003cem\u003eDoes childhood diarrhea influence cognition beyond the diarrhea-stunting pathway?\u003c/em\u003e PLoS One, 2012. \u003cstrong\u003e7\u003c/strong\u003e(10): p. e47908.\u003c/li\u003e\n\u003cli\u003eCheckley, W., et al., \u003cem\u003eMulti-country analysis of the effects of diarrhoea on childhood stunting.\u003c/em\u003e Int J Epidemiol, 2008. \u003cstrong\u003e37\u003c/strong\u003e(4): p. 816-30.\u003c/li\u003e\n\u003cli\u003eControl, C.f.D., \u003cem\u003eWhen and How to Wash Your Hands | Handwashing | CDC.\u003c/em\u003e 2022.\u003c/li\u003e\n\u003cli\u003eControl, C.f.D., \u003cem\u003eShow me the science - why wash your hands?\u003c/em\u003e CDC website, 2020.\u003c/li\u003e\n\u003cli\u003eUNICEF, \u003cem\u003eHandwashing with soap, critical in the fight against coronavirus, is \u0026lsquo;out of reach\u0026rsquo; for billions.\u003c/em\u003e 2020.\u003c/li\u003e\n\u003cli\u003eAmon-Tanoh, M.A., et al., \u003cem\u003eEffects of a social norm-based handwashing intervention including handwashing stations, and a handwashing station-only intervention on handwashing with soap in urban C\u0026ocirc;te d\u0026apos;Ivoire: a cluster randomised controlled trial.\u003c/em\u003e The Lancet Global Health, 2021. \u003cstrong\u003e9\u003c/strong\u003e(12): p. e1707-e1718.\u003c/li\u003e\n\u003cli\u003eDe Buck, E., et al., \u003cem\u003eApproaches to promote handwashing and sanitation behaviour change in low- and middle-income countries: a mixed method systematic review.\u003c/em\u003e Campbell Systematic Reviews, 2017. \u003cstrong\u003e13\u003c/strong\u003e(1): p. 1-447.\u003c/li\u003e\n\u003cli\u003eBadowski, N., et al., \u003cem\u003eUnderstanding household behavioral risk factors for diarrheal disease in Dar es Salaam: a photovoice community assessment.\u003c/em\u003e J Environ Public Health, 2011. \u003cstrong\u003e2011\u003c/strong\u003e: p. 130467.\u003c/li\u003e\n\u003cli\u003eMaponga, B.A., et al., \u003cem\u003eRisk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study.\u003c/em\u003e BMC Infect Dis, 2013. \u003cstrong\u003e13\u003c/strong\u003e: p. 567.\u003c/li\u003e\n\u003cli\u003eMidzi, S.M., et al., \u003cem\u003eAn outbreak of dysentery in a rural district of Zimbabwe: the role of personal hygiene at public gatherings.\u003c/em\u003e Cent Afr J Med, 2000. \u003cstrong\u003e46\u003c/strong\u003e(6): p. 150-3.\u003c/li\u003e\n\u003cli\u003eOyugi, E.O., et al., \u003cem\u003eAn outbreak of cholera in western Kenya, 2015: a case control study.\u003c/em\u003e Pan Afr Med J, 2017. \u003cstrong\u003e28\u003c/strong\u003e(Suppl 1): p. 12.\u003c/li\u003e\n\u003cli\u003eTetteh-Quarcoo, P.B., et al., \u003cem\u003eMicrobial Content of \u0026ldquo;Bowl Water\u0026rdquo; Used for Communal Handwashing in Preschools within Accra Metropolis, Ghana.\u003c/em\u003e International Journal of Microbiology, 2016. \u003cstrong\u003e2016\u003c/strong\u003e: p. 2617473.\u003c/li\u003e\n\u003cli\u003eEnkhbat, M., et al., \u003cem\u003eHandwashing Practice among Elementary Schoolchildren in Urban Setting, Mongolia: A School-Based Cross-Sectional Survey.\u003c/em\u003e Journal of Environmental and Public Health, 2022. \u003cstrong\u003e2022\u003c/strong\u003e: p. 3103241.\u003c/li\u003e\n\u003cli\u003eJ\u0026ouml;nsson, H., M. 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Tarekegn, \u003cem\u003ePrevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan District, Northwest Ethiopia, 2014.\u003c/em\u003e BMC Public Health, 2017. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 99.\u003c/li\u003e\n\u003cli\u003eAsamane, E.A., et al., \u003cem\u003eProtocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022).\u003c/em\u003e Trials, 2023. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 68.\u003c/li\u003e\n\u003cli\u003ePope, C., S. Ziebland, and N. 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Clarke, \u003cem\u003eUsing thematic analysis in psychology.\u003c/em\u003e Qualitative research in psychology, 2006. \u003cstrong\u003e3\u003c/strong\u003e(2): p. 77-101.\u003c/li\u003e\n\u003cli\u003eChidziwisano, K., et al., \u003cem\u003eImproving complementary food hygiene behaviors using the risk, attitude, norms, ability, and self-regulation approach in rural Malawi.\u003c/em\u003e The American Journal of Tropical Medicine and Hygiene, 2020. \u003cstrong\u003e102\u003c/strong\u003e(5): p. 1104.\u003c/li\u003e\n\u003cli\u003eGautam, O.P., et al., \u003cem\u003eTrial of a novel intervention to improve multiple food hygiene behaviors in Nepal.\u003c/em\u003e The American Journal of Tropical Medicine and Hygiene, 2017. \u003cstrong\u003e96\u003c/strong\u003e(6): p. 1415.\u003c/li\u003e\n\u003cli\u003eManjang, B., et al., \u003cem\u003ePromoting hygienic weaning food handling practices through a community-based programme: intervention implementation and baseline characteristics for a cluster randomised controlled trial in rural Gambia.\u003c/em\u003e BMJ Open, 2018. \u003cstrong\u003e8\u003c/strong\u003e(8): p. e017573.\u003c/li\u003e\n\u003cli\u003eMorse, T., et al., \u003cem\u003eDeveloping a contextually appropriate integrated hygiene intervention to achieve sustained reductions in diarrheal diseases.\u003c/em\u003e Sustainability, 2019. \u003cstrong\u003e11\u003c/strong\u003e(17): p. 4656.\u003c/li\u003e\n\u003cli\u003eAsamane, E., et al., \u003cem\u003eGood Intentions but bad outcomes: Communal-bowl hand-rinsing before meals transmits pathogens and diseases: a systematic review.\u003c/em\u003e MedRxiv, 2024: p. 2024.08. 19.24311865.\u003c/li\u003e\n\u003cli\u003eDemissie, G.D., et al., \u003cem\u003eDiarrhea and associated factors among under five children in sub-Saharan Africa: evidence from demographic and health surveys of 34 sub-Saharan countries.\u003c/em\u003e Plos One, 2021. \u003cstrong\u003e16\u003c/strong\u003e(9): p. e0257522.\u003c/li\u003e\n\u003cli\u003eManaseki-Holland, S., et al., \u003cem\u003eEffects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia.\u003c/em\u003e PLoS Medicine, 2021. \u003cstrong\u003e18\u003c/strong\u003e(1): p. e1003260.\u003c/li\u003e\n\u003cli\u003eMichie, S., et al., \u003cem\u003eBehaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data).\u003c/em\u003e Health Technology Assessment, 2015. \u003cstrong\u003e19\u003c/strong\u003e(99).\u003c/li\u003e\n\u003cli\u003eGautam, O.P. and V. Curtis, \u003cem\u003eFood hygiene practices of rural women and microbial risk for children: Formative research in Nepal.\u003c/em\u003e The American Journal of Tropical Medicine and Hygiene, 2021. \u003cstrong\u003e105\u003c/strong\u003e(5): p. 1383.\u003c/li\u003e\n\u003cli\u003eChidziwisano, K., E. Tilley, and T. Morse, \u003cem\u003eSelf-reported versus observed measures: validation of child caregiver food hygiene practices in rural Malawi.\u003c/em\u003e International Journal of Environmental Research and Public Health, 2020. \u003cstrong\u003e17\u003c/strong\u003e(12): p. 4498.\u003c/li\u003e\n\u003cli\u003eKwasnicka, D., et al., \u003cem\u003eTheoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories.\u003c/em\u003e Health Psychology Review, 2016. \u003cstrong\u003e10\u003c/strong\u003e(3): p. 277-296.\u003c/li\u003e\n\u003cli\u003eOgba, O.M., P.E. Asukwo, and I.B. Otu-Bassey, \u003cem\u003eAssessment of bacterial carriage on the hands of primary school children in Calabar municipality, Nigeria.\u003c/em\u003e Biomedical Dermatology, 2018. \u003cstrong\u003e2\u003c/strong\u003e: p. 1-7.\u003c/li\u003e\n\u003cli\u003eTetteh-Quarcoo, P.B., et al., \u003cem\u003eMicrobial content of \u0026ldquo;bowl water\u0026rdquo; used for communal handwashing in preschools within Accra Metropolis, Ghana.\u003c/em\u003e International Journal of Microbiology, 2016. \u003cstrong\u003e2016\u003c/strong\u003e(1): p. 2617473.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"handwashing, communicable diseases, common/communal bowl, shared bowl, infection control, hygiene, sanitation, social norms.","lastPublishedDoi":"10.21203/rs.3.rs-4999129/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4999129/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiarrhoeal disease is a leading cause of death in children under 5 years old globally, despite being largely preventable. It is widely known that individual handwashing with soap is key in preventing transmission of enteric pathogens. Communal bowl hand rinsing (CB-HR) is the act of two or more people washing hands in a shared bowl of water without the use of soap, and without changing the water between individuals; this remains a commonplace cultural practice in many African countries. It occurs before household mealtimes, at gatherings and in schools. Evidence demonstrates that communal water provides a reservoir for communicable diseases, however there is limited evidence about the motivations including the social and cultural norms underpinning its continued practice. The aim of this study was to gain a better understanding of public perspectives on CB-HR, identifying the reasoning and exploring the beliefs behind the practice and determining factors preventing the improvement of hand hygiene.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe recorded 59 semi-structured interviews and 26 focus groups, in the local language of Bambara, across both rural and urban communities in Mali. Participants included mothers, fathers, grandmothers and grandfathers. Recordings were transcribed into French, translated into English and analysed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e CB-HR was commonplace amongst our participants, they confirmed that CB-HR was rooted in tradition for the purposes of social cohesion and family unity. The exact way in which CB-HR was practised varied. There was wide awareness of the infection-related risks associated with CB-HR. Various reasons were given for not practising and maintaining individual handwashing with soap. Ways of combining CB-HR and individual handwashing with soap were described, including the need for role models to maintain motivation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCB-HR was widespread in our rural \u0026amp; urban sample despite knowledge of its health risks, and access to running water and handwashing equipment (vessels and soap) because of the belief that it maintained social cohesion. Programmes aimed at improving infection control need to address the social and cultural drivers of CB-HR, or to adapt interventions in ways that are not perceived to threaten family unity.\u003c/p\u003e","manuscriptTitle":"The tradition of washing hands in a common bowl before eating: a qualitative study of the practice of communal bowl hand rinsing before mealtimes, in rural and urban Mali ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-22 04:58:29","doi":"10.21203/rs.3.rs-4999129/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-06T10:06:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-05T13:49:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-05T13:49:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-08-29T16:28:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d61a572-ad64-43e6-b023-0e87c2e09821","owner":[],"postedDate":"October 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-20T05:39:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-22 04:58:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4999129","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4999129","identity":"rs-4999129","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}