A study of the acceptability and use of alcohol based waterless hand sanitizer among street food vendors in Pilani, India
Robins, Melissa L.
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Background: Several studies have shown an increased risk of enteric infections among persons eating food from street food vendors. Mobile street vendors often have limited access to water and soap for hand washing. Waterless hand sanitizer may be a useful tool to improve the hand hygiene of street food vendors, given its demonstrated impact on hand contamination and portability. In a pilot study, we assessed the acceptability and use of alcohol-based waterless hand sanitizer among Indian street food vendors in Pilani, Rajasthan, India. Methods: We enumerated street vendors working in Pilani town and on BITS-Pilani campus, and obtained informed consent. A pre- intervention questionnaire of vendors' knowledge, attitudes and practices of enteric disease and hand hygiene was administered. This was followed by an intervention that included information on enteric disease symptoms and prevention, and hand hygiene. We taught vendors to use the sanitizer at critical times, such as after using the toilet and before preparing food, and provided ample supply for a 2-week period. We conducted structured observations to assess sanitizer use among a sample of the vendors. At follow-up, we queried self-reported sanitizer acceptability and use, and measured the volume in sanitizer dispensers. A follow up questionnaire knowledge, attitudes and practices questionnaire was administered. Results: We enrolled 30 vendors, and completed follow-up interviews with 28. Twenty-five vendors (89%) found the sanitizer an acceptable method for cleansing hands through a self-reported measure; of these 12 (43%) used sanitizer ≥ 4 applications per day. During observations of 10 vendors, we recorded 81 critical times total when hand cleansing should have occurred; hand sanitizer was used in 27% of the critical times. Also, hands were washed with soap and water 19% of the critical times, with water alone 38% of the critical times, and not washed at all 16% of the critical times. Those that did not find the sanitizer an acceptable method for cleaning hands believed it contained acid that would harm the food, and found it difficult to use. We did not find statistically significant differences when comparing pre- and post knowledge, attitudes, and practices variables. Conclusion: Waterless hand sanitizer was acceptable to street food vendors in India, although the majority did not use it as much as prescribed. Further study is needed in larger study populations to confirm these findings and to refine the intervention in order to maximize sanitizer use. Current cost of commercially available sanitizer is prohibitive for scaling up this potentially useful diarrhea prevention tool in resource-poor settings.