This formative research was designed to capture detailed information on the lives and handwashing practices of new mothers in Serang, Indonesia. Handwashing with soap occurs at a low level, but is not constrained by water or soap availability. Hands are typically washed after eating, cooking, doing household chores and after cleaning a child: times when hands are visibly dirty, oily, smelly, sticky or otherwise uncomfortable. We divided the participants into handwashing ‘types’ (such as those who use soap only when they are motivated by hands which are visibly dirty or smell – so-called ‘reactive washers’) to illustrate the range of hygiene behaviours that take place with respect to hands, and the differences between individuals in terms of whether and when soap is used to wash hands. We believe this categorization is insightful and may be true of other populations, and so could usefully guide program development on handwashing behaviour in future projects. This classification may also have implications for health promotion efforts, as it is possible that each of these types will require different kinds of intervention, since they appear to be motivated to use soap in different kinds of circumstances. While it is difficult to make specific recommendations for other handwashing programs without knowing their objectives, we believe that any ability to predict the types of handwashers likely to be found in a population can assist other programs, especially if they are not able to conduct research themselves. Knowing such types has program implications – for example, reactive washers are likely to be motivated by disgust at visible contamination on their hands, while avoiders seem not to respond to such cues to handwash, and so will require other means to change their behaviour.
Emotional drivers of behaviour are also important determinants of handwashing . Observation of when hands are washed, supported by interview responses about why hands are washed, lead us to hypothesise that handwashing at these times is most likely to be driven by feelings of “disgust” directed at substances or smells perceived to have contaminated hands; and “comfort”, desire for hands to feel clean . “Disgust” is therefore also the probable motivator for urban women who wash hands after returning home, ridding hands of dirt from the environment or other people they have contacted, while rinsing hands after doing laundry could be to remove the harsh feeling of detergent (“comfort”). Conversely, washing hands that look and feel clean derives little benefit, which fits with the low levels of handwashing observed at relevant food-hygiene junctures (i.e. before cooking or eating). Observed handwashing behaviour is consistent with other low-income countries [6, 37] and other studies in Indonesia .
Both the video footage and interviews indicate that handwashing is infrequent and does not seem to be prompted by having a new child, although “nurture” (desire to care for one’s offspring) has been previously demonstrated to drive maternal handwashing behaviour . Failure to wash hands is not because of a lack of time; these mothers have considerable time on their hands, being almost exclusively concerned with child-care, and having been relieved of other responsibilities by others in the household. Rather, hand washing may not be seen as a necessary part of being a good mother in this society. Sporadic instances of handwashing/using baby wipes before breastfeeding are likely to be an attempt to practice a behaviour desired by the midwife: information provided in interviews about the advice midwives gave concerning handwashing before breastfeeding thus matched the behaviours observed on film. The same mother was observed to respond differently to different child defecation events, possibly due to whether or not hands were contaminated with faeces. In a previous study in Burkina Faso, the stools of young children were regarded as less offensive than the stools of older children . It is possible that mothers do not find their infant’s faeces disgusting and for this reason “disgust” may not be a strong driver of handwashing behaviour at this time. It would have been interesting to have collected more information on this. However, encouraging the mother to handwash after clearing up a baby’s stool would hopefully translate into correct hygiene behaviour later in life. Although hands are allegedly washed after cooking with chilli for the protection of the child, it is more probable that handwashing after cooking is habitual.
The automaticity of existing handwashing behaviour  is one reason why it is hard to change. A “habit” can be defined as a behaviour that is performed frequently in a constant context . The context winds up cueing the behaviour so it occurs automatically in that situation. This means that habits are context-dependent. When the context changes existing habits are disrupted, providing an opportune time to insert new behaviours and form new habits . Our findings confirm that new motherhood results in many changes to a woman’s daily routine and diet, giving us reason to be optimistic about the potential for behaviour change at this time. They also confirm that new motherhood is an appropriate teachable moment as defined by McBride : women are aware of and concerned about health risks their child faces; their social role has changed; and they adore their new baby, undoubtedly a strong emotional response. New mothers are likely to prove a receptive audience if they can be convinced of the benefit of an intervention: although handwashing behaviour at present does not appear to have changed as a result of the new baby, “nurture” motives could be stimulated if women see handwashing as a trait of a “good mother” or they believe it will be beneficial to their child’s health. This could be an important campaign angle. Primiparous women are particularly open to new advice and would be a relevant target. Furthermore, as women willingly follow the advice of health professionals and family members, it could be relevant for midwives – who frequently contact women during the peri-natal period – to be involved in delivery of a community-based intervention to improve hand hygiene in this population, and for that intervention to also target influential family members. The frequency of contact with the health system at this time could be useful for reinforcing handwashing messages.
Further, rather than attempt to introduce handwashing with soap before breastfeeding (one of the current recommendation from midwives), which happens too frequently to be constantly interrupted by trips to a handwashing location, it is contact with faeces that should be the primary concern if the desire is to set a handwashing habit that will benefit the child’s health at a later date. In addition, we know from the videos that considerable time and care is already invested in cleaning and dressing babies in some households after a defecation event. The videos also showed us how variable handwashing practices were, even within the same individual, partially due to the presence of cues such as the physical setting, presence of an object, or visually dirty hands. Baskets for the various clothes and ointments needed at this time are a part of every new mother’s ‘kit’ for newborn childcare in Indonesia. It would probably be relatively easy to insert handwashing with soap soon after cleaning the baby’s bottom and before extensive further contact with the child. This is likely to be especially true if there is a handwash stand or other visual reminder present in a relevant location within the household as well. As we observed these cleaning and changing rituals being explicitly taught to young mothers by their mothers, it is natural to target these mothers-of-mothers as the appropriate channel for communicating the need to include handwashing with soap as part of normal child-care operations.
This study had some obvious limitations. After every interview a discussion took place to clarify any points of confusion. However, we cannot exclude the possibility that the presence of “foreigners” during interviews may have influenced respondents, nor the fact that bias can also stem from local researchers’ perceptions of their own culture. The collection of video footage provided a rich data source, although the challenge of filming at first light and the inability to capture activity occurring inside a closed bathroom remained drawbacks, the latter a perennial difficulty in studies of handwashing behaviour [34, 42]. Although some degree of reactivity might be expected in any study of behaviour [34, 42], it was only evident in three films where the women in question were clearly performing tasks they had not done previously in an attempt to look good. In one particular film, her mother could be heard issuing instructions in the background. It is difficult to know what other activities women did or did not do because they were being filmed, but we did not see obvious posing for the camera, women performed multiple activities many times in the same way on film, and they did not know exactly what behaviour we were interested in capturing. As participants were identified using the village midwife’s records, we have not included women who do not access antenatal services or those who give birth at home without a skilled birth attendant. As accessing antenatal services and choosing to be helped by a skilled attendant are strongly correlated with income, education, and living in an urban or rural locality , and handwashing practices in this study and other studies are associated with the same factors, it is possible that we would have seen different behaviour if these women had been included.