Asian Journal of Social Health and Behavior

: 2022  |  Volume : 5  |  Issue : 3  |  Page : 122--130

Determinants of regional prevalence and variations in handwashing practices among households in Bangladesh: An application of generalized mixed-effects model

Md Ismail Hossain1, Md Jakaria Habib1, Iqramul Haq2, Maliha Afroj Zinnia3, Samia Kabir1, Ahmed Abdus Saleh Saleheen1, Md Mohibul Alam4, Md Rifat Hasan1, Ashis Talukder5,  
1 Department of Statistics, Jagannath University, Dhaka, Bangladesh
2 Department of Agricultural Statistics, Sher-e-Bangla Agricultural University, Dhaka, Bangladesh
3 Department of Pharmacy, East West University, Dhaka, Bangladesh
4 Training Department, Eskayef Pharmaceuticals Limited, Dhaka, Bangladesh
5 Statistics Discipline, Khulna University, Khulna, Bangladesh

Correspondence Address:
Iqramul Haq
Department of Agricultural Statistics, Sher-e-Bangla Agricultural University, Dhaka-1207


Introduction: Handwashing practice is an effective way to minimize severe infectious diseases such as COVID-19, diarrhea, and pneumonia. The study aimed to explore the prevalence of handwashing behavior and associated determinants in rural and urban areas of Bangladesh. Methods: The research was performed using cross-sectional survey data from the 2019 Bangladesh Multiple Indicator Cluster Survey, and 61,242 household members were the sample for this study. The Chi-square test was applied for the bivariate analysis. A generalized linear mixed-effects model was used to identify the risk factors of practicing handwashing in both urban and rural areas of Bangladesh. Results: Only 65% of the country's households had access to handwashing facilities (place, water, and materials). While urban dwellers were more likely to wash their hands, rural dwellers were only 63% likely to do so. The level of education of household heads, wealth status, division, number of family members, sanitation facilities, and water source were the key factors associated with handwashing behavior. This study revealed that the odds were significantly lower among illiterate respondents compared to those with secondary and above-secondary education in both areas of Bangladesh, and a positive association was found between wealth status and handwashing behavior practiced in both urban and rural areas. In this study, the size of the family was statistically significant for both rural and urban areas of Bangladesh. Conclusion: Handwashing is the most prominent consideration for controlling COVID-19. Policymakers are striving to improve handwashing facilities by increasing awareness-raising programs, especially among rural residents of Bangladesh.

How to cite this article:
Hossain MI, Habib MJ, Haq I, Zinnia MA, Kabir S, Saleheen AA, Alam MM, Hasan MR, Talukder A. Determinants of regional prevalence and variations in handwashing practices among households in Bangladesh: An application of generalized mixed-effects model.Asian J Soc Health Behav 2022;5:122-130

How to cite this URL:
Hossain MI, Habib MJ, Haq I, Zinnia MA, Kabir S, Saleheen AA, Alam MM, Hasan MR, Talukder A. Determinants of regional prevalence and variations in handwashing practices among households in Bangladesh: An application of generalized mixed-effects model. Asian J Soc Health Behav [serial online] 2022 [cited 2023 Dec 3 ];5:122-130
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Full Text


Hygiene practices constitute a very essential public health intervention for the prevention of infectious diseases and an improved quality of life.[1] Handwashing and hand hygiene are often interchangeably used to describe the most effective method of avoiding getting infected and spreading infections to others.[2] Handwashing is the act of cleaning hands under running water with improved facilities (soaps and antiseptics) for 10–15 s, and then, the hands are dried with a disposable paper towel to remove unwanted elements.[3],[4] People infect themselves with germs by touching their eyes, nose, and mouth or spreading them to others as they touch other people, surfaces, and objects throughout the day, and by doing so, they gather germs on their hands. Although it is quite impossible, frequently washing hands is the only way to restrict the transfer of germs. The World Health Organization suggests washing hands, especially during these key times: (a) before and after caring for any diseased person; (b) before, during, and after preparing food; (c) before eating; (d) after using the bathroom; (e) after helping someone who just used the bathroom; (f) after blowing one's nose, or coughing or sneezing; (g) after touching an animal, animal feed, or animal waste; and (h) after touching garbage.[5]

Handwashing could be a vital Sustainable Development Goal (SDG) that has the potential to achieve all SDGs. Regular handwashing behavior holds enormous potential to achieve good health. Good hygiene promotes good nutrition, expands educational opportunities by reducing missed school days, and prevents disease, which limits child growth and thus improves economic opportunity.[6] Hand hygiene is a simple way to dramatically reduce the rates of common diseases. Almost half of all diarrheal diseases can be prevented by washing hands with soap.[7],[8] Handwashing may also be the most cost-effective strategy for reducing illness globally.[9] Several studies have shown that handwashing with improved facilities reduces the risk of diarrheal disease by half.[7],[10]

Handwashing, on the other hand, remains more deplorable in developing countries than in developed countries.[11] In 2017, the WHO and UNICEF estimated that 3 billion people worldwide lacked home hand hygiene facilities (HHFs): 1.6 billion (22%) had limited HHF lacking soap or water, and 1.4 billion (18%) had no HHF at all.[12] Several studies conducted in Vietnam and West Africa showed that an insignificant number of people wash their hands properly.[11],[13] Bangladesh is a country with a dense population and limited facilities for controlling infections, making it vulnerable to easily spreadable infections.[14] Here, 81% of the nonsoap users are willing to use improved handwash facilities but cannot afford them. In Bangladesh, 44% of women washed both hands, which reduces diarrheal disease by 40%.[15] Although the government continuously spreads hygiene messages about hygiene nationwide, the practice of handwashing is in relatively poor condition.[16]

Hand hygiene is a simple, effective means of restraining the spread of germs at a surprisingly low cost and keeps everyone healthy. Practicing handwashing since childhood is perhaps the best marker of a child's health. Furthermore, the most effective preventive measure to alleviate this condition is to wash hands regularly with soap for 20 s during the COVID-19 pandemic.[17] Hygiene was omitted from the Millennium Development Goals but has been included in SDGs Target 6.2, which aims to achieve universal access to a basic handwashing facility at home. In order to meet the SDG 6.2 target, the main purpose of this study is to find the effects of risk factors that are associated with the practice of handwashing in Bangladesh.

Handwashing practice is based on many factors and may vary across different levels of factors. Previously, many studies explored the factors in handwashing behavior using different statistical models. Among these models, the binary logistic regression model was the most popular.[18],[19] However, the binary logistic regression model depends on some rigid assumptions that may not always be able to be followed all the time, especially when it is a hierarchically formed dataset. Alternatively, a mixed-effects logistic regression model (both fixed and random effects) can be applied.[20],[21] To the best of the author's search, no study considered the hierarchical nature of the data to determine the factors associated with handwashing practices in rural and urban households in Bangladesh. As a result, our study aims to investigate the prevalence of handwashing practice and its potential risk factors in Bangladeshi residents using a mixed-effects logistic regression model, as the necessary information was obtained from the Bangladesh Multiple Indicator Cluster Survey (MICS), 2019, which has a hierarchical structure. As a consequence, the findings of this study may aid in the exploration of susceptible populations in order to lessen hygiene hazards.


Sources of data

This study used secondary data based on a cross-sectional survey from the Bangladesh MICS 2019, managed by the Bangladesh Bureau of Statistics, and funded by the UNICEF in Bangladesh. The MICS collects information on children, women, adolescents, and key indicators related to the SDGs using a household questionnaire.[22]

Sample design and sample size

The sample was selected in a two-stage stratified cluster sampling technique approach, which used the same sampling frame as the 2011 Population and Housing Census of Bangladesh. In the first stage, 3220 enumeration areas (EAs) were selected with a probability proportional to the size of the EA, which was the primary sampling unit. On average, a systematic sample of 20 households was drawn from each sample of EA, and 64,400 households were selected in the second stage, while 61,602 households were successfully interviewed. The data are weighted to ensure that the survey results are accurately represented at the national level, and after weighting, we obtained a sample size of 61,242 households in Bangladesh, with 13,564 households in urban areas and 47,678 households in rural areas of the inquiry fields.[22]

Dependent variable

The dependent variable for this study was “handwashing practice,” and we classify our response variable into two categories: practice of handwashing and not practice of handwashing. A household was considered to practice handwashing if

The household had a specific place where members most often wash their handsWater available in the handwashing placeMaterials (soap/detergent) were available at the handwashing place.

On the other hand, if a household does not meet these criteria, it was classified as having “no handwashing practice.”.

To evaluate a family's handwashing practice using MICS data, this method was discussed by a great number of authors in the literature.[2],[23]

Independent variables

This work deals with some of the independent variables. Our interest in choosing independent variables is expressed in those variables, for which we are eager to detect the influence of the dependent variable. Some of the variables are considered socioeconomically important, while some are demographically significant. The following is the list: household head's education, wealth status, division, residence, number of family members, sanitation facility, water source, and toilet facility share.

Ethical consideration

As this study was a secondary data analysis from the Bangladesh MICS from, ethical

approval was not required.

Statistical analysis

Various statistical methods were used to analyze the data to achieve the different objectives of this analysis. The Chi-square test of independence was used to determine the significance of the association between practicing handwashing and sociodemographic characteristics of the data. It can be defined as,


Here, the degrees of freedom can be written as, ([row – 1] × [column – 1]).

Let, Hij denotes the binary dependent variable. Here,


Since the outcome variable was binary, an established model – Generalized Linear Mixed-Effects Model (GLMM) – was used to examine the determinants of practicing handwash in residence of Bangladesh. In GLMM:

The explanatory variables are referred as fixed factors which are responsible for systematic variation in responsesThe sampling structures which contribute to the random variability in responses are referred as random factors. In this study, the census enumeration block or cluster is used as a random factor.

Readers interested in more technical mathematical and computational details regarding GLMM[24] should consult the excellent resources already published on these topics. Before applying any GLMM, intra-class correlation coefficient (ICC) should be calculated by the following formula,



[INSIDE:1] refers to the standard logistic distribution. A GLMM can be applied if the ICC is >0.

The statistical analyses were performed using the Statistical Package for Social Sciences v25 (IBM Corporation, Armonk, New York, NY, USA) and R-programming (version 4.0.0, R Core Team).


Sociodemographic and economic characteristics

[Table 1] shows the percentage distribution of respondents by selected sociodemographic and economic characteristics in urban and rural areas of Bangladesh. A total of 61,242 respondents were used in this study. In Bangladesh, less than a quarter of respondents (22.1%) lived in urban areas, while more than three-quarters (77.9%) lived in rural areas.{Table 1}

Regarding the level of education, there has been a clear trend of an increasing number of household heads who have attained secondary and above education levels in both regions of Bangladesh. In urban areas, approximately half of the respondents (53.3%) have attained secondary and above education levels, whereas in rural areas, this percentage is only 33.5%.

In terms of household wealth status, the maximum number of respondents in rural areas came from lower-class families, and the proportion was 49.4%. This proportion has decreased (around 13%) in Bangladesh's urban areas. Results from [Table 1] show that the percentage of households with two to five members was larger in rural areas than in urban areas, with 19.6% and 16.6%, respectively.

With regard to improved sanitation and water facilities, most households in urban and rural areas of Bangladesh had improved sanitation and water facilities. 85.4% of rural areas had improved sanitation, and 98.0% had improved water facilities. 95.1% of urban areas had improved sanitation, and 97.9% had improved water facilities. The percentage of respondents who share their toilet facilities with others was higher in rural areas (72.9%) than in urban areas (33.3%) of Bangladesh.

Analysis demonstrated that approximately 65% of households had handwashing behavior, and in urban and rural areas, this proportion was 72% and 62.6%, respectively [Figure 1].{Figure 1}

Association of sociodemographic and economic factors on the practice of handwashing

[Table 2] clarifies the association between percentage distribution and handwashing practice, which was accompanied by sociodemographic characteristics in urban and rural areas of Bangladesh. The results in [Table 2] showed that the educational level of the household head, household wealth status, number of family members, sanitation facilities, water source, and toilet facility shares were significantly associated with the practice of handwashing in both urban and rural areas of Bangladesh (P< 0.001).{Table 2}

Results from both areas (urban and rural) showed that household educational attainment had a significant and positive association with handwashing practice. Handwashing was practiced by 83.6% of urban residential households where the head of household had a secondary or higher education, while it was 73.1% in rural areas.

This study found a highly significant and positive association between household wealth status and handwashing practice in both areas of Bangladesh. Poor households practiced handwashing less in urban and rural areas (50.7% and 50.1%, respectively), whereas rich households practiced handwashing more in both urban and rural areas. It may be caused by the extra cost of cleansing materials.

[Table 2] shows that households with more than six family members practiced more handwashing (78%) in urban areas of Bangladesh than in rural areas (65.3%), and we found highly significant (P < 0.001) interconnections between number of family members and handwashing practice in both urban and rural areas of Bangladesh.

Improvements in sanitation and water sources had a significant association with handwashing behavior in Bangladesh, particularly in urban and rural areas. If we compared urban and rural areas, This study compared urban and rural areas and found that about 73% of households with improved sanitation facilities in urban areas practice handwashing more frequently than in rural areas (64.5%). For improved water source, approximately 72% of households in urban areas had specific place, water, and materials for handwash, whereas only 63% in rural areas of Bangladesh.

Among urban residents of Bangladesh, respondents who do not share their toilet facilities with others had higher handwashing practice than rural residents of Bangladesh (87.9% for urban residents and 67.4% in rural areas). These differences in the practice of handwashing by toilet facility share were statistically significant (P < 0.001).

This study shows that respondent's area had a significant connection with handwashing practice in Bangladesh. Rangpur division had the highest percentage of respondents with handwashing practice in urban and rural areas of Bangladesh (83% and 70.4%, respectively). However, in terms of overall country, Khulna division had the highest percentage of the handwashing practice respondents (approximately 72%), according to this study. In Bangladesh, about 72% of participants practicing handwash reside in urban areas, while 62.6% reside in rural areas.

Identify factors contributing to practicing handwash

The results of the GLMM are shown in [Table 3]. Considering fixed effects, the odds ratio (OR) of handwashing practice was significantly lower in the household where the household head had less than secondary education. Compared to rich households of the urban area, the odds of practicing handwash were significantly 80% and 70% lower for poor (OR = 0.20, 95% CI [0.17–0.25]) and middle (OR = 0.30, 95% CI [0.25–0.36]) income households, respectively, whereas the respective odds were 79% and 64% lower for the rural household. Rural households of size one member had significantly 38% less likely (OR = 0.62, 95% CI [0.54–0.72]) to wash their hand than the reference category of 6+ household members. Both urban and rural households with improved sanitation facilities were significantly more likely to practice handwashing behavior than those with unimproved facilities. In the urban area, improved water source in the household significantly increases handwashing practice compared with household with unimproved water facilities (OR = 1.50, 95% CI [0.95–2.37]). In the context of urban residents, the odds of practicing handwash in the household with private toilet facility were significantly ten times higher (OR = 9.93, 95% CI [8.82–11.2]) as compared to the household which share toilet facility, while the odds of handwashing practice among rural households with private toilet facility was 1.86 (OR = 1.86, 95% CI [1.76–1.96]). Households from a rural area of Khulna, Rajshahi, and Rangpur were significantly more likely to practice handwashing behavior than Sylhet division, whereas households of Chattogram, Dhaka, and Mymensingh were significantly less likely to practice handwashing behavior.{Table 3}

The random variance component indicates that the total variability of handwashing practice between communities was estimated to be 0.68 for the urban residents and 0.22 for the rural residents. The result of ICC for urban, rural, and combined is 0.17, 0.06, and 0.09, respectively. This implies that households living in the same community of the urban area have a higher chance of correlation of handwashing practice than household in adjacent communities.


This study used data from the MICS to determine the prevalence of practicing handwashing and examine regional variations in practicing handwashing. In this study, we used a GLMM to identify the factors related to practicing handwash in the residences of Bangladesh. The result showed that overall 65% of households practiced handwashing in Bangladesh. This result is in good agreement with the recent MICS in Bangladesh.[22]

Education is strongly positively associated with handwashing practice in both urban and rural areas of Bangladesh. In previous research, a similar finding was made and found that a lack of school education was correlated with lower handwashing rates.[25],[26] According to the results, uneducated and primary educated people had lower handwashing practice compared with people having at least a secondary education in both urban and rural areas. Household heads with higher education degrees also have a higher attitude toward handwashing.[27],[28],[29] People who are better educated are more conscious of proper hygiene procedures, and our findings are consistent with past research.[2],[25] This specific study outcome is also compatible with results from previous studies based in Bangladesh.[8],[30]

There was a positive association between wealth status and households practicing handwashing in Bangladesh (both urban and rural areas, as well as overall areas of Bangladesh). In both Vietnam and Senegal, a similar pattern of results was obtained and demonstrated that handwashing practice was positively correlated with the household wealth index.[31],[32] When compared to the richest households, lower- and middle-class families demonstrated less handwashing behavior. It noted that several previous studies exempted the less common use of hand hygiene among lower-class households.[7],[8],[33],[34],[35],[36]

A family of one in a rural household was substantially less likely to wash their hands than a family of six or more. This finding is consistent with previous Bangladeshi research.[37]

Another outcome of the study shows that sanitation facilities have a significant impact on handwashing facilities. Handwashing is becoming more common in households with improved sanitation facilities in both urban and rural parts of Bangladesh. This result confirms the results shown by previous studies of Vietnam and Bangladesh.[2],[30],[38]

There has been an association between water sources and handwashing behavior in urban and overall areas in Bangladesh. In the urban area, households with improved water facilities have significantly more handwashing practices compared with households with unimproved water facilities. The results of this study were consistent with the results of another study conducted in Ethiopia.[18] The result suggests that households with the worst water source showed less handwashing behavior. A recent study conducted in Ghana and Vietnam also showed the same result.[2],[39]

In the context of toilet facility sharing, the odds of practicing handwashing were considerably greater in households that did not share toilet facilities than in those that did. Furthermore, households sharing toilet facilities with others were less likely to develop effective handwashing facilities (EHFs) than households not sharing that facility, according to a previous study in Bangladesh.[30]

Handwashing practice varies depending upon the division of the respondents as well as the divisional aspects. In terms of urban, the respondent's household in the Dhaka division and Rangpur division had shown more handwashing behavior in contrast to the Sylhet division. On the other hand, in rural areas, Chattogram, Dhaka, and Rangpur divisions had higher odds of handwashing practice compared to the Sylhet division in rural areas of Bangladesh. Another study in Bangladesh 2019 MICS data had the opposite result and revealed that the divisions of Dhaka, Khulna, Mymensingh, Rajshahi, Rangpur, and Sylhet had higher risks of having EHF than the division of Barisal.[30] Several previous studies in Bangladesh observed a lack of EHFs in the Chittagong hill tracts and Khulna coastal areas.[40],[41]

The random variance component indicates that households living in the same community of the urban area have a higher chance of correlation of handwashing practice than household in adjacent communities. The unadjusted odds ratio suggests that urban residents have greater access to handwashing facilities, but the adjusted data show no difference between rural and urban residents.[30]


This study has some limitations. Due to the cross-sectional survey, the cause–effect relationship cannot be shown. Another limitation of the study is related to the MICS's measurement of handwashing behavior. Although indirect observation has its limits, it is nonetheless a viable approach for assessing handwashing.[2],[23]


In the current study, we used a GLMM to identify possible risk factors related to handwashing behavior in all three settings in Bangladesh. In sum, the education status of the household head, wealth status, sanitation facility, toilet facility share, and division were determinants of handwashing behavior practice in all three settings (urban, rural, and overall) of Bangladesh. However, family members were the only potential risk factors for handwashing behavior for rural and overall settings in Bangladesh, while the source of water was an important risk factor for urban and overall settings in Bangladesh. It additionally highlights substantial factors to adopt some implementation challenges, especially increased HHFs as well as facility-based information. And instead, governmental action should be taken in education, especially in the rural areas of Bangladesh, to increase handwashing practice in Bangladesh and raise awareness of proper handwashing technique, which substantially prevents diarrheal diseases.


A special thanks goes to the United Nations Children's Fund (UNICEF) for allowing us to use the Bangladesh MICS for our study from

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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