Effect of an equipment-behavior change intervention on handwashing behavior among primary school children in Kenya: the Povu Poa school pilot study

Preparing schools for future pandemics: Insights on water, sanitation and hygiene solutions from the Brazilian school reopening policies

Post-COVID-19, schools urgently need to enhance infection control and prevention (IPC) measures, including water, sanitation, and hygiene (WASH), to prepare for future outbreaks and pandemics. Particularly in Brazil, that is of particular concern, as students are still recovering from the 20th longest school closure in the world. Hence, the current study had two goals: (i) to describe WASH solutions outlined in policies released at the federal, state, and capital city levels in Brazil during the COVID-19 pandemic for the safe reopening of schools and (ii) to discuss their potential to enhance school's capacity to remain operational during a new pandemic or outbreak. With a qualitative exploratory approach, we performed content analysis to discuss the direction (what, where, how and for whom?) of 66 public policies by integrating four frameworks. Solutions were discussed in the light of the principles of human rights and the human rights to water and sanitation, international guidelines for WASH and IPC in schools and the Sphere minimum standards for humanitarian aid. One hundred and fifty-nine solutions, spanning five thematic areas and five population groups, including software and hardware interventions, were compiled for potential use in Brazil and beyond. While suggested solutions have the potential to provide a cleaner and safer learning environment, it is essential to exercise caution when implementing these measures and adapt them to the specific circumstances of each school.

Nongovernmental Organization Practitioners' Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study

BACKGROUND

Increasing handwashing with soap (HWWS) among older children (aged 5-14 years) can achieve a substantial public health impact. However, HWWS interventions targeting older children have had mixed success. Recent research has attempted to quantitatively identify effective intervention techniques; however, success is likely also influenced by the wider context of implementation. We explore nongovernmental organization (NGO) practitioners' perspectives on the challenges and solutions to HWWS interventions targeting older children to enhance understanding of what is required, beyond intervention content, for them to be effective.

METHODS

We conducted in-depth, semistructured interviews in April-November 2020 with 25 practitioners employed across 11 NGOs and involved in HWWS interventions targeting older children in development and humanitarian settings. We used purposive and snowball sampling to recruit participants in roles at the global, national/regional, and local levels. Interviews were audio-recorded, transcribed, and thematically analyzed to identify challenges and solutions to HWWS interventions targeting older children. Results were organized according to program development cycle stages.

RESULTS

Twelve themes relating to perceived challenges emerged: (1) lack of prioritization, (2) funding inconsistency, (3) insufficient formative research, (4) demand on resources, (5) unengaging intervention content, (6) non-enabling physical environments, (7) availability of skilled implementers, (8) reaching out-of-school children, (9) community mistrust, (10) lack of coordination, (11) lack of evaluation rigor, and (12) failure to assign older children's HWWS as a primary outcome in evaluations of hygiene interventions. Recommended solutions were at the intervention, organization, and sector levels.

CONCLUSION

Intervention design and delivery are important for the success of HWWS interventions for older children, but contextual factors, such as the availability of human and material resources and the level of coordination within and beyond the NGO sector, should also be considered. NGOs need to prioritize HWWS promotion among older children and support programs accordingly.

Effects of Micro Architectural Environmental Interventions on Handwashing Compliance of Adolescents: A School-Based Intervention Trial

PURPOSE

Aimed to explore more practical interventions for handwashing compliance (HWC) and protect the minor' health with the pandemic background, this study tested whether micro architectural interventions would promote HWC of adolescents through active experience.

BACKGROUND

Despite the well-documented benefits of handwashing (HW), low compliance is common among adolescents. HW space in schools has always been treated as attached spaces of little matter, which is unfavorable to public health. According to environment behavior perspective, personal motivation of HWC may be motivated by active environment.

METHOD

A school-based investigation and a 30-week environmental behavior experiment were conducted when students returned to school after the COVID-19 pandemic closure in 2020 in China to evaluate the effects of active environment interventions selected by previous survey on promoting adolescents' HW rate. Digital infrared counters were used to unobtrusively document their behavior.

RESULTS

Results in summer revealed a positive effect on all intervention groups. The effects of combined interventions were higher than the effect of any single intervention. However, HW rates of all groups declined sharply in the coldest month and the between-group differences decreased. Significant correlations were found between HW rates and satisfaction with the intervention schemes.

CONCLUSIONS

Findings suggest that architectural environmental intervention may potentially be a positive, friendly, and one-time investment mean to expand the HWC intervention scope from passive policies to positive experience, and HW space design for adolescents should be treated as a public health strategy.

Implementation practice models for development in low- and middle-income countries: systematic review of peer-reviewed literature

Introduction

This study operationally defines a relatively small, but growing field of study on implementation practice models for health behavior change in the context of international development. We define ‘implementation practice models’ as theoretical models that take a practical and practitioner-focused approach to behavior change, and we illustrate how these models have been developed and applied. The paper examines the continuum of behavioral theories and their application in the context of development programs and research in low- and middle-income countries (LMICs). We describe implementation practice models, examine how they have been used to design and evaluate theory-based interventions in LMIC, and describe the state of evidence in this field of study.

Methods

The authors conducted a systematic search of the published, peer-reviewed literature following the widely accepted PRISMA methods for systematic reviews. We aimed to identify all relevant manuscripts published in the English language in health, social science, and business literature that apply implementation practice models, located in an LMIC, with a behavior change objective. We located 1,078 articles through database searching and 106 through other means. Ultimately, we identified 25 relevant articles for inclusion.

Results

We found that the peer-reviewed literature on implementation practice models for development has been growing in recent years, with 80% of reviewed papers published since 2015. There was a wide range of different models revealed by this review but none demonstrated clear-cut evidence of being most effective. However, the models found in this review share common characteristics of focusing on the three central tenets of Opportunity, Ability, and Motivation (OAM).

Conclusions

This review found that implementation practice models for development are a promising and growing approach to behavior change in LMICs. Intervention practice models research should be expanded and applied in new domains, such as vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13530-0.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

Behavioral drivers and observation of face covering use during the COVID-19 pandemic among outpatients and visitors at a tertiary hospital in Thailand

BACKGROUND

Use of face covering may help prevent COVID-19 transmission. However, there is a lack of data on behavioral drivers of face covering use and compliance to mandatory face covering policy at health facilities. This study aimed to describe behavioral drivers and observed face covering use among outpatients and visitors at a tertiary hospital in Southern Thailand during the COVID-19 pandemic.

MATERIALS AND METHODS

We conducted a hospital-based, cross-sectional study in June 2020. We developed, pilot-tested and finalized an interview questionnaire in Thai. We also developed a structured observation questionnaire. Two trained enumerators recruited outpatients and visitors at the hospital's internal medicine outpatient department (OPD), surgery OPD, and the pharmacy using the convenience sampling. Another enumerator conducted structured observation of face covering use among outpatients and visitors when interviews were not taking place. We analyzed the data using the descriptive statistics.

RESULTS

A total of 206 persons that our interview enumerators approached agreed to participate (n = 206; response rate = 62.4%). Nearly all participants stated that the use of face covering was beneficial in preventing COVID-19 infection from others and preventing others from being infected (94.0% and 98.0%, respectively). Common barriers included inconvenience in breathing and speaking (19.7%) and pain at the ears (9.6%). Structured observation of 408 outpatients and visitors showed that nearly everyone (>99%) had a face covering on their person, most of whom (94.6%) covered both their nose and mouth.

CONCLUSION

We found near-universal perceived benefits and compliance, but variations in perceived barriers, cues, and social norms for the use of face coverings. The findings of this study can inform future intervention programs on face covering use promotion.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment

Background

Nudging, a strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion.

Methods

A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations.

Results

This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience.

Conclusion

Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of ‘what works’ and ‘how it works’. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.

Behavior is at the core of neglected tropical disease (NTD) prevention and control, certainly within low-, and middle- income countries (LMIC) where resources are often limited. Therefore, strategies to promote behavior change should be included and investigated in future efforts. Nudging, a low-cost strategy that subtly directs people towards positive behavioral choices, has recently gained attention in global health promotion. Nudge strategies have been applied to a wide range of health-promoting behaviors such as handwashing. To understand which strategies were used, where and how these were applied, and whether these were ethically informed and implemented, we undertook a comprehensive review of the available sources. This resulted in 33 included studies, with a total of 67 nudge strategies for behavior-based prevention and control of NTDs in LMIC. Only two studies targeted NTDs in particular, the other 31 included studies were focused on more general health promoting behaviors, with the majority targeting handwashing with soap. The most common nudge strategies were those targeting decision assistance, such as fostering commitment and reminder actions. In general, the ethical assessment presented favorable results. We identified the need for robust study designs to better understand how nudges can be implemented in the future.

Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial

Background

Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA).

Methods

The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants’ interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs’ HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders’ insight workshop.

The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children’s wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention.

Discussion

The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs’ HH practice.

Trial registration

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06082-3.

Can Social Motivators Improve Handwashing Behavior among Children? Evidence from a Cluster Randomized Trial of a School Hygiene Intervention in the Philippines

This study reports the impact of the HiFive program, a 6-week handwashing campaign that targets social and emotional motivators to improve student handwashing in primary schools in the Philippines. We designed a clustered randomized trial to evaluate the impact of HiFive on student handwashing behavior, motivation, and access. Of the sample of 196 primary schools located in two districts, half were randomly assigned to receive the program in the 2017–2018 school year. Survey and observation data were collected 3 months after the conclusion of the campaign. In control schools, only 2.5% of students were observed washing their hands with soap and water, our primary outcome and 14.8% were observed washing their hands with at least water. HiFive led to a 3.7 percentage point (p.p.) increase (P < 0.01) in the rate of handwashing with soap and water and a 5.6 p.p. increase (P = 0.03) in handwashing with at least water after toilet use. HiFive also led to a 10.8 p.p. (P < 0.01) increase in the number of handwashing facilities stocked with soap. The program had limited impact on the motivators targeted by the program, suggesting that the small improvements in handwashing may have been driven by increases in the availability of soap. More research is needed to understand how interventions can effectively trigger social motivators to improve handwashing behavior among schoolchildren, and whether the effectiveness of these programs can be augmented with “nudge”-based interventions from the behavioral sciences.

Designing a Food Hygiene Intervention in Low-Income, Peri-Urban Context of Kisumu, Kenya: Application of the Trials of Improved Practices Methodology

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city’s population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6–9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food.