Is hygiene promotion cost-effective? A case study in Burkina Faso

Cost analysis for "The Magic Glasses Philippines" health education package to prevent intestinal worm infections among Filipino schoolchildren

BACKGROUND

Soil-transmitted helminth (STH) infections are a significant public health problem affecting over 900 million people globally. Health education has been shown to complement mass drug administration (MDA) for the control of these intestinal worms. We reported recently results of a cluster randomised control trial (RCT) showing the positive impact of the "The Magic Glasses Philippines (MGP)" health education package in reducing STH infections among schoolchildren in intervention schools with ≤15% STH baseline prevalence in Laguna province, the Philippines. To inform decision making on the economic implications of the MGP, we evaluated the in-trial costs and then quantified the costs of scaling up the intervention both regionally and nationally.

METHODS

Costs were determined for the MGP RCT conducted in 40 schools in Laguna province. We estimated the total cost and the costs incurred per student for the actual RCT and the total costs for regional and national scale-up in all schools regardless of STH endemicity. The costs associated with the implementation of standard health education (SHE) activities and mass drug administration (MDA) were determined with a public sector perspective.

FINDINGS

The cost per participating student in the MGP RCT was Php 58.65 (USD 1.15) but if teachers instead of research staff had been involved, the estimated cost would have been considerably lower at Php 39.45 (USD 0.77). Extrapolating the costs for regional scale-up, the costs per student were estimated to be Php 15.24 (USD 0.30). As it is scaled up at the national level to include more schoolchildren, the estimated cost was increased at Php 17.46 (USD 0.34). In scenario 2 and 3, consistently, labour/salary costs associated with the delivery of the MGP contributed most to overall programme expenditure. Furthermore, the estimated average cost per student for SHE and MDA were Php 117.34 (USD 2.30) and Php 58.17 (USD 1.14), respectively. Using national scale up estimates, the cost of combining the MGP with SHE and MDA was Php 192.97 (USD 3.79).

INTERPRETATION

These findings suggest that the integration of MGP into the school curriculum would be an affordable and scalable approach to respond to the continuous burden of STH infection among schoolchildren in the Philippines.

FUNDING

National and Medical Research Council, Australia, and the UBS-Optimus Foundation, Switzerland.

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)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

Effect of Hand Hygiene Intervention in Community Kindergartens: A Quasi-Experimental Study

This study aimed to evaluate the effect of hand hygiene interventions on the overall hand hygiene (HH) status of teaching instruction of hand hygiene in kindergartens, given the vulnerability of kindergarten children and their high risk due to infectious diseases and the current COVID-19 epidemic. We investigated the HH status of teachers from two kindergartens in the same community. The participants were recruited from 28 classes in both kindergartens. After completing the baseline survey, the intervention program consisted of three components: lectures on infectious diseases, lectures on HH, and seven-step hand washing techniques conducted in two kindergartens. The intervention program effectively increased teachers' perceived disease susceptibility (p < 0.05), reduced the total bacterial colonization of children's hands (p < 0.001), and improved the HH environment (p < 0.01). We recommend that health authorities or kindergartens adopt this HH intervention program to effectively improve the HH status in kindergartens and allow for preventive responses to the COVID-19 epidemic or other emerging infectious diseases.

Determinants of diarrhoeal infections among users of shared sanitation in informal settlements in Durban, South Africa

Diarrhoeal disease continues to be a major health problem in many parts of the world, especially in developing countries, mainly due to the lack of access to sanitation, water, and hygienic living conditions. Identifying the determinants of diarrhoeal infections continues to be a challenge in developing countries. In this study, we ascertained the factors behind diarrhoea among inhabitants of informal settlements in the city of Durban, South Africa. Prevalence of diarrhoea in the study area varied between 7-year historical clinical records and data collected during the current study (primary data), with the primary data giving the highest monthly prevalence odds ratio (POR) up to 18.1 (±1.6)%. The main factors associated with diarrhoeal infections were open defaecation (POR = 1.8; 95% confidence interval (CI): 0.9-3.12), use of shared sanitation (POR = 1.7; 95%; CI: 1.05-2.26), and exposure to faecal matter around the homes (POR = 1.69; 95% CI: 1.25-3.10). Several other factors were also determined to be associated with diarrhoeal infections, such as hygiene practices in the communities, the non-treatment of water before use, and the presence of solid waste and faecal materials around the households. This study shows that diarrhoeal disease infections in informal settlements could be multifactorial; therefore, a multifactorial approach is needed to reduce these infections. These could include improving education on hygiene practices within the home setting as well as in public places, such as the community ablution blocks.

Costs of treating childhood malaria, diarrhoea and pneumonia in rural Mozambique and Uganda

Background

Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resources for such programmes it is necessary to evaluate their costs, costs-effectiveness, and affordability. This study aimed to estimate the provider costs of treating malaria, diarrhoea, and pneumonia among children under the age of 5 years in routine settings at the health facility level in rural Uganda and Mozambique.

Methods

Service and cost data was collected from health facilities in midwestern Uganda and Inhambane province, Mozambique from private and public health facilities. Financial and economic costs of providing care for childhood illnesses were investigated from the provider perspective by combining a top-down and bottom-up approach to estimate unit costs and annual total costs for different types of visits for these illnesses. All costs were collected in Ugandan shillings and Mozambican meticais. Costs are presented in 2021 US dollars.

Results

In Uganda, the highest number of outpatient visits were for children with uncomplicated malaria and of inpatient admissions were for respiratory infections, including pneumonia. The highest unit cost for outpatient visits was for pneumonia (and other respiratory infections) and ranged from $0.5 to 2.3, while the highest unit cost for inpatient admissions was for malaria ($19.6). In Mozambique, the highest numbers of outpatient and inpatient admissions visits were for malaria. The highest unit costs were for malaria too, ranging from $2.5 to 4.2 for outpatient visits and $3.8 for inpatient admissions. The greatest contributors to costs in both countries were drugs and diagnostics, followed by staff.

Conclusions

The findings highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient cases, particularly at higher level health facilities. Timely treatment to prevent severe complications associated with these illnesses can also avoid high costs to health providers, and households.

Trial registration: ClinicalTrials.gov, identifier: NCT01972321.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04254-y.

Different Behavior-Change Messaging Techniques Do Not Increase Customers' Hand Sanitization Adherence During the COVID-19 Pandemic: A Natural Behavioral Study

Introduction

Hand hygiene is an integral public health strategy in reducing the transmission of COVID-19, yet the past research has shown hand hygiene practices among the public is sub-optimal. This study aimed to (1) quantify hand sanitization rates among the public to minimize the transmission of COVID-19 and (2) evaluate whether different public health messaging, based on various behavior-change theories influences hand hygiene behavior in a natural setting.

Methods

An observational, naturalistic study design was used with real-time customer activity data recorded against hand sanitizer usage in a regional hardware store. Primary outcome from the study was to measure the usage ratio by counting the amount of activity versus usage of hand sanitizer per hour against individual messages based on their behavioral change technique (BCT).

Results

There was no significant difference between the baseline message and any of the intervention messages [F(16,904) = 1.19, p = 0.279] or between BCT groups [F(3,906) = 1.33, p = 0.263]. Post hoc tests showed no significant difference between messages (social comparison, p = 0.395; information, p = 1.00; and action planning, p = 1.00).

Conclusion

This study showed that even during a pandemic, hand hygiene usage rates in a public setting were similar to the past studies and that compliance did not shift dependent on the public message displayed. This raises questions on whether requirements imposed on businesses to provide hand sanitizer to patrons are an ineffective and maybe an unnecessary economic burden. A measured approach to risk and behavioral analysis surrounding the use of hand sanitizer in a pandemic is suggested as a better approach to inform public policy on the value of hand sanitizer.

Diarrhoeal outcomes in young children depend on diarrhoeal cases of other household members: a cross-sectional study of 16,025 people in rural Uganda

Background

There is a limited understanding of how diarrhoeal cases across other household members influence the likelihood of diarrhoea in young children (aged 1–4 years).

Methods

We surveyed 16,025 individuals from 3421 households in 17 villages in Uganda. Using logistic regressions with standard errors clustered by household, diarrhoeal cases within households were used to predict diarrhoeal outcomes in young children. Regressions were adjusted for socio-demographic, water, sanitation, and hygiene (WASH), and ecological covariates. Selection bias for households with (1632/3421) and without (1789/3421) young children was examined.

Results

Diarrhoeal prevalence was 13.7% (2118/16,025) across all study participants and 18.5% (439/2368) in young children. Young children in households with any other diarrhoeal cases were 5.71 times more likely to have diarrhoea than young children in households without any other diarrhoeal cases (95% CI: 4.48–7.26), increasing to over 29 times more likely when the other diarrhoeal case was in another young child (95% CI: 16.29–54.80). Diarrhoeal cases in older household members (aged ≥ 5 years) and their influence on the likelihood of diarrhoea in young children attenuated with age. School-aged children (5–14 years) had a greater influence on diarrhoeal cases in young children (Odds Ratio 2.70, 95% CI: 2.03–3.56) than adults of reproductive age (15–49 years; Odds Ratio 1.96, 95% CI: 1.47–2.59). Diarrhoeal cases in individuals aged ≥ 50 years were not significantly associated with diarrhoeal outcomes in young children (P > 0.05). These age-related differences in diarrhoeal exposures were not driven by sex. The magnitude and significance of the odds ratios remained similar when odds ratios were compared by sex within each age group. WASH factors did not influence the likelihood of diarrhoea in young children, despite influencing the likelihood of diarrhoea in school-aged children and adults. Households with young children differed from households without young children by diarrhoeal prevalence, household size, and village WASH infrastructure and ecology.

Conclusions

Other diarrhoeal cases within households strongly influence the likelihood of diarrhoea in young children, and when controlled, removed the influence of WASH factors. Future research on childhood diarrhoea should consider effects of diarrhoeal cases within households and explore pathogen transmission between household members.

Supplementary information

The online version contains supplementary material available at 10.1186/s12879-022-07468-2.

Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries

INTRODUCTION

Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs.

METHODS

Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation.

RESULTS

An estimated US$12.2-US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for 'top-up' promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%).

CONCLUSION

The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Cost-effectiveness of a weaning food safety and hygiene programme in rural Gambia

OBJECTIVE

The main objective of the economic evaluation was to determine the cost-effectiveness of a weaning food safety and hygiene programme in reducing rates of diarrhoea compared with the control in rural Gambia.

METHODS

The public health intervention, using critical control points and motivational drivers, was evaluated in a cluster randomised controlled trial at 6- and 32-month follow-up. An economic evaluation was undertaken alongside the RCT with data collected prospectively from a societal perspective. Decision-analytic modelling was used to explore cost-effectiveness over a longer time period (4 years).

RESULTS

Direct out-of-pocket healthcare expenditure for households due to diarrhoea was large. The intervention significantly reduced reported childhood diarrhoeal episodes after 6 months (incident risk ratio = 0.40, 95% CI 0.33, 0.49) and 2 years after the intervention (incident risk ratio = 0.68, 95% CI 0.46, 1.02). The within-trial analysis found that the intervention led to total savings of 8064 dalasi 6 months after the intervention and 4224 dalasi 2 years after the intervention. Based on the model results, if the intervention is successful in maintaining the reduction in the risk of diarrhoea, the ICER is US$ 814 per DALY avoided over 4 years. This is cost-effective.

CONCLUSIONS

This study suggests that there are substantial household costs associated with diarrhoeal episodes in children. The within-trial analysis and model results suggest that the community-based approach to improving weaning food hygiene and safety is likely to be cost-effective compared with control.

COVID-19 and handwashing: Implications for water use in Sub-Saharan Africa

Because the main modes of transmission of the COVID-19 virus are respiration and contact, WHO recommends frequent washing of hands with soap under running water for at least 20 s. This article investigates how the level of concern about COVID-19 affects the likelihood of washing hands frequently in sub-Saharan Africa. We discuss the implication of the findings for water-scarce environment. The study makes use of a unique survey dataset from 12 sub-Saharan African countries collected in April 2020 (first round) and May 2020 (second round) and employs an extended ordered probit model with endogenous covariate. The results show that the level of concern about the spread of the virus increases the likelihood of washing hands with soap under running water for a minimum of 20 s at least five times a day. The increase in the probability of handwashing due to concern about COVID-19, ranges from 3% for Benin to 6.3% for South Africa. The results also show heterogeneous effects across gender- and age-groups, locality and various water sources. However, in Africa, the sustainability of the handwashing protocol could be threatened by the severe water scarcity that exists in the region. To sustain frequent handwashing, sub-Saharan Africa needs an effective strategy for water management and supply.

Relationship between the Toothbrushing Behavior and Hand Hygiene Practices of Korean Adolescents: A Study Focused on the 15th Korea Youth Risk Behavior Survey Conducted in 2019

Hand hygiene is one of the most important measures available to prevent infectious diseases such as COVID-19, and it is recommended that individuals wash their hands periodically before and after meals, after using toilets, before preparing food at home, at schools, and in public places. The aim of this study was to investigate the relationship between oral hygiene and hand hygiene in Korean adolescents. Data from 57,303 adolescents who participated in the 2019 Korea Youth Risk Behavior web-based survey were analyzed to determine the relationship between oral hygiene and hand hygiene. A complex sample logistic regression analysis was performed to determine association between toothbrushing behavior and handwashing practices. According to the results of this study, adolescents who brushed their teeth after lunch were 1.48 times more likely to practice handwashing before lunch than were those who did not brush their teeth after lunch (p < 0.001). In addition, the odds ratios adjusted for gender, grade, school type, and residence were found to be 1.87 (p < 0.001). Moreover, these adjusted odds ratios were higher in students who received personal hygiene education (OR: 1.98, p < 0.001). Oral hygiene practices were found to be related to personal hygiene, as assessed by handwashing, in Korean adolescents. Additional studies are needed to develop ways of improving the hygiene and health of adolescents.

Determinants of under-5 mortality in Burkina Faso

BACKGROUND

The aim of this article is to determine the factors associated with under-5 mortality and their evolution from 1993 to 2010 and to analyse the contributors of socioeconomic inequalities in mortality of children under-5 years during the same period.

DATA AND METHODS

The data used in this study were derived from the four rounds of Demographic and Health Survey (DHS) conducted in Burkina Faso in 1993, 1998 and 2010. Concentration measurement, logistics regression and Oaxaca-Blinder decomposition method were used to analyse data.

RESULTS

Multivariate analysis revealed that being the first child (odds ratio = 1.8 for 1993, 1.7 for 1998, 1.2 for 2003 and 1.3 for 2010) or a twin (odds ratio = 4.5 for 1993, 2.8 for 1998, 2.7 for 2003 and 4.8 for 2010) were also significantly associated with the probability of dying. The variable (parity) was the main contributor to the part of the inequality due to differences in group characteristics and that would be due to the fact that women from poor households have greater parity compared to those from rich households.

CONCLUSION

For a reduction in mortality and inequalities related to mortality, the implementation of actions in favour of poor households and promotion of family planning programmes for birth spacing will be required.

Food Hygiene Practices at the Ghana School Feeding Programme in Wa and Cape Coast Cities

Objective

The integrity and the wholesomeness of the food served to school pupils cannot be overlooked, especially when one considers the magnitude of health and sanitation issues that are plaguing the West African nations. This study aimed to investigate some of the personal hygiene practices by the pupils and the hygienic conditions in which food is cooked and served to these school-going children under the Ghana School Feeding Programme (GSFP).

Design

A cross-sectional and descriptive survey research designs were used in the study. Purposive and simple random sampling techniques were employed in selecting participants. Participants. There were 720 respondents for the study, comprising 600 pupils, 60 teachers, and 60 kitchen staff members from 20 schools. Information was obtained using questionnaire, observation, and unstructured interview instruments.

Results

Findings from the study revealed that the majority of pupils (92% in Wa and 65% in Cape Coast) did not wash their hands with soap under running water. No hand washing centers for pupils were also seen in most of the schools studied. Majority of the cooks did not have health certificate, and neither had attended any in-service training in two years. In both Wa and Cape Coast municipal schools, none of the kitchen staff admitted that pupils and teachers ever complained about the meals they served to the pupils.

Conclusion

The GSFP in basic schools forms part of the integral diet of the school children; hence, provision of good quality food can affect the health, learning, and physical activities of these children. Observational checklist revealed that most of the kitchen staff do not strictly adhere to basic food hygiene practices, and this affects the wholesomeness of the food served to the children. There is, therefore, a need for kitchen staff training on hygiene and food preparation practices.

Refining hand washing interventions by identifying active ingredients: A cluster-randomized controlled trial in rural Zimbabwe

RATIONALE

Consistent hand washing with soap can reduce the risk of diarrhea, but changing hand-washing behavior is difficult. Systematic behavior change approaches promise to enhance hand washing with soap effectively, and allow the identification of active intervention ingredients using mediation analysis. This knowledge can then be used to derive hypotheses for systematically refining the intervention.

OBJECTIVE

We demonstrate this at the example of a behavior change intervention to promote hand washing with soap based on the RANAS approach (risk, attitudes, norms, ability, and self-regulation).

METHODS

Sixteen wards of Masvingo province in Zimbabwe were randomly allocated to the RANAS-based intervention or a wait-list control group. Hand washing at baseline and follow-up was observed for 224 randomly selected caregivers of young children. They additionally participated in quantitative face-to-face interviews assessing psychosocial factors.

RESULTS

At baseline, hand washing with soap was <3% on average, and did not differ between groups (p = .526). At follow-up, intervention participants washed hands with soap more frequently than controls (in 29.4% vs. 8.2% of all stool- and food-related situations, B = 1.88, SE = 0.32, OR = 6.6, p < .001). Mediation analyses revealed that the intervention enhanced several of the targeted psychosocial factors; return, descriptive and injunctive norms, action knowledge, action self-efficacy, maintenance self-efficacy, action planning, and remembering. The intervention effect was mediated through increased remembering.

CONCLUSION

This study supports the efficacy of a systematic approach to behavior change to promote hand washing with soap. The analyses of the mechanisms revealed important insights into the active ingredients of the intervention, which will facilitate its future refinement.

21st century research in urban WASH and health in sub-Saharan Africa: methods and outcomes in transition

Tackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue - 58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening. Abbreviations: CBA: Controlled Before and After; GSD: Government Service Delivery; IWDSSD: International Drinking-Water, Supply and Sanitation Decade (IDWSSD); KAP: Knowledge, Attitudes and Practices; IBD: Irritable Bowel Diseases; MDG: Millennium Development Goals; NTD: Neglected Tropical Diseases; PSSD: Private Sector Service Delivery; SDG: Sustainable Development Goals; SSA: Sub Saharan Africa; SODIS: Solar Disinfection System; STH: Soil Transmitted Helminths; RCT: Randomised Control Trial; WASH: Water Sanitation and Hygiene; WHO: World Health Organization.

Helminthiasis among School-Age Children and Hygiene Conditions of Selected Schools in Lafia, Nasarawa State, Nigeria

The burden of soil-transmitted helminths (STHs) infections in Nigeria is enormous with serious public health significance. This study, therefore, assessed helminthiasis among school-age children and the hygiene conditions of schools in Lafia, Nasarawa State, Nigeria between December 2015 and April 2016 from four randomly selected primary schools. Stool samples were collected from 200 primary school pupils including 80 males (40%) and 120 females (60%) between five and 16 years, using clean sample bottles and a standard parasitology examination technique at the central laboratory at the Federal University, Lafia. An overall prevalence of 33.5% (67/200) helminths infections was recorded. A checklist of Ascaris lumbricoides, hookworm, Trichuris trichiura, and Strongyloides stercoralis was generated from the pooled data of the four studied schools in which A. lumbricoides occurred highest with 13% (26/200) while S. stercoralis was the least prevalent at 2.50% (5/200). Among the schools sampled, St. James Pilot Science Primary School's children were the most infected at 44% (22/50). Multiple infections were observed in three of the four schools sampled. There was no significant difference (p > 0.05) in prevalence rates of different STHs infections in relation to age group and gender across schools. Our findings showed that the hygiene conditions in the studied schools were poor without water, hand washing materials, refuse bins, as well as poor sanitary conditions. This study also identified ova and larvae of STHs parasites in the analyzed soil samples from the studied schools. Most school-age children had knowledge about contamination but few among them washed their hands with water and soap. The obtained result indicated a negative association between the prevalence of STHs and the proportion of pupils that cleaned up with water after defection. We, therefore, advise that hygiene conditions in schools be improved and that the government should prioritize enrolling all primary schools in Nasarawa state for the school health program so as to reduce the burden of STHs among school-age children in the state.

A multimodal intervention to improve hand hygiene compliance via social cognitive influences among kindergarten teachers in China

Children attending kindergarten are at high risk for contracting infections, for which hand hygiene (HH) has been recognized as the most cost-effective prevention measure globally. Kindergarten teachers’ HH behavior plays a vital role in encouraging favorable hygiene techniques and environment. This study aims to evaluate the effectiveness of a multimodal intervention at changing kindergarten teachers’ HH behavior and social cognitive factors that influences HH behavior in China. The intervention named “Clean Hands, Happy Life” includes HH products with refills, reminders and cues for action, a kick-off event with awards, and training programs. We evaluated the intervention using a self-administrative questionnaire with a stratified random sample of 12 kindergartens. Two surveys was completed by 176 teachers at baseline and 185 after the 6-month intervention. Compared with the baseline scores, there was a significant improvement in the overall self-reported HH compliance of teachers (9.38 vs. 9.68 out of 10, p = 0.006), as well as teachers’ perceived disease susceptibility, disease severity and behavioral control after the intervention (p<0.05). We found that teachers’ HH compliance was likely to be higher among those who have better HH guideline awareness (β = 0.48, p<0.01) and perceived behavioral control (β = 0.26, p = 0.01), which explained 24.2% of the variance of self-reported compliance of teachers at baseline. The assessed intervention may provide Chinese kindergarten teachers with behavioral skills and cognitions that associated with the compliance of HH behavior. We thus recommend future intervention studies consider our HH behavior change techniques, address multiple social cognitive determinants of HH behavior and include the change of targeted influences in the impact evaluation.

Cost-effectiveness and economies of scale of a mass radio campaign to promote household life-saving practices in Burkina Faso

Introduction

Child health promotion through mass media has not been rigorously evaluated for cost-effectiveness in low-income and middle-income countries. We assessed the cost-effectiveness of a mass radio campaign on health-seeking behaviours for child survival within a trial in Burkina Faso and at national scale.

Methods

We collected provider cost data prospectively alongside a 35-month cluster randomised trial in rural Burkina Faso in 2012–2015. Out-of-pocket costs of care-seeking were estimated through a household survey. We modelled intervention effects on child survival based on increased care-seeking and estimated the intervention’s incremental cost-effectiveness ratio (ICER) in terms of the cost per disability-adjusted life year (DALY) averted versus current practice. Model uncertainty was gauged using one-way and probabilistic sensitivity analyses. We projected the ICER of national-scale implementation in five sub-Saharan countries with differing media structures. All costs are in 2015 USD.

Results

The provider cost of the campaign was $7 749 128 ($9 146 101 including household costs). The campaign broadcast radio spots 74 480 times and 4610 2-hour shows through seven local radio stations, reaching approximately 2.4 million people including 620 000 direct beneficiaries (pregnant women and children under five). It resulted in an average estimated 24% increase in care-seeking for children under five and a 7% reduction in child mortality per year. The ICER was estimated at $94 ($111 including household costs (95% CI −38 to 320)). The projected provider cost per DALY averted of a national level campaign in Burkina Faso, Burundi, Malawi, Mozambique and Niger in 2018–2020, varied between $7 in Malawi to $27 in Burundi.

Conclusion

This study suggests that mass-media campaigns can be very cost-effective in improving child survival in areas with high media penetration and can potentially benefit from considerable economies of scale.

Trial registration number

NCT01517230; Results.

Evaluation of a multi-layered health promotion approach in rural China

BACKGROUND

To explore the effectiveness of a multi-layered health promotion approach in rural China.

METHODS

A two-year intervention was applied to the 18 intervention rural villages while the 18 controls received standard health communication materials. Data were collected at baseline and post-intervention respectively to evaluate the effectiveness.

RESULTS

All intervention villages had developed healthy policies addressing prioritized health issues such as livestock captivity, garbage disposal, etc.; however, no healthy policies had been developed in the controls. The two-week morbidity rate and incidence of diarrhea of the intervention villages decreased to 13.4% from 18.5% (p = 0.009), and to 9.5% from 13.0% (p = 0.038), respectively, whereas no statistically significant change was found in the controls. The knowledge about hepatitis B and rabies transmission had increased significantly among the intervention villagers (hepatitis B from 27.5% to 34.4%, p = 0.005; rabies from 12.0% to 24.6%, p < 0.001) but not in the control for rabies (p > 0.05). Among both intervention and control groups, the proportion of proper hand-washing and chopping board use increased significantly (all p < 0.01). Greater changes had been found in physical inactivity and alcohol drinking among the intervention group than the control. No change was found in smoking rate among both groups. Score values (mean ± SD) for environmental quality, livestock captivity, and vector density (e.g., mosquitoes, flies, rats, and cockroaches) increased significantly from 2.8 ± 0.9 to 3.4 ± 0.7, from 1.9 ± 0.9 to 2.5 ± 0.9, and from 0.6 ± 0.9 to 1.8 ± 0.4, respectively (p < 0.05) in the intervention villages.

CONCLUSIONS

The two-year multi-layered health promotion approach shows real promise in empowering the rural communities to take control over, and protect their own health.

The true costs of participatory sanitation: Evidence from community-led total sanitation studies in Ghana and Ethiopia

Evidence on sanitation and hygiene program costs is used for many purposes. The few studies that report costs use top-down costing methods that are inaccurate and inappropriate. Community-led total sanitation (CLTS) is a participatory behavior-change approach that presents difficulties for cost analysis. We used implementation tracking and bottom-up, activity-based costing to assess the process, program costs, and local investments for four CLTS interventions in Ghana and Ethiopia. Data collection included implementation checklists, surveys, and financial records review. Financial costs and value-of-time spent on CLTS by different actors were assessed. Results are disaggregated by intervention, cost category, actor, geographic area, and project month. The average household size was 4.0 people in Ghana, and 5.8 people in Ethiopia. The program cost of CLTS was $30.34-$81.56 per household targeted in Ghana, and $14.15-$19.21 in Ethiopia. Most program costs were from training for three of four interventions. Local investments ranged from $7.93-$22.36 per household targeted in Ghana, and $2.35-$3.41 in Ethiopia. This is the first study to present comprehensive, disaggregated costs of a sanitation and hygiene behavior-change intervention. The findings can be used to inform policy and finance decisions, plan program scale-up, perform cost-effectiveness and benefit studies, and compare different interventions. The costing method is applicable to other public health behavior-change programs.

Enhancing handwashing frequency and technique of primary caregivers in Harare, Zimbabwe: A cluster-randomized controlled trial using behavioral and microbial outcomes

RATIONALE

Consistent hand hygiene prevents diarrheal and respiratory diseases, but it is often not practiced. The disease burden is highest in low-income settings, which need effective interventions to promote domestic handwashing. To date, most handwashing campaigns have focused on promoting frequent handwashing at key times, whereas specifically promoting handwashing techniques proven to be effective in removing microbes has been confined to healthcare settings.

METHODS

We used a cluster-randomized, factorial, controlled trial to test the effects of two handwashing interventions on the behavior of primary caregivers in Harare, Zimbabwe. One intervention targeted caregivers directly, and the other targeted them through their children. Outcome measures were surveyed at baseline and six weeks' follow-up and included observed handwashing frequency and technique and fecal hand contamination before and after handwashing.

RESULTS

Combining the direct and indirect interventions resulted in observed handwashing with soap at 28% of critical handwashing times, while the corresponding figure for the non-intervention control was 5%. Observed handwashing technique, measured as the number of correctly performed handwashing steps, increased to an average of 4.2, while the control averaged 3.4 steps. Demonstrated handwashing technique increased to a mean of 6.8 steps; the control averaged 5.2 steps. No statistically significant group differences in fecal hand contamination before or after handwashing were detected.

CONCLUSIONS

The results provide strong evidence that the campaign successfully improved handwashing frequency and technique. It shows that the population-tailored design, based on social-cognitive theory, provides effective means for developing powerful interventions for handwashing behavior change. We did not find evidence that children acted as strong agents of handwashing behavior change. The fact that the microbial effectiveness of handwashing did not improve despite strong improvements in handwashing technique calls for critical evaluation of existing handwashing recommendations. The aim of future handwashing campaigns should be to promote both frequent and effective handwashing.

Handwashing, but how? Microbial effectiveness of existing handwashing practices in high-density suburbs of Harare, Zimbabwe

BACKGROUND

Consistent domestic hand hygiene can reduce diarrhea-related morbidity and mortality and the spread of other communicable diseases. However, it remains uncertain which technique of handwashing is most effective and practicable during everyday life. The goal of this study is to determine how the handwashing technique, as performed in the daily life by the participants of this case study in Harare, Zimbabwe, influences microbial handwashing effectiveness.

METHODS

Handwashing technique of 173 primary caregivers was observed in their homes and hand rinse samples were collected before and after handwashing. Samples were analyzed for Escherichia coli and total coliform concentrations. Generalized linear models were used to predict fecal hand contamination after washing from observed handwashing technique.

RESULTS

Cleaning under fingernails, scrubbing the fingertips, using soap, and drying hands through rubbing on clothes or a clean towel statistically significantly reduced E coli contamination of hands after washing. Tap use, scrubbing fingertips, and rubbing hands on clothes to dry them statistically significantly reduced total coliform contamination.

CONCLUSIONS

Recommendations for effective and practicable domestic handwashing in Harare, Zimbabwe, should include performing specific handscrubbing steps (ie, cleaning under the fingernails and rubbing the fingertips), and soap and tap use. This calls for further research to develop behavior change interventions that explicitly promote effective handwashing technique at critical times.

Contextual and Psychosocial Determinants of Effective Handwashing Technique: Recommendations for Interventions from a Case Study in Harare, Zimbabwe

Handwashing has been shown to considerably reduce diarrhea morbidity and mortality. To decontaminate hands effectively, the use of running water, soap, and various scrubbing steps are recommended. This study aims to identify the behavioral determinants of effective handwashing. Everyday handwashing technique of 434 primary caregivers in high-density suburbs of Harare, Zimbabwe, was observed and measured as an 8-point sum score of effective handwashing technique. Multiple linear and logistic regression analyses were performed to predict observed handwashing technique from potential contextual and psychosocial determinants. Knowledge of how to wash hands effectively, availability of a handwashing station with functioning water tap, self-reported frequency of handwashing, perceived vulnerability, and action planning were the main determinants of effective handwashing technique. The models were able to explain 39% and 36% of the variance in overall handwashing technique and thoroughness of handscrubbing. Memory aids and guided practice are proposed to consolidate action knowledge, and personalized risk messages should increase the perceived vulnerability of contracting diarrhea. Planning where, when, and how to maintain a designated place for handwashing with sufficient soap and water is proposed to increase action planning. Since frequent self-reported handwashing was associated with performing more effective handwashing technique, behavior change interventions should target both handwashing frequency and technique concurrently.

Estimating Access to Drinking Water Supply, Sanitation, and Hygiene Facilities in Wolaita Sodo Town, Southern Ethiopia, in Reference to National Coverage

Introduction. The coverage of sanitation and access to safe drinking water in Ethiopia especially in Wolaita Sodo town are not well studied. Therefore, the main objective of this study was estimating access to drinking water supply, sanitation, and hygiene facilities in Wolaita Sodo town, southern Ethiopia, in reference to national coverage. Methods. A community based cross-sectional study design method was employed in the study in 588 households of Wolaita Sodo town inhabitants. Face-to-face interview to household owners, in-depth interview to key informants, reviewing secondary data, and observational check lists were used to collect data. Districts were selected using simple random sampling techniques, while systematic random sampling technique was applied to select households. Data was analyzed using Epi Info version 3.5.4 and SPSS version 16 statistical software. Bivariate and multivariable logistic regression analysis were carried out. Results. The community has access to improved water supply which was estimated to be 67.9%. The main water sources of the town were tap water within the yard, which was estimated to be 44.7%, and tap water in the community was 40.0% followed by private protected well which was 14.5%. Ninety-one percent of the households had at least one type of latrine in their homes. The most common type of latrine available to households was pit latrine with superstructure which was estimated to be 75.9% followed by a pit without superstructure, 21.3%, and more than half of the respondents had hand washing facilities in their compound. Occupational status, educational status, and training on water, sanitation, and hygiene related topics were significantly associated with use of improved water source, improved sanitation, and hygiene facilities. Conclusion. In order to address the demand of the town, additional water, sanitation, and hygiene programs are required.

Microbial Content of "Bowl Water" Used for Communal Handwashing in Preschools within Accra Metropolis, Ghana

Objective. This study aimed at determining the microbial content of “bowl water” used for communal handwashing in preschools within the Accra Metropolis. Method. Six (6) preschools in the Accra Metropolis were involved in the study. Water samples and swabs from the hands of the preschool children were collected. The samples were analysed and tested for bacteria, fungi, parasites, and rotavirus. Results. Eight different bacteria, two different parasites, and a fungus were isolated while no rotavirus was detected. Unlike the rest of the microbes, bacterial isolates were found among samples from all the schools, with Staphylococcus species being the most prevalent (40.9%). Out of the three schools that had parasites in their water, two of them had Cryptosporidium parvum. The fungus isolated from two out of the six schools was Aspergillus niger. All bacteria isolated were found to be resistant to cotrimoxazole, ciprofloxacin, and ampicillin and susceptible to amikacin and levofloxacin. Conclusion. Although handwashing has the ability to get rid of microbes, communal handwashing practices using water in bowls could be considered a possible transmission route and may be of public concern.

Natural Rheological Modifiers for Personal Care

The development of personal care formulations incorporates the deliberation of the prerequisite product rheology and the right rheology modifier to deliver these effects. While the effectiveness of the finished product will hinge on the selection and level of active ingredients and excipients, the aesthetics and even the penetration of these actives into the stratum corneum will be affected by the product rheology. Rheology modifiers are frequently denoted as thickeners and, whilst increasing the apparent viscosity should enhance the perception of quality in a formulation, this is only one aspect of rheological control. The product itself can be Newtonian or pseudoplastic, thixotropic, exist as a ringing gel or a stringy flowable liquid. This changes the way that the product appears in the bottle, the ease with which aliquots are poured or scooped from the packaging, the process of rubbing it into the skin or along the hair shaft, and upon using, the rinsing and removal of the product. It will also be vital to select the correct rheological characteristics to guarantee the stability of the finished formulation. By changing the structure of polymeric rheology modifiers, the impact on the sensorial properties and performance characteristics can be investigated. Careful selection of monomers, structure and other co-ingredients will result in products optimised for use in skin care formulations.

The Knowledge Base for Achieving the Sustainable Development Goal Targets on Water Supply, Sanitation and Hygiene

Safe drinking water, sanitation, and hygiene (WASH) are fundamental to an improved standard of living. Globally, 91% of households used improved drinking water sources in 2015, while for improved sanitation it is 68%. Wealth disparities are stark, with rural populations, slum dwellers and marginalized groups lagging significantly behind. Service coverage is significantly lower when considering the new water and sanitation targets under the sustainable development goals (SDGs) which aspire to a higher standard of ‘safely managed’ water and sanitation. Lack of access to WASH can have an economic impact as much as 7% of Gross Domestic Product, not including the social and environmental consequences. Research points to significant health and socio-economic consequences of poor nutritional status, child growth and school performance caused by inadequate WASH. Groundwater over-extraction and pollution of surface water bodies have serious impacts on water resource availability and biodiversity, while climate change exacerbates the health risks of water insecurity. A significant literature documents the beneficial impacts of WASH interventions, and a growing number of impact evaluation studies assess how interventions are optimally financed, implemented and sustained. Many innovations in behavior change and service delivery offer potential for scaling up services to meet the SDGs.

Assessment of Three "WHO" Patient Safety Solutions: Where Do We Stand and What Can We Do?

Background:

Most medical errors are preventable. The aim of this study was to compare the current execution of the 3 patient safety solutions with WHO suggested actions and standards.

Methods:

Data collection forms and direct observation were used to determine the status of implementation of existing protocols, resources, and tools.

Results:

In the field of patient hand-over, there was no standardized approach. In the field of the performance of correct procedure at the correct body site, there were no safety checklists, guideline, and educational content for informing the patients and their families about the procedure. In the field of hand hygiene (HH), although availability of necessary resources was acceptable, availability of promotional HH posters and reminders was substandard.

Conclusions:

There are some limitations of resources, protocols, and standard checklists in all three areas. We designed some tools that will help both wards to improve patient safety by the implementation of adapted WHO suggested actions.

Teacher perspectives on implementing and sustaining a handwashing promotion intervention in Western Kenyan primary schools

School-based handwashing programs are challenging to establish and sustain, especially in low-resource settings. This qualitative study described teacher perspectives associated with implementing and sustaining a handwashing program in primary schools participating in the Nyando Integrated Child Health and Education (NICHE) project. Structured key informant interviews were conducted with teachers. Prevalent concepts and themes were grouped into themes and topic areas using an iterative, open coding approach. Forty-one teacher respondents reported favorable expectations and benefits of handwashing programs. The importance of available resources (e.g., reliable water) was cited as a primary concern. Other challenges included time and personal or institutional financial commitment necessary to ensure program sustainability. Handwashing programs in low-income, rural schools, where infrastructure is lacking and "student ambassadors" extend the intervention to the surrounding community, hold great promise to improve community health. Teachers must have adequate support and resources to implement and sustain the programs.

Systematic review of the effectiveness of mass media interventions for child survival in low- and middle-income countries

Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (n = 33), moderate (n = 32), and stronger evaluations (n = 46) on the basis of the sampling method, the evaluation design, and efforts to address threats to inference of mass media effects. The moderate and stronger evaluations provide evidence that mass media-centric campaigns can positively impact a wide range of child survival health behaviors.

Protecting child health and nutrition status with ready-to-use food in addition to food assistance in urban Chad: a cost-effectiveness analysis

Background

Despite growing interest in use of lipid nutrient supplements for preventing child malnutrition and morbidity, there is inconclusive evidence on the effectiveness, and no evidence on the cost-effectiveness of this strategy.

Methods

A cost effectiveness analysis was conducted comparing costs and outcomes of two arms of a cluster randomized controlled trial implemented in eastern Chad during the 2010 hunger gap by Action contre la Faim France and Ghent University. This trial assessed the effect on child malnutrition and morbidity of a 5-month general distribution of staple rations, or staple rations plus a ready-to-use supplementary food (RUSF). RUSF was distributed to households with a child aged 6–36 months who was not acutely malnourished (weight-for-height > = 80% of the NCHS reference median, and absence of bilateral pitting edema), to prevent acute malnutrition in these children. While the addition of RUSF to a staple ration did not result in significant reduction in wasting rates, cost-effectiveness was assessed using successful secondary outcomes of cases of diarrhea and anemia (hemoglobin <110 g/L) averted among children receiving RUSF.

Total costs of the program and incremental costs of RUSF and related management and logistics were estimated using accounting records and key informant interviews, and include costs to institutions and communities. An activity-based costing methodology was applied and incremental costs were calculated per episode of diarrhea and case of anemia averted.

Results

Adding RUSF to a general food distribution increased total costs by 23%, resulting in an additional cost per child of 374 EUR, and an incremental cost per episode of diarrhea averted of 1,083 EUR and per case of anemia averted of 3,627 EUR.

Conclusions

Adding RUSF to a staple ration was less cost-effective than other standard intervention options for averting diarrhea and anemia. This strategy holds potential to address a broad array of health and nutrition outcomes in emergency settings where infrastructure is weak and other intervention options are infeasible in the short-term. However, further research is needed to establish the contexts in which RUSF is most effective and cost-effective in preventing acute malnutrition and morbidity among vulnerable children, compared to other options.

Impact of regular soap provision to primary schools on hand washing and E. coli hand contamination among pupils in Nyanza Province, Kenya: a cluster-randomized trial

We assessed whether supplying soap to primary schools on a regular basis increased pupil hand washing and decreased Escherichia coli hand contamination. Multiple rounds of structured observations of hand washing events after latrine use were conducted in 60 Kenyan schools, and hand rinse samples were collected one time in a subset of schools. The proportion of pupils observed practicing hand washing with soap (HWWS) events was significantly higher in schools that received a soap provision intervention (32%) and schools that received soap and latrine cleaning materials (38%) compared with controls (3%). Girls and boys had similar hand washing rates. There were non-significant reductions in E. coli contamination among intervention school pupils compared with controls. Removing the barrier of soap procurement can significantly increase availability of soap and hand washing among pupils; however, we discuss limitations in the enabling policy and institutional environment that may have prevented reaching desired levels of HWWS.

Handwashing behaviour among Chinese adults: a cross-sectional study in five provinces

OBJECTIVES

To describe the patterns of handwashing behaviour among Chinese adults, and assess their associations with sociodemographic factors and knowledge of hand hygiene.

STUDY DESIGN

A representative sample (n = 6159) of Chinese adults aged 18-60 years in five provinces was attained by multiple-stage, stratified sampling mainly based on geographical location and economic status. Data on handwashing behaviour, knowledge of hand hygiene and sociodemographic factors were collected through self-administrated questionnaires.

METHODS

Associations between handwashing behaviour and sociodemographic factors were tested in logistic models. Path analysis was applied to examine the associations between sociodemographic factors, knowledge of hand hygiene and proper handwashing behaviour in order to evaluate the relative magnitude of these determinants and internal relationships.

RESULTS

This study found that 52.7% (rural vs urban: 44.6% vs 56.8%) and 67.3% (rural vs urban: 59.7% vs 71.1%) of Chinese adults reported they always washed hands before eating and after defaecation, and 30.0% (rural vs urban: 25.1% vs 32.8%) of adults always used soap or other sanitizers during washing. Using the criteria of 'always or very often washing hands with soap before eating and after defaecation without sharing a towel with family members after washing', only 47.2% (rural vs urban: 23.8% vs 59.1%) of the adults were graded to practice proper handwashing behaviour. Urban area, high level of education level, high level of knowledge about diseases, female gender and older age were protective factors for good hand hygiene; of these, area was found to be associated most strongly with handwashing behaviour.

CONCLUSIONS

Adherence to an appropriate handwashing method and duration of handwashing are critical problems among Chinese adults. Area difference, level of education and level of knowledge of hand hygiene were most strongly associated with handwashing behaviour, and should be targeted in future health education.

Health Care Utilization and Attitudes Survey: understanding diarrheal disease in rural Gambia

Diarrheal disease causes ∼1.34 million deaths per year among children under 5 years of age globally. We conducted a Health Care Utilization and Attitudes Survey of 1,012 primary caregivers of children aged 0–11, 12–23, and 24–59 months randomly selected from a Demographic Surveillance population in rural Gambia. Point prevalence of diarrhea was 7.7% (95% confidence interval [CI] = 6.1–9.8); 23.3% had diarrhea within the previous 2 weeks. Caregivers of 81.5% of children with diarrhea sought healthcare outside their home, but only 48.4% of them visited a health center. Only 17.0% (95% CI = 12.1–23.2) of children with diarrhea received oral rehydration solution (ORS) at home. Abbreviated surveys conducted on six occasions over the subsequent 2 years showed no change in prevalence or treatment-seeking behavior. Diarrhea remains a significant problem in rural young Gambian children. Encouraging care-seeking behavior at health centers and promoting ORS use can reduce mortality and morbidity in this population.

"Think the sink:" Preliminary evaluation of a handwashing promotion campaign

Owing to its utility in guiding the planning and evaluation of health promotion campaigns, the Theory of Planned Behavior was used to implement a 1-month campaign aimed at increasing handwashing among college students. Based on observations of bathroom users' handwashing behavior (n = 1,005) and an online survey (n = 188), overall handwashing did not increase as a result of the campaign; however, more students did use soap (58% vs 70%). Future campaigns designed to increase handwashing behavior in students may be advised to target messages according to gender difference-based responsiveness to handwashing norms.

Experimental pretesting of hand-washing interventions in a natural setting

OBJECTIVES

We pretested interventions derived from different domains of behavior change theory to determine their effectiveness at increasing hand washing with soap in a natural setting.

METHODS

We installed wireless devices in highway service station restrooms to record entry and soap use. Two text-only messages for each of 7 psychological domains were compared for their effect on soap-use rates. We collected data on nearly 200 000 restroom uses.

RESULTS

The knowledge activation domain was most effective for women, with a relative increase in soap use of 9.4% compared with the control condition (P = .001). For men, disgust was the most effective, increasing soap use by 9.8% (P = .001). Disgust was not significantly better than the control condition for women, nor was knowledge activation for men. Messages based on social norms and social status were effective for both genders.

CONCLUSIONS

Our data show that unobtrusive observation of behavior in a natural setting can help identify the most effective interventions for changing behaviors of public health importance. The gender differences we found suggest that public health interventions should target men and women differently.

The value of hygiene promotion: cost-effectiveness analysis of interventions in developing countries

Hygiene promotion can greatly improve the benefits of water and sanitation programmes in developing countries at relatively limited costs. There are, however, few studies with hard data on the costs and effectiveness of individual programmes and even fewer have compared the cost-effectiveness of different promotional approaches. This article argues that objectively measured reductions of key sanitation and hygiene risks are better than DALYs for evaluating hygiene and sanitation promotion programmes. It presents a framework for the cost-effectiveness analysis of such programmes, which is used to analyse six field programmes. At costs ranging from US dollar 1.05 to US dollar 1.74 per person per year in 1999 US dollar values, they achieved (almost) complete abandonment of open defecation and considerable improvements in keeping toilets free from faecal soiling, safe disposal of child faeces, and/or washing hands with soap after defecation, before eating and after cleaning children's bottoms. However, only two studies used a quasi-experimental design (before and after studies in the intervention and - matched - control area) and only two measured costs and the degree to which results were sustained after the programme had ended. If the promotion of good sanitation and hygiene is to receive the political and managerial support it deserves, every water, sanitation and/or hygiene programme should give data on inputs, costs, processes and effects over time. More and better research that reflects the here-presented model is also needed to compare the cost-effectiveness of different promotional approaches.

Economic evaluation of environmental health interventions to support decision making

Environmental burden of disease represents one quarter of overall disease burden, hence necessitating greater attention from decision makers both inside and outside the health sector. Economic evaluation techniques such as cost-effectiveness analysis and cost-benefit analysis provide key information to health decision makers on the efficiency of environmental health interventions, assisting them in choosing interventions which give the greatest social return on limited public budgets and private resources. The aim of this article is to review economic evaluation studies in three environmental health areas-water, sanitation, hygiene (WSH), vector control, and air pollution-and to critically examine the policy relevance and scientific quality of the studies for selecting and funding public programmers. A keyword search of Medline from 1990-2008 revealed 32 studies, and gathering of articles from other sources revealed a further 18 studies, giving a total of 50 economic evaluation studies (13 WSH interventions, 16 vector control and 21 air pollution). Overall, the economic evidence base on environmental health interventions remains relatively weak-too few studies per intervention, of variable scientific quality and from diverse locations which limits generalisability of findings. Importantly, there still exists a disconnect between economic research, decision making and programmer implementation. This can be explained by the lack of translation of research findings into accessible documentation for policy makers and limited relevance of research findings, and the often low importance of economic evidence in budgeting decisions. These findings underline the importance of involving policy makers in the defining of research agendas and commissioning of research, and improving the awareness of researchers of the policy environment into which their research feeds.

Measuring the benefits of health promotion programmes: application of the contingent valuation method

Economic evaluation of health promotion programmes presents well documented challenges. These programmes often generate significant non-health benefits which are typically ignored within economic evaluation. This study explored the use of the contingent valuation (CV) method to value the broader benefits of a women's group programme to improve maternal and newborn health in Nepal. Interviews were conducted with 93 women's group members, 70 women non-members and 33 men. Respondents were asked to give reasons for their willingness-to-pay (WTP) in terms of health and/or non-health benefits. WTP was regressed against socio-economic and demographic variables using ordinary least squares. Seventy eight percent of respondents were willing-to-pay for the women's groups. There was no significant difference between the WTP of women's group members compared to female non-members. Men were willing-to-pay significantly more than women. WTP reflected non-health benefits in over 80% of cases. At least 11% of women attending meetings and 38% of those not attending were WTP for altruistic motives. Future research should address the relative value of non-health compared to health benefits; and motivations behind non-user values and their consistency across settings.

Hand washing for preventing diarrhoea

BACKGROUND

Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens.

OBJECTIVES

To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.

SEARCH STRATEGY

In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 to May 2007), SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field.

SELECTION CRITERIA

Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote hand washing.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and methodological quality. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based, five were community-based, and one was in a high-risk group (AIDS patients). Interventions promoting hand washing resulted in a 29% reduction in diarrhoea episodes in institutions in high-income countries (IRR 0.71, 95% CI 0.60 to 0.84; 7 trials) and a 31% reduction in such episodes in communities in low- or middle-income countries (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials).

AUTHORS' CONCLUSIONS

Hand washing can reduce diarrhoea episodes by about 30%. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.

Weather Variability and the Incidence of Cryptosporidiosis: Comparison of Time Series Poisson Regression and SARIMA Models

PURPOSE

Few studies have examined the relationship between weather variables and cryptosporidiosis in Australia. This paper examines the potential impact of weather variability on the transmission of cryptosporidiosis and explores the possibility of developing an empirical forecast system.

METHODS

Data on weather variables, notified cryptosporidiosis cases, and population size in Brisbane were supplied by the Australian Bureau of Meteorology, Queensland Department of Health, and Australian Bureau of Statistics for the period of January 1, 1996-December 31, 2004, respectively. Time series Poisson regression and seasonal auto-regression integrated moving average (SARIMA) models were performed to examine the potential impact of weather variability on the transmission of cryptosporidiosis.

RESULTS

Both the time series Poisson regression and SARIMA models show that seasonal and monthly maximum temperature at a prior moving average of 1 and 3 months were significantly associated with cryptosporidiosis disease. It suggests that there may be 50 more cases a year for an increase of 1 degrees C maximum temperature on average in Brisbane. Model assessments indicated that the SARIMA model had better predictive ability than the Poisson regression model (SARIMA: root mean square error (RMSE): 0.40, Akaike information criterion (AIC): -12.53; Poisson regression: RMSE: 0.54, AIC: -2.84). Furthermore, the analysis of residuals shows that the time series Poisson regression appeared to violate a modeling assumption, in that residual autocorrelation persisted.

CONCLUSIONS

The results of this study suggest that weather variability (particularly maximum temperature) may have played a significant role in the transmission of cryptosporidiosis. A SARIMA model may be a better predictive model than a Poisson regression model in the assessment of the relationship between weather variability and the incidence of cryptosporidiosis.

Hygiene behaviour of adolescents in the Pacific: associations with socio-demographic, health behaviour and school environment

This study presents findings on health-related hygiene behaviours of 9,013 adolescents from Vanuatu, Tonga and Pohnpei in the Federal States of Micronesia as part of the Health Behaviour of Pacific Youth Life surveys. We examined the prevalence of and relationship between tooth brushing, hand washing before eating, hand washing after toileting and a range of psychosocial factors such as sociodemographic charac-teristics, health behaviour and school affiliation. The results showed that patterns of prevalence and relationships were consistent for all countries, with weaker associations observed in Pohnpei. In general, adolescents reported moderate levels of optimal hygiene practice. Girls reported significantly more frequent optimal hygiene practice than boys. Logistic regression analysis confirmed that frequent hygiene behaviours were significantly associated with gender, parental occupations and high levels of school affiliation. These findings suggest the need to consider psycho-social and economic factors when examining potential influences on hygiene behaviour to ensure effective interventions.

Handwashing and risk of respiratory infections: a quantitative systematic review

Objective  To determine the effect of handwashing on the risk of respiratory infection.

Methods  We searched PubMed, CAB Abstracts, Embase, Web of Science, and the Cochrane library for articles published before June 2004 in all languages. We had searched reference lists of all primary and review articles. Studies were included in the review if they reported the impact of an intervention to promote hand cleansing on respiratory infections. Studies relating to hospital‐acquired infections, long‐term care facilities, immuno‐compromised and elderly people were excluded. We independently evaluated all studies, and inclusion decisions were reached by consensus. From a primary list of 410 articles, eight interventional studies met the eligibility criteria.

Results  All eight eligible studies reported that handwashing lowered risks of respiratory infection, with risk reductions ranging from 6% to 44% [pooled value 24% (95% CI 6–40%)]. Pooling the results of only the seven homogenous studies gave a relative risk of 1.19 (95% CI 1.12%–1.26%), implying that hand cleansing can cut the risk of respiratory infection by 16% (95% CI 11–21%).

Conclusions  Handwashing is associated with lowered respiratory infection. However, studies were of poor quality, none related to developing countries, and only one to severe disease. Rigorous trials of the impact of handwashing on acute respiratory tract infection morbidity and mortality are urgently needed, especially in developing countries.