Abstract: Empowering Women by Targeting Male Leaders: Using an Intersectional Perspective to Increase Handwashing among Sierra Leonean Women

◆ Hanna Luetke Lanfer, University of Erfurt
◆ Constanze Rossmann, University of Erfurt

Handwashing with soap is one of the most cost-effective measures to prevent diarrheal and respiratory infections, yet in Sierra Leone handwashing is a neglected practice (WHO, 2017). In West African families, women are traditionally in charge of food preparation and caretaking of children and sick people (Waterhouse, Hill, & Hinde, 2017); thus, increasing handwashing practice among women can decrease infectious risks. However, due to patriarchic structures, women experience low levels of autonomy and are difficult to reach (Carlson, Kordas, & Murray-Kolb, 2015).
This calls for an intersectional perspective: This concept stems from feminist, antidiscrimination research (Crenshaw, 1989) and has recently become recognized as an analytical tool in health-related research to provide insights into the complex nature of health, power, and identity in human interactions (Bauer, 2014; Gkiouleka et al., 2018). Focusing on power relations, we conducted two studies to develop a handwashing campaign: study 1 investigated women’s access to health information and their barriers to handwashing practice; study 2 developed and tested an intervention aimed at empowering women to practice handwashing.
In our first study, we conducted eight focus group discussions with recipients (N=58) and 20 expert interviews with communicators across Sierra Leone and analyzed them with qualitative content analysis. Our findings indicate that despite similar poverty status and low literacy among all recipients, women in rural areas appear to be least exposed to health messages. Due to their low social status, lack of education and money, they have no opportunity to independently access information. Communicators further emphasized difficulties in behavior change programs for women as decisions are generally made by the male household heads.
Acknowledging that rural women cannot be reached and empowered to increase hand hygiene without the involvement of men, we developed a campaign targeting three types of leaders whose influence had been mentioned repeatedly during our first study: religious leaders who are trusted sources of information to men and women; male community elders who are the local law-enforcing body and respected role models; and influential women, e.g. traditional birth attendants.
The campaign was tested in five rural villages with similar characteristics in Sierra Leone, of whom four received various interventions between April and August 2019, one served as control group. A pre- and post-intervention survey with 60 community members in each village and covert observations of handwashing behavior were carried out before and one month after the last intervention. Preliminary results indicate positive behavior changes in all intervention groups. However, change evolved differently and to varying extent: In the two communities with well-respected united leaders women felt socially supported in practicing handwashing and were observed practicing handwashing more often than in the other two.
Exploring access to health information and behavior change from an intersectional perspective has deepened our understanding of the complex power relations and the difficulties of targeting women in a hierarchical society. Even though our study took place in West Africa, our findings holds important lessons for health communication approaches in other countries when targeting migrants from a similar societal background.