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Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid-upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77-0.99], but no effect in the combined WSHN group weakens this finding.

Enteric pathogens can be transmitted within the household and the surrounding neighborhood. The objective of this study was to understand the effect of neighborhood-level sanitation coverage on contamination of the household environment with levels of fecal indicator bacteria in rural Bangladesh. We conducted spot-check observations of sanitation facilities in neighboring households (NHs) within a 20-m radius of target households with children aged 6-24 months. Sanitation facilities were defined as improved (a private pit latrine with a slab or better) or unimproved. Fecal coliforms (FCs) on children's hands and sentinel toy balls were measured and used as indicators of household-level fecal contamination. We visited 1,784 NHs surrounding 428 target households. On average, sentinel toy balls had 2.11(standard deviation [SD] = 1.37) log10 colony-forming units (CFUs) of FCs/toy ball and children's hands had 2.23 (SD = 1.15) log10 CFU of FCs/two hands. Access to 100% private improved sanitation coverage in the neighborhood was associated with a small and statistically insignificant difference in contamination of sentinel toy balls (difference in means = -0.13 log10 CFU/toy ball; 95% confidence intervals [CI]: -0.64, 0.39; P = 0.63) and children's hands (difference in means = -0.11 log10 CFU/two hands; 95% CI: -0.53, 0.32; P = 0.62). Improved sanitation coverage in the neighborhood had limited measurable effect on FCs in the target household environment. Other factors such as access to improved sanitation in the household, absence of cow dung, presence of appropriate water drainage, and optimal handwashing practice may be more important in reducing FCs in the household environment.

In Lao PDR, 30% of children under age 5 years are affected by stunting. Stunting in childhood is associated with poorer outcomes for both physical and cognitive development. Baby WASH is a focused approach to water supply, sanitation, and hygiene for infants and children that targets numerous contextual and psychosocial factors including child handwashing, food hygiene, clean play spaces, and management of animal feces in the household environment. Using the risks, attitudes, norms, abilities, and self-regulation approach to behavior change (BC), the objective of this study was to investigate psychosocial factors of Baby WASH and nutrition related-behaviors, considering caregivers mental well-being, to design evidence-based BC interventions. A cross-sectional survey of 616 caregivers of a child under 2 years was conducted in Lao PDR. Caregivers well-being was significantly associated with handwashing before feeding a baby, controlling "mouthing," and the intention to exclusively breastfeed for the first 6 months. All psychosocial factors of the three behaviors were correlated with mental well-being. Results suggest that attitudinal and ability factors underlying handwashing with soap before feeding a child should be the primary focus of BC interventions. For controlling mouthing factors, interventions should target attitude and norm factors. To increase the intention of exclusive breastfeeding for the first 6 months attitude, ability, and self-regulation factors should be targeted through BC interventions. The findings of this study can be used to support the inclusion of vulnerable caregivers with poor mental well-being with BC interventions designed to improve child health and prevent stunting.

In preparation for a larger trial, the Water, Sanitation, and Hygiene (WASH) Benefits pilot study enrolled 72 villages and 499 subjects in two closely related randomized trials of WASH interventions in rural western Kenya. Intervention households received hardware and promotion for one of the following: water treatment, sanitation and latrine improvements, handwashing with soap, or the combination of all three. Interventions were clustered by village. A follow-up survey was conducted 4 months after intervention delivery to assess uptake. Intervention households were significantly more likely than controls to have chlorinated stored water (36-60 percentage point increases), covers over latrine drop holes (55-75 percentage point increases), less stool visible on latrine floors (16-47 percentage point reductions), and a place for handwashing (71-85 percentage point increases) with soap available (49-66 percentage point increases). The high uptake in all arms shows that combined interventions can achieve high short-term adoption rates if well-designed.

We conducted a randomized, non-inferiority field trial in urban Dhaka, Bangladesh among mothers to compare microbial efficacy of soapy water (30 g powdered detergent in 1.5 L water) with bar soap and water alone. Fieldworkers collected hand rinse samples before and after the following washing regimens: scrubbing with soapy water for 15 and 30 seconds; scrubbing with bar soap for 15 and 30 seconds; and scrubbing with water alone for 15 seconds. Soapy water and bar soap removed thermotolerant coliforms similarly after washing for 15 seconds (mean log10 reduction = 0.7 colony-forming units [CFU], P < 0.001 for soapy water; mean log10 reduction = 0.6 CFU, P = 0.001 for bar soap). Increasing scrubbing time to 30 seconds did not improve removal (P > 0.05). Scrubbing hands with water alone also reduced thermotolerant coliforms (mean log10 reduction = 0.3 CFU, P = 0.046) but was less efficacious than scrubbing hands with soapy water. Soapy water is an inexpensive and microbiologically effective cleansing agent to improve handwashing among households with vulnerable children.

Poor water sanitation and hygiene is a public health problem in developing and underdeveloped countries, including Ethiopia, and remains an important public health issue among primary school students. Students have been repeatedly exposed to various communicable diseases associated with water sanitation and hygiene. The objective of this study was to assess predictors of handwashing practice among second-cycle public primary school students in East Dembiya District, northwestern Ethiopia, 2022. A cross-sectional study was conducted among 752 second-cycle primary school students. Data were gathered through face-to-face interviews using a structured interviewer-administered questionnaire and observational checklists adopted and modified from different sources of literature. The data were checked further by visualizing and computing rates with the SPSS version 26 statistical software. Multivariable logistic regression was used to identify predictors. The prevalence of washing practices among second-cycle primary school students was 57.6% (95% CI 53.90-61.10). Residency (urban) (adjusted odds ratio [aOR] = 2.17, 95% CI: 1.30-2.87), access to media (aOR = 1.66, 95% CI: 1.11-2.49), hygiene and sanitation club membership (aOR = 1.88, 95% CI: 1.26-2.80), good knowledge about handwashing (aOR = 3.93, 95% CI: 2.34-6.60), and a positive attitude toward handwashing (aOR = 3.63, 95% CI: 2.01-5.584) were predictors of handwashing practice among second-cycle primary school students. This study showed that handwashing practice among primary school students was low. Availing handwashing facilities, better media access, formation of a hygiene and sanitation club in the school, celebration of "Handwashing Day" with students, and leading behavior change communication are all important for improving students' handwashing practice.

Improvement in hand hygiene has been strongly associated with positive outcomes in maternal and child health. Although Bangladesh has a high level of awareness of key hygiene messages, the practice of handwashing, the most effective hygiene behavior, is low. Suchana, a multisectoral nutrition program, aims to increase knowledge and practices around various water, sanitation, and hygiene settings in Sylhet region, the northeast of rural Bangladesh. This study aimed to investigate the changes in indicators related to handwashing knowledge and practices among Suchana beneficiaries in final compared with baseline evaluations. Data were derived from the baseline and final cross-sectional evaluation survey. The following handwashing knowledge and practices were considered: handwashing before preparing food, before eating food and feeding children, before serving food, after defecation, and after touching animals. The descriptive findings indicate that Suchana intervention improved handwashing knowledge and practices in the intervention area compared with the control. The odds of having knowledge of hand washing before preparing food (adjusted odds ratio [aOR]: 1.60; 95% CI: 1.30-1.98), before eating food and feeding children (aOR: 1.68; 95% CI: 1.25-2.25), before serving food (aOR: 1.35; 95% CI: 1.04-1.76), after defecation (aOR: 1.74; 95% CI: 1.25-2.41), and after touching animals (aOR: 1.67; 95% CI: 1.29-2.16) were higher in intervention area than the control area. Similarly, the impact on maternal handwashing practices at final evaluation indicated successful effects of the intervention. These results suggest scaling-up of similar interventions for larger populations living in vulnerable areas of rural Bangladesh.

The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) mobile health program promotes water, sanitation, and hygiene (WASH) behaviors through interactive voice response (IVR), voice, and text messages to reduce diarrheal diseases in Bangladesh. The objective of this study was to investigate the relationship between responses to CHoBI7 WASH IVR quiz messages and subsequent diarrhea and WASH behaviors. Fourteen CHoBI7 IVR quiz messages on handwashing with soap and treatment of stored water were sent to 517 households with 1,777 participants during the 12-month program period. IVR message responses were classified as correct answer, incorrect answer, no response (did not press 1 or 2), and failed (did not answer the phone). Diarrhea prevalence was assessed through self-reported monthly clinical surveillance visits. Handwashing with soap was assessed by a 5-hour structured observation, and stored water quality was defined by Escherichia coli concentration. Households that responded correctly to a CHoBI7 IVR quiz message had significantly lower odds of diarrhea for all age groups (adults and children) at the subsequent visit 1 month later (odds ratio [OR], 0.73; 95% CI, 0.54-0.98), and significantly greater odds of handwashing with soap after stool-related events (OR, 2.48; 95% CI, 1.12-5.49) and E. coli levels < 100 colony forming units (CFU)/100 mL (World Health Organization high-risk cutoff) in the stored household water (OR, 2.04; 95% CI, 1.25-3.33) compared with households that did not answer CHoBI7 IVR quiz calls. Correct responses to CHoBI7 IVR quizzes were associated with decreased diarrhea prevalence and improved stored drinking water quality and handwashing with soap behaviors at the subsequent visits. These findings suggest engagement in the CHoBI7 mobile health (mHealth) program and awareness of diarrheal disease prevention can reduce diarrhea and facilitate changes in WASH behaviors.

This study aims to inform multisectoral development programs by exploring the extent to which social and behavior change (SBC) messages, environment, and household infrastructure are associated with knowledge and practice of handwashing behaviors. A cross-sectional survey of 2,708 households in the Maradi and Zinder districts of Niger was collected in April 2021. Household data were integrated with two local environmental measures: 1) water level at the nearest waterhole point, and 2) anomalous rainfall for the previous rainy season derived from climate hazards infrared precipitation with station rainfall (CHIRPS) data. Logistic regression models were constructed to explore how environment, household infrastructure, and exposure to SBC messages were associated with two hygiene-related outcomes: 1) observed water and soap available at household handwashing stations, a behavior, and 2) knowledge of critical moments for handwashing, a behavioral determinant. We find that in households near a water point with higher water depth, households were statistically significantly more likely (odds ratio [OR] = 1.25); (confidence interval [CI] = 1.12-1.49) to have water and soap observed at the handwashing station. Women in households near a water point with increased water depth (more water) were more likely to know three or more critical handwashing moments (OR = 1.07; CI = 1.03-1.11). Exposure to messages about the importance of handwashing was significantly associated with knowledge of critical handwashing moments and having water and soap observed at a handwashing station. Multisectoral programming should consider layering efforts so that development projects that increase access to water sources are complemented with SBC approaches focused on hygiene.

The objective of our study was to develop and test observational methods to evaluate COVID-19 preventive hygiene behaviors and physical distancing, and to evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An observational study was conducted of 4,736 individuals from April to October 2021 using 5-hour and rapid (10-minute) structured observations and spot checks to evaluate mask-wearing, handwashing, and physical-distancing behaviors, and the functionality of handwashing stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered mask wearing). Fully covered mask wearing was lowest inside schools (1%), universities (2%), religious establishments (22%), and health facility wards (28%). Overall physical distancing of more than 1-m inside indoor public spaces was 22%, and was lowest inside schools and religious establishments (7%). Thirty-nine percent of handwashing stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured observations (16% versus 15%). The odds of fully covered mask wearing was significantly greater with increased government enforcement of mask wearing in public spaces through fines (odds ratio, 2.72; 95% CI, 1.02-7.30). This study presents rigorous methods using structured observations to assess government mandates and programs on COVID-19 preventive hygiene behaviors in indoor public spaces in settings globally.

Acute respiratory infections are a leading cause of morbidity and mortality among young children globally. The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on respiratory illness among diarrhea patients and their household members in urban Dhaka, Bangladesh. A cluster-randomized controlled trial of the CHoBI7 mHealth program was conducted among diarrhea patient households in Dhaka, Bangladesh. Patients were randomized to three arms: standard recommendation on oral rehydration solution use, health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages for 12 months) (no home visits), and health facility delivery of CHoBI7 plus two home visits and mHealth. Respiratory symptoms were assessed during monthly clinical surveillance over the 12-month surveillance period. Respiratory illness was defined as rapid breathing, difficulty breathing, wheezing, or coughing. Two thousand six hundred twenty-six participants in 769 households were randomly allocated to three arms: 849 participants to the standard message arm, 886 to the mHealth with no home visits arm, and 891 to the mHealth with two home visits arm. Compared with the standard message arm, participants in the mHealth with no home visits arm (Prevalence Ratio [PR]: 0.89 [95% CI: 0.80, 0.98]), and the mHealth with two home visits arm (PR: 0.89 [95% CI: 0.81, 0.99]) had significantly lower respiratory illness prevalence over the 12-month program period. Our findings demonstrate that the CHoBI7 mHealth program is effective in reducing respiratory illness among diarrhea patient households.

Factors associated with nontyphoidal Salmonella (NTS) infection have not been well characterized to date. We aimed to compare the associated factors among children under age 5 years with NTS infection in sub-Saharan Africa and South Asia. Data from children having moderate-to-severe diarrhea (MSD) and asymptomatic children with NTS isolated from fecal specimens were extracted from the Global Enteric Multicenter Study (GEMS), conducted from December 2007 to March 2011. Compared with NTS-negative children, NTS-associated MSD cases in South Asia were associated with the presence of goat in the house (adjusted odds ratio [aOR]: 2.15; 95% confidence interval [CI]: 1.25-3.70) and handwashing after handling an animal (aOR: 2.26; 95% CI: 1.36-3.74). In sub-Saharan Africa, children with NTS associated MSD had a greater association with stunting (1.21 95% CI: 1.01-1.45), longer duration of diarrhea (aOR: 1.25 95% CI: 1.19-1.31); presence of cow in house (aOR: 1.54 95% CI: 1.09-2.16), handwashing after handling animal (aOR: 2.41 95% CI: 1.74-3.33). Drinking tube well water (aOR: 0.54 95% CI: 0.32-0.91), availability of toilet facility (aOR: 0.58 95% CI: 0.53-0.65), and handwashing before eating (aOR: 0.76 95% CI: 0.57-1.00) and after defecation (aOR: 0.80 95% CI: 0.69, 0.94) were found to be protective. The differentials between children of both regions having fecal NTS are distinct and underscore the need for policymaking for preventive and control strategies targeting stunted children.

Handwashing is key to preventing the transmission of various infectious diseases of which school-aged children are particularly susceptible. Traditional, information-messaging campaigns may increase handwashing awareness but have had limited success in promoting behavior change. Behavioral economics "nudges," which explicitly target the knowledge-behavior gap, is a promising alternative. We evaluate the impact of school-based nudges in the first fully powered cluster randomized controlled trial in the Philippines. Out of our sample of 132 eligible schools, we randomly assigned half to receive nudges, including contextual cues (painted footpath from toilet to handwashing station) and visible reminders (posters and eye sticker), and half to the control group. Four months after implementation, we measured handwashing with soap (HWWS) after toilet use among grades 1-6 students using direct observation and compared this outcome between treatment and control schools. We also assessed whether nudges increased soap availability. The intervention increased HWWS rates by 17.3% points (pp), [95% CI: 4.2, 30.4] in treatment schools from the control group mean of 11.7%. The effect size was comparable across gender and age groups. Access to functioning handwashing facilities with soap increased by 36% (+20.2 pp, 95% CI: 10.9, 29.4). Mediation analysis suggests the program simultaneously nudged students to wash hands with soap in classrooms that already had soap, and nudged teachers to provide soap where it was not already available. These findings demonstrate that behavioral nudges costing less than $70 per school can lead to significant increases in HWWS among students 4 months post-intervention.

Safe water supply, sanitation, and hygiene (WaSH) are among key components to prevent and control waterborne diseases such as cholera, schistosomiasis, and other gastrointestinal morbidities in the community. In 2018, there was cholera outbreak in Ngorongoro district that was fueled by inadequate and unsafe water as well as poor sanitation and hygiene. We used an analytical cross-sectional study first to determine the proportion of households with access to WaSH and second to assess factors associated with coverage of household's access to WaSH. Methods included interviewing heads of the household to assess the availability of safe drinking water, use of unshared toilet/latrine by household members only, and the availability of functional handwashing facility. Eight percent of households had access to WaSH. Access to household's WaSH was positively associated with household's monthly income, education of heads of the household, and water use per person per week. To control water-related morbidities, there is a need to improve access to reliable safe drinking water, expand alternatives of households to earn more incomes, and enhance proper sanitation and hygiene services to rural areas and marginalized groups like the Maasai of Ngorongoro in Tanzania.

Water, sanitation, and handwashing interventions that use intensive interpersonal communication improve targeted behaviors, but are expensive at scale. Mass media is an alternative that could reach more people at lower cost but has rarely been rigorously evaluated. We assessed the effectiveness of a mass media campaign in improving handwashing knowledge and practices in rural Bangladesh. We conducted a cross-sectional assessment before the campaign among 8,947 households and again after 4 months of the campaign among 8,400 different households in the same areas. Trained enumerators conducted spot checks of water, sanitation, and hygiene facilities, and recorded reported knowledge and practices. We compared these outcomes after versus before the campaign using generalized linear models with robust standard errors. After the media campaign, caregivers were more likely to recall ≥ 3 messages regarding handwashing (prevalence ratio [PR] = 1.44, 1.34-1.55), sanitation (PR = 1.45, 1.35-1.55), and safe water (PR = 1.17, 1.08-1.26). After the campaign, the prevalence of using soap and water during handwashing demonstrations was higher among caregivers (PR = 1.15, 1.12-1.19) and children (PR = 1.31, 1.22-1.41). Hands were more commonly observed to be visibly clean among caregivers (PR = 1.14, 1.07-1.20) and children (PR = 1.13, 1.05-1.21). Soap and water was more commonly observed in handwashing stations near latrines (PR = 1.12, 1.06-1.19) and in cooking/eating places (PR = 1.09, 1.01-1.18). Our findings indicate improved handwashing knowledge and behaviors following a mass media campaign. This promising approach can be deployed to improve water, sanitation, and hygiene practices at scale and should be evaluated in other contexts.

In countries without adequate access to improved sanitation, government-imposed restrictions during the COVID-19 pandemic can impact toilet usage. In India, where millions have recently transitioned to using a toilet, pandemic-related barriers to use might increase open defecation practices. We assessed changes in reported defecation practices in peri-urban communities in Tamil Nadu. Field assistants conducted phone surveys in 26 communities in two districts from May 20, 2020 to May 25, 2020. They asked respondents about their access to a toilet, whether they or a family member left their house to defecate in the past week, and whether specific practices had changed since the lockdown. Among 2,044 respondents, 60% had access to a private toilet, 11% to a public or community toilet, whereas 29% lacked access to any toilet facility. In our study, 92% of the respondents did not change their defecation behaviors in the 2 months following the pandemic-related lockdown. About a third (27%) reported that they or a family member left their house daily to defecate amid lockdown measures. A majority of those with private toilets (91%) or with public toilets (69%) continued using them. Respondents with private toilet access were more likely to report an increased frequency of handwashing with soap (prevalence ratio [PR]: 1.78, 95% CI: 1.04-3.05) since the lockdown. The lack of private toilets contributes to the need to leave the house amid a lockdown. Maintaining shared toilets require disinfection protocols and behavioral precautions to limit the risk of fomite transmission. Robust urban COVID-19 control strategies should include enhanced sanitation facility management and safe usage messaging.

Observational data suggest maternal handwashing with soap prevents neonatal mortality. We tested the impact of a chlorhexidine-based waterless hand cleansing promotion on the behavior of mothers and other household members. In rural Bangladesh in 2014, we randomized consenting pregnant women to chlorhexidine provision and hand cleansing promotion or standard practices. We compared hand cleansing with chlorhexidine or handwashing with soap before baby care, among mothers and household members in the two groups, and measured chlorhexidine use in the intervention arm. Chlorhexidine was observed in the baby's sleep space in 97% of 130 intervention homes, versus soap in 59% of 128 control homes. Hand cleansing before baby care was observed 5.6 times more frequently among mothers in the intervention arm than in the controls (95% CI = 4.0-7.7). Hand cleansing was significantly more frequently observed in the intervention arm among women other than the mother (RR = 10.9) and girls (RR = 37.0). Men and boys in the intervention arm cleansed hands before 29% and 44% of baby care events, respectively, compared with 0% in the control arm. The median number of grams consumed during the neonatal period was 176 (IQR = 95-305 g), about 7.8 g/day (IQR = 4.2-13.8 g). Promotion of waterless chlorhexidine increased hand cleansing behavior among mothers and other household members. Discrepancy between observed use and measured chlorhexidine consumption suggested courtesy bias in structured observations. A waterless hand cleanser may represent one component of the multimodal strategies to prevent neonatal infections in low-resource settings.

Formative research findings from the fast-growing Babati town were used to assess the prevalence of sanitation and hygiene practices among individuals and institutions and associated factors. A cross-sectional study involving household surveys, spot-checks, focus group discussions, in-depth interviews, and structured observations of behaviors showed that 90% of households have sanitation facilities, but 68% have safely managed sanitation services. The most common types of household sanitation facilities were pit latrines with slab (42%) followed by flush/pour flush toilets (32%). Therefore, the management of wastewater depends entirely on onsite sanitation systems. The majority of households (70%) do not practice proper hygiene behaviors. Thirteen percent of the households had handwashing stations with soap and water, handwashing practice being more common to women (38%) than men (18%). The reported handwashing practices during the four critical moments (handwashing with soap before eating and feeding, after defecation, after cleaning child's bottom, and after touching any dirt/dust) differed from the actual/observed practices. Households connected to the town's piped water supply were more likely to practice handwashing than those not directly connected. Sanitation and hygiene behaviors of the people in the study area were seen to be influenced by sociodemographic, cultural, and economic factors. The conditions of sanitation and hygiene facilities in public places were unsatisfactory. There is an urgent need to ensure that the sanitation and hygiene services and behaviors along the value chain (from waste production/source to disposal/end point) are improved both at the household level and in public places through improved sanitation services and the promotion of effective hygiene behavior change programs integrated into ongoing government programs and planning.

The COVID-19 pandemic represents a major public health, economic, political, and scientific concern in most countries around the globe where COVID-19 cases and deaths have been confirmed. This study assessed the attitudes, anxiety, and behavioral practices of university students in Jordan regarding COVID-19 during the early period of the infection (March 19-21, 2020) using a validated, self-administered survey questionnaire. Positive attitudes or low-risk practices were given 1 point, whereas negative attitudes or high-risk practices were scored 0. Percentages of the total score were used for categorizing data into negative attitudes or high-risk practices (≤ 60%), moderate attitudes or moderate-risk practices (60.01-80%), and positive attitudes or low-risk practices (> 80%). Generally, the university students displayed positive attitudes and low-risk practices toward preventing COVID-19, with an average score of 81.1% and 84.3%, respectively. Approximately two-thirds (69.1%) of the students showed a positive attitude toward COVID-19 seriousness, concern of contracting the virus, and the appropriate prevention measures, and low-risk practices (67.6%) toward preventing COVID-19 including implementation of social distancing and good hygiene. Female, older, medical, or postgraduate students practiced significantly more ( P ≤ 0.05) appropriate hygiene and social distancing behaviors toward COVID-19 than their counterparts of each group. More than two-thirds (69.2%) of the students were anxious that they might become infected with COVID-19. These results are important for health authorities to develop appropriate educational programs and protective health measures including good respiratory etiquette and handwashing practices, to enhance safer lifestyles and prevent COVID-19 transmission.

Typhoid fever transmission occurs through ingestion of food or water contaminated with Salmonella Typhi, and case-control studies are often conducted to identify outbreak sources and transmission vehicles. However, there is no current summary of the associations among water, sanitation, and hygiene (WASH); and food exposures and typhoid from case-control studies. We conducted a systematic review and meta-analysis of case-control studies to evaluate the associations among typhoid fever and predicted WASH or food exposure risk factors (13), and protective factors (7). Overall, 19 manuscripts describing 22 case-control studies were included. Two studies were characterized as having low risk of bias, one as medium risk, and 19 as high risk. In total, nine of 13 predicted risk factors were associated with increased odds of typhoid (odds ratio [OR] = 1.4-2.4, I 2 = 30.5-74.8%.), whereas five of seven predicted protective factors were associated with lower odds of typhoid (OR = 0.52-0.73, I 2 = 38.7-84.3%). In five types of sensitivity analyses, two (8%) of 26 summary associations changed significance from the original analysis. Results highlight the following: the importance of household hygiene transmission pathways, the need for further research around appropriate food interventions and the risk of consuming specific foods and beverages outside the home, and the absence of any observed association between sanitation exposures and typhoid fever. We recommend that typhoid interventions focus on interrupting household transmission routes and that future studies provide more detailed information about WASH and food exposures to inform better targeted interventions.

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.

The study evaluated the effectiveness of an intervention to improve complementary food hygiene behaviors among child caregivers in rural Malawi. Formative research and intervention development was grounded in the risk, attitude, norms, ability, and self-regulation (RANAS) model and targeted washing hands and kitchen utensils with soap, safe utensil storage, reheating of leftover food, and feeding of children by caregivers. Longitudinal research was applied at baseline and follow-up surveys among 320 caregivers. Determinants of selected behaviors were found, and interventions were developed based on the behavior change techniques aligned with these determinants in the RANAS model. The intervention was delivered over 9 months through group (cluster) meetings and household visits and included demonstrations, games, rewards, and songs. We randomly assigned villages to the control or intervention group. Follow-up results indicated a significant increase in three targeted behaviors (washing kitchen utensils with soap, safe utensil storage, and handwashing with soap) among intervention recipients. Several psychosocial factors differed significantly between the intervention and control groups. Mediation results showed that the intervention had a significant effect on these three targeted behaviors. For handwashing, feelings, others' behavior in the household, and remembering; for washing kitchen utensils, others' behavior in the household and difficulty to get enough soap; for safe utensils storage, others' behavior in the village and remembering mediated the effect of the intervention on the targeted behaviors. The study demonstrated that targeting food hygiene behaviors with a theory-driven behavior change approach using psychosocial factors can improve the behavior of child caregivers in rural Malawi.

Schoolchildren are commonly linked to influenza transmission. Handwashing with soap has been shown to decrease infections; however, improving handwashing practices using soap and water is difficult in low-resource settings. In these settings, alternative hygiene options, such as hand sanitizer, could improve handwashing promotion to reduce influenza virus infections. We conducted a cluster randomized control trial in 24 primary schools in Dhaka to assess the effectiveness of hand sanitizer and a respiratory hygiene education intervention in reducing influenza-like illness (ILI) and laboratory-confirmed influenza during June-September 2015. Twelve schools were randomly selected to receive hand sanitizer and respiratory hygiene education, and 12 schools received no intervention. Field staff actively followed children daily to monitor for new ILI episodes (cough with fever) through school visits and by phone if a child was absent. When an illness episode was identified, medical technologists collected nasal swabs to test for influenza viruses. During the 10-week follow-up period, the incidence of ILI per 1,000 student-weeks was 22 in the intervention group versus 27 in the control group ( P -value = 0.4). The incidence of laboratory-confirmed influenza was 53% lower in the intervention schools (3/1,000 person-weeks) than in the control schools (6/1,000 person-weeks) ( P -value = 0.01). Hand sanitizer and respiratory hygiene education can help to reduce the risk of influenza virus transmission in schools.

Trachoma is the leading infectious cause of blindness, and facial cleanliness is associated with reduced odds of trachomatous inflammation and Chlamydia trachomatis infection, but there is little evidence of how to drive this behavior change at scale. We report the results of a program integrating face washing into a school-based handwashing promotion program in Turkana County, Kenya. Children aged 5-15 years participated in an intervention delivered to schools in two phases, along with a third phase receiving the intervention after the evaluation, which served as a control. The primary outcome was the number of face washing events that took place when handwashing occurred, which was measured by a 3-hour structured observation at all 67 schools, and a total of 3,871 handwashing events were observed. Differences in observed in face washing behavior between each phase and the control schools were calculated using log-binomial regression with clustering at the school level, whereas survey responses on knowledge of trachoma transmission and prevention were compared using χ 2 tests adjusted for clustering at the school level. Face washing during handwashing events was higher in schools after 12 months (59.3%) and 20 months (44.2%) than in control schools (18.7%, P < 0.001). Trachoma knowledge was higher in schools evaluated after 12 months (80%) and 20 months (70%) than in control schools (42%, P < 0.001), and knowledge of some of key preventive behaviors was higher in intervention schools. Integrating face washing messages into school-based handwashing promotion programs increased face washing, which may help to prevent trachoma when combined with other interventions.

Despite being preventable, foodborne diseases remain a global health challenge. Poor food hygiene practices such as improper handling of kitchen utensils are among the major causes of diarrhea transmission. A formative study was conducted in Malawi to inform an intervention design to promote complementary food hygiene practices. An assessment of contextual and psychosocial factors for behavior change was conducted using Risk, Attitude, Norms, Ability, and Self-regulation model. We conducted 323 household surveys with caregivers of children aged 6 to 24 months. Analysis of variance was used to estimate difference between doers and non-doers of three targeted behaviors: washing utensils with soap, keeping utensils on a raised place, and handwashing with soap. Analysis of variance analyses revealed that literacy level, ownership of animals, and presence of handwashing facility and dish racks were contextual factors predicting storage of utensils on an elevated place and handwashing frequencies. Psychosocial factors, such as time spent to wash utensils with soap, distance to the handwashing facility, and cost for soap, had an influence on washing utensils and handwashing practices. Perceived vulnerability determined effective handwashing and storage of utensils. Perceived social norms and ability estimates were favorable for the three targeted behaviors. Promotion of already existing targeted beneficial behaviors should be encouraged among caregivers. Risk perceptions on storage of utensils and handwashing practices should be increased with motivational exercises such as paint games. Caregivers' technical know-how of local dish rack and tippy tap construction is essential.

To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interventions did not reduce diarrhea-associated hospitalization for children aged ≤ 5 years in this trial. We randomly allocated 90 geographic clusters comprising > 60,000 low-income households into three groups: cholera vaccine only, vaccine plus behavior change (cholera vaccine and handwashing plus drinking water chlorination promotion), and control. We calculated reported diarrhea prevalence within the last 2 days using data collected from two different survey methods. The "census" data were collected from each household every 6 months for updating household demographic information. The "monthly survey" data were collected every month from a subset of randomly selected study households for monitoring the uptake of behavior change interventions. We used binomial regression with a logarithmic link accounting for clustering to compare diarrhea prevalence across intervention and control groups separately for both census and monthly survey data. No intervention impact was detected in the census (vaccine only versus control: 2.32% versus 2.53%; P = 0.49; vaccine plus behavior change versus control: 2.44% versus 2.53%; P = 0.78) or in the vaccine only versus control in the monthly survey (3.39% versus 3.80%; P = 0.69). However, diarrhea prevalence was lower in the vaccine-plus-behavior-change group than control in the monthly survey (2.08% versus 3.80%; P = 0.02). Although the reasons for different observed treatment effects in the census and monthly survey data in this study are unclear, these findings emphasize the importance of assessing objective outcomes along with reported outcomes from non-blinded trials.

Handwashing with soap reduces the transmission of diarrheal pathogens, but access to hand-washing facilities, water, and soap in humanitarian emergencies is limited. The SuperTowel ® (ST) is a fabric treated with permanent antimicrobial bonding and has been designed as a soap alternative in emergency situations. The aim of this study was to test the efficacy of the ST as a hand-cleaning product. Two sets of laboratory tests, with 16 volunteers in each, were conducted to test the efficacy of different prototypes of the ST. Volunteers pre-contaminated their hands with nonpathogenic Escherichia coli . Comparisons were made between hand cleaning with the ST and handwashing with the reference soap, using a crossover design. Participants also completed a questionnaire about product perceptions. Three of the prototypes of the ST were more efficacious at removing E. coli from pre-contaminated hands than handwashing with soap (mean log 10 reduction of 4.11 ± 0.47 for ST1, 3.84 ± 0.61 for ST2, and 3.71 ± 0.67 for ST3 versus 3.01 ± 0.63 for soap [ P < 0.001, P = 0.002, and P = 0.005, respectively]). The ST prototypes used less water than handwashing with soap, were well accepted, and were considered preferable in communal settings. The ST has the potential to be a suitable complementary hand-cleaning product for humanitarian emergencies.

Provision of basic water, sanitation, and hygiene (WASH) services in health-care facilities is gaining increased attention, given growing acceptance of its importance to the maternal and newborn quality of care agenda and the universal health coverage framework. Adopting and contextualizing an emerging World Health Organization/United Nations Children's Fund Joint Program Monitoring service ladder approach to national data collected in 2010/2011, we estimated the national coverage of primary health centers (PHCs) ( N = 8,831), auxiliary PHCs ( N = 22,853), village health posts ( N = 28,692), and village maternity clinics ( N = 14,396) with basic WASH services in Indonesia as part of a Sustainable Development Goal baseline assessment. One quarter of PHCs did not have access to a combination of basic water and sanitation (WatSan) services (23.6%) with significant regional variation (10.6-59.8%), whereas more than two-third of PHCs (72.0%) lacked handwashing facility with soap in all three locations (general consulting room, immunization room, and delivery room). More than a half of the three lower health service level facility types lacked basic WatSan services. National health facility monitoring systems need to be urgently strengthened for tracking the progress and addressing gaps in basic WASH services in health facilities in Indonesia.

Case-control studies are conducted to identify cholera transmission routes. Water, sanitation, and hygiene (WASH) exposures can facilitate cholera transmission (risk factors) or interrupt transmission (protective factors). To our knowledge, the association between WASH exposures and cholera from case-control studies has not been systematically analyzed. A systematic review was completed to close this gap, including describing the theory of risk and protection, developing inclusion criteria, searching and selecting studies, assessing quality of evidence, and summarizing associations between cholera and seven predicted WASH protective factors and eight predicted WASH risk factors using meta-analysis and sensitivity analysis. Overall, 47 articles describing 51 individual studies from 30 countries met the inclusion criteria. All eight predicted risk factors were associated with higher odds of cholera (odds ratio [OR] = 1.9-5.6), with heterogeneity ( I 2 ) of 0-92%. Of the predicted protective factors, five of seven were associated with lower odds of cholera (OR = 0.35-1.4), with heterogeneity of 57-91%; exceptions were insignificant associations for improved water source (OR = 1.1, heterogeneity 91%) and improved sanitation (OR = 1.4, heterogeneity 68%). Results were robust; 3/70 (5%) associations changed directionality or significance in sensitivity analysis. Meta-analysis results highlight that predicted risk factors are associated with cholera; however, predicted protective factors are not as consistently protective. This variable protection is attributed to 1) cholera transmission via multiple routes and 2) WASH intervention implementation quality variation. Water, sanitation, and hygiene interventions should address multiple transmission routes and be well implemented, according to international guidance, to ensure that field effectiveness matches theoretical efficacy. In addition, future case-control studies should detail WASH characteristics to contextualize results.

Integrating public health interventions with antenatal clinic (ANC) visits may motivate women to attend ANC, thereby improving maternal and neonatal health, particularly for human immunodeficiency virus (HIV)-infected persons. In 2009, in an integrated ANC/Preventing Mother-to-Child Transmission program, we provided free hygiene kits (safe storage containers, WaterGuard water treatment solution, soap, and oral rehydration salts) to women at their first ANC visit and refills at subsequent visits. To increase fathers' participation, we required partners' presence for women to receive hygiene kits. We surveyed pregnant women at baseline and at 12-month follow-up to assess ANC service utilization, HIV counseling and testing (HCT), test drinking water for residual chlorine, and observe handwashing. We conducted in-depth interviews with pregnant women, partners, and health workers. We enrolled 106 participants; 97 (92%) were found at follow-up. During the program, 99% of pregnant women and their partners received HCT, and 99% mutually disclosed. Fifty-six percent of respondents had ≥ 4 ANC visits and 90% delivered at health facilities. From baseline to follow-up, the percentage of women who knew how to use WaterGuard (23% versus 80%, P < 0.0001), had residual chlorine in stored water (0% versus 73%, P < 0.0001), had confirmed WaterGuard use (0% versus 70%, P < 0.0003), and demonstrated proper handwashing technique (21% versus 64% P < 0.0001) increased. Program participants showed significant improvements in water treatment and hygiene, and high use of ANC services and HCT. This evaluation suggests that integration of hygiene kits, refills, and HIV testing during ANC is feasible and may help improve household hygiene and increase use of health services.

Undernourished children in low-income contexts often suffer from environmental enteric disorder-damage to the intestines probably caused by chronic exposure to bacterial pathogens from feces. We aimed to identify strategies for reducing infants and young children's (IYC) exposure to human and animal feces in rural farming families by conducting direct observation of 30 caregiver-infant dyads for 143 hours and recording water, sanitation, and hygiene (WASH)-related behaviors to identify possible pathways of fecal-oral transmission of bacteria among IYC in rural Zambia. In addition to mouthing visibly dirty hands, toys, sibling's body parts, and food, 14 IYC actively ingested 6.1 ± 2.5 (mean ± standard deviation [SD]) pieces of soil and stones and one ingested animal feces 6.0 ± 0 times in the span of 5 hours. Ninety-three percent (21 of 30) of mothers reported observing the index-child eating soil and 17% (5 of 30) of mothers reported observing the index-child eating chicken feces. Adult and child handwashing was uncommon, and even though 70% (28 of 30) of households had access to a latrine, human feces were found in 67% of homestead yards. Most animals present in the household were un-corralled, and the highest observable counts of feces came from chickens, pigs, and cattle. To protect IYC in low-income communities from the exploratory ingestion of feces and soil, Baby WASH interventions will need to interrupt fecal-oral microbial transmission vectors specific to IYC with a focus on feasibility, caregiver practices, and local perceptions of risk.

In 2009, a common set of questions addressing handwashing behavior was introduced into nationally representative Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), providing large amounts of comparable data from numerous countries worldwide. The objective of this analysis is to describe global handwashing patterns using two proxy indicators for handwashing behavior from 51 DHS and MICS surveys conducted in 2010-2013: availability of soap anywhere in the dwelling and access to a handwashing place with soap and water. Data were also examined across geographic regions, wealth quintiles, and rural versus urban settings. We found large disparities for both indicators across regions, and even among countries within the same World Health Organization region. Within countries, households in lower wealth quintiles and in rural areas were less likely to have soap anywhere in the dwelling and at designated handwashing locations than households in higher wealth quintiles and urban areas. In addition, disparities existed among various geographic regions within countries. This analysis demonstrates the need to promote access to handwashing materials and placement at handwashing locations in the dwelling, particularly in poorer, rural areas where children are more vulnerable to handwashing-preventable syndromes such as pneumonia and diarrhea.

AbstractIn this study, we report on the results of a trial of an intervention to improve five food hygiene behaviors among mothers of young children in rural Nepal. This novel intervention targeted five behaviors; cleanliness of serving utensils, handwashing with soap before feeding, proper storage of cooked food, and thorough reheating and water treatment. Based on formative research and a creative process using the Behavior-Centered Design approach, an innovative intervention package was designed and delivered over a period of 3 months. The intervention activities included local rallies, games, rewards, storytelling, drama, competitions linking with emotional drivers of behavior, and "kitchen makeovers" to disrupt behavior settings. The effect of the package on behavior was evaluated via a cluster-randomized before-after study in four villages with four villages serving as controls. The primary outcome was the difference in the mean cluster level proportions of mothers directly observed practicing all five food hygiene behaviors. The five targeted food hygiene behaviors were rare at baseline (composite performance of all five behaviors in intervention 1% [standard deviation (SD) = 2%] and in control groups 2% [SD = 2%]). Six weeks after the intervention, the target behaviors were more common in the intervention than in the control group (43% [SD = 14%] versus 2% [SD = 2%], P = 0.02) during follow-up. The intervention appeared to be equally effective in improving all five behaviors in all intervention clusters. This study shows that a theory-driven, systematic approach employing emotional motivators and modifying behavior settings was capable of substantially improving multiple food hygiene behaviors in Nepal.

AbstractUrban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains ("poor FSM"). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.

AbstractHousehold contacts of cholera patients are at a 100 times higher risk of a Vibrio cholerae infection than the general population. To examine risk factors for V. cholerae infections and investigate intervention strategies among this population, we followed household contacts of cholera patients for the 1-week high-risk period after the index patient obtained care. This study was nested within a randomized controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7), a handwashing with soap and water treatment intervention in Dhaka, Bangladesh. Rectal swab results were available from 320 household contacts of cholera patients at five time points over a 1-week period. Fecal and water samples were analyzed for V. cholerae by bacterial culture. All analyses were stratified by study arm. Within the intervention arm, stored household drinking water with a median free chlorine concentration below 0.5 mg/L was associated with a three times higher odds of a cholera infection (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.32, 6.63). In the control arm, having V. cholerae in stored water was associated with a significantly higher odds of a symptomatic cholera infection (OR: 8.66; 95% CI: 2.11, 35.48). No association was found between observed handwashing with soap at food and stool-related events and V. cholerae infections. Stored household drinking water with detectable V. cholerae and chlorine concentrations below the World Health Organization guideline were found to be important risk factors for cholera infection among household contacts of cholera patients. These findings emphasize the need for water treatment interventions targeting this high risk population.

The association between heavy rainfall and an increased risk of diarrhea has been well established but less is known about the effect of drought on diarrhea transmission. In 2011, the Pacific island nation of Tuvalu experienced a concurrent severe La Niña-associated drought and large diarrhea outbreak. We conducted a field investigation in Tuvalu to identify factors that contributed to epidemic transmission in the context of a drought emergency. Peak case numbers coincided with the nadir of recorded monthly rainfall, the lowest recorded since 1930. Independent factors associated with increased risk of diarrhea were households with water tank levels below 20% (odds ratio [OR] = 2.31; 95% confidence interval = 1.16-4.60) and decreased handwashing frequency (OR = 3.00 [1.48-6.08]). The resolution of the outbreak occurred after implementation of a hygiene promotion campaign, despite persistent drought and limited water access. These findings are potentially important given projections that future climate change will cause more frequent and severe droughts.

Previous studies have demonstrated that household contacts of cholera patients are highly susceptible to cholera infections for a 7-day period after the presentation of the index patient in the hospital. However, there is no standard of care to prevent cholera transmission in this high-risk population. Furthermore, there is limited information available on awareness of cholera transmission and prevention among cholera patients and their household contacts. To initiate a standard of care for this high-risk population, we developed the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7), which delivers a handwashing with soap and water treatment intervention to household contacts during the time they spend with the admitted cholera patient in the hospital and reinforces these messages through home visits. To test CHoBI7, we conducted a randomized controlled trial among 302 intervention cholera patient household members and 302 control cholera patient household members in Dhaka, Bangladesh. In this study, we evaluated the effectiveness of the CHoBI7 intervention in increasing awareness of cholera transmission and prevention, and the key times for handwashing with soap. We observed a significant increase in cholera knowledge score in the intervention arm compared with the control arm at both the 1-week follow-up {score coefficient = 2.34 (95% confidence interval [CI] = 1.96, 2.71)} and 6 to 12-month follow-up period (score coefficient = 1.59 [95% CI = 1.05, 2.13]). This 1-week hospital- and home-based intervention led to a significant increase in knowledge of cholera transmission and prevention which was sustained 6 to 12 months post-intervention. These findings suggest that the CHoBI7 intervention presents a promising approach to increase cholera awareness among this high-risk population., (© The American Society of Tropical Medicine and Hygiene.)

Household members of cholera patients are at a 100 times higher risk of cholera than the general population. Despite this risk, there are only a handful of studies that have investigated the handwashing practices among hospitalized diarrhea patients and their accompanying household members. To investigate handwashing practices in a hospital setting among this high-risk population, 444 hours of structured observation was conducted in a hospital in Dhaka, Bangladesh, among 148 cholera patients and their household members. Handwashing with soap practices were observed at the following key events: after toileting, after cleaning the anus of a child, after removing child feces, during food preparation, before eating, and before feeding. Spot-checks were also conducted to observe the presence of soap at bathroom areas. Overall, 4% (4/103) of key events involved handwashing with soap among cholera patients and household members during the structured observation period. This was 3% (1/37) among cholera patients and 5% (3/66) for household members. For toileting events, observed handwashing with soap was 7% (3/46) overall, 7% (1/14) for cholera patients, and 6% (2/32) for household members. For food-related events, overall observed handwashing with soap was 2% (2/93 overall), and 0% (0/34) and 3% (2/59) for cholera patients and household members, respectively. Soap was observed at only 7% (4/55) of handwashing stations used by patients and household members during spot-checks. Observed handwashing with soap at key times among patients and accompanying household members was very low. These findings highlight the urgent need for interventions to target this high-risk population., (© The American Society of Tropical Medicine and Hygiene.)

Even though washing hands with soap is among the most effective measures to reduce the risk of infection, handwashing rates in infrastructure-restricted settings remain seriously low. Little is known about how context alone and in interaction with psychosocial factors influence hand hygiene behavior. The aim of this article was to explore how both contextual and psychosocial factors affect handwashing practices. A cross-sectional survey was conducted with 660 caregivers of primary school children in rural Burundi. Hierarchical regression analyses revealed that household wealth, the amount of water per person, and having a designated place for washing hands were contextual factors significantly predicting handwashing frequency, whereas the contextual factors, time spent collecting water and amount of money spent on soap, were not significant predictors. The contextual factors explained about 13% of the variance of reported handwashing frequency. The addition of the psychosocial factors to the regression model resulted in a significant 41% increase of explained variation in handwashing frequency. In this final model, the amount of water was the only contextual factor that remained a significant predictor. The most important predictors were a belief of self-efficacy, planning how, when, and where to wash hands, and always remembering to do so. The findings suggest that contextual constraints might be perceived rather than actual barriers and highlight the role of psychosocial factors in understanding hygiene behaviors., (© The American Society of Tropical Medicine and Hygiene.)

To assess the health impact of reusable, antimicrobial hand towels, we conducted a cluster randomized, yearlong field trial. At baseline, we surveyed mothers, and gave four towels plus hygiene education to intervention households and education alone to controls. At biweekly home visits, we asked about infections in children < 2 years old and tested post-handwashing hand rinse samples of 20% of mothers for Escherichia coli. At study's conclusion, we tested 50% of towels for E. coli. Baseline characteristics between 188 intervention and 181 control households were similar. Intervention and control children had similar rates of diarrhea (1.47 versus 1.48, P = 0.99), respiratory infections (1.38 versus 1.48, P = 0.92), skin infections (1.76 versus 1.79, P = 0.81), and subjective fever (2.62 versus 3.40, P = 0.04) per 100 person-visits. Post-handwashing hand contamination was similar; 67% of towels exhibited E. coli contamination. Antimicrobial hand towels became contaminated over time, did not improve hand hygiene, or prevent diarrhea, respiratory infections, or skin infections., (© The American Society of Tropical Medicine and Hygiene.)

Diarrhea is the second leading cause of death in children under 5 years of age globally. The time patients and caregivers spend at a health facility for severe diarrhea presents the opportunity to deliver water, sanitation, and hygiene (WASH) interventions. We recently developed Cholera-Hospital-Based Intervention for 7 days (CHoBI7), a 1-week hospital-based handwashing with soap and water treatment intervention, for household members of cholera patients. To investigate if this intervention could lead to sustained WASH practices, we conducted a follow-up evaluation of 196 intervention household members and 205 control household members enrolled in a randomized controlled trial of the CHoBI7 intervention 6 to 12 months post-intervention. Compared with the control arm, the intervention arm had four times higher odds of household members' handwashing with soap at a key time during 5-hour structured observation (odds ratio [OR]: 4.71, 95% confidence interval [CI]: 2.61, 8.49) (18% versus 50%) and a 41% reduction in households in the World Health Organization very high-risk category for stored drinking water (OR: 0.38, 95% CI: 0.15, 0.96) (58% versus 34%) 6 to 12 months post-intervention. Furthemore, 71% of observed handwashing with soap events in the intervention arm involved the preparation and use of soapy water, which was promoted during the intervention, compared to 9% of control households. These findings demonstrate that the hospital-based CHoBI7 intervention can lead to significant increases in handwashing with soap practices and improved stored drinking water quality 6 to 12 months post-intervention., (© The American Society of Tropical Medicine and Hygiene.)

Safe water storage and hand hygiene have been shown to reduce fecal contamination and improve health in experimental settings; however, triggering and sustaining such behaviors is challenging. This study investigates the extent to which personalized information about Escherichia coli contamination of stored water and hands influenced knowledge, reported behaviors, and subsequent contamination levels among 334 households with less than 5-year-old children in peri-urban Dar es Salaam, Tanzania. One-quarter of the study participants received information about strategies to reduce risk of water- and sanitation-related illness. Respondents in another three study cohorts received this same information, along with their household's water and/or hand-rinse test results. Findings from this study suggest that additional work is needed to elucidate the conditions under which such testing represents a cost-effective strategy to motivate improved household water management and hand hygiene.

In an earlier study in Karachi, Pakistan, households that received free soap and handwashing promotion for 9 months reported 53% less diarrhea than controls. Eighteen months after the intervention ended, these households were enrolled in a follow-up study to assess sustainability of handwashing behavior. Upon re-enrollment, mothers in households originally assigned to the intervention were 1.5 times more likely to have a place with soap and water to wash hands (79% versus 53%, P = 0.001) and when asked to wash hands were 2.2 times more likely to rub their hands together at least three times (50% versus 23%, P = 0.002) compared with controls. In the ensuing 14 months, former intervention households reported a similar proportion of person-days with diarrhea (1.59% versus 1.88%, P = 0.66) as controls. Although intervention households showed better handwashing technique after 2 years without intervention, their soap purchases and diarrhea experience was not significantly different from controls.

A cholera outbreak occurred in Lusaka city between November 28, 2003 and June 8, 2004, and 6,542 cases with 187 deaths (case fatality rata: 2.86) were reported. We analyzed the distribution of cholera cases, the mode of cholera transmission, and the risk factors affecting cholera infection in a peri-urban area of Lusaka by using a Geographic Information System (GIS) and a matched case-control method. Chloropleth mapping of the incidences of cholera showed variation of the incidences in the study area. Our analysis indicated a significant association between the lack of latrine and drainage systems surrounding houses and high incidence of cholera. The matched case-control study showed the protective role of chlorination of drinking water and of hand washing with soap for cholera prevention. We concluded that cholera occurred because of personal behavior and the environment conditions of daily life.

To prevent diarrhea in rural Western Kenya, we implemented the Safe Water System (water treatment with bleach, safe storage, and behavior-change communications) in 2000. We implemented a pilot project in a school in May 2003. Teachers taught students about safe water and hygiene. Safe water storage vessels were placed between classrooms. Two large water tanks for handwashing were positioned by the kitchen and latrines. The vessels were filled daily with water, which was treated with bleach and monitored for free chlorine residuals. Daily student care logs at the local clinic were reviewed. Clinic visits for diarrhea peaked during the January through March period in 2002 at 130 and in 2003 at 71, but in 2004, after project implementation, only 13 diarrhea episodes were recorded. The project saved the school about 5.49 dollars per student per year. The project has been expanded to 70 schools, and an evaluation is planned.

A case-control study was conducted to examine the relationship between severe acute respiratory syndrome (SARS) and the time-dependent precautionary behaviors taken during an outbreak of SARS in Hanoi French Hospital (HFH), Vietnam. Masks (odds ratio [OR] = 0.3; 95% confidence interval [CI]: 0.1, 0.7) and gowns (OR = 0.2; 95% CI: 0.0, 0.8) appeared to prevent SARS transmission. The proportion of doctors and nurses who undertook each measure significantly improved (chi(2) = 9.8551, P = 0.043) after the onset of secondary cases. The impact of individual behaviors on an outbreak was investigated through mathematical approaches. The reproduction number decreased from 4.1 to 0.7 after notification. The basic reproduction number was estimated, and the use of masks alone was shown to be insufficient in containing an epidemic. Intuitive results obtained by means of stochastic individual-based simulations showed that rapid improvements in behavior and isolation would increase the probability of extinction.

We introduced home drinking water disinfection and handwashing with soap in Karachi squatter settlements to evaluate their effect on diarrhea. In April 2000, 150 households received soap, 76 received dilute bleach and a water storage vessel, and 76 were enrolled as controls. In 2000, among households wealthy enough to own a refrigerator, children in households that received bleach and a vessel had a 73% lower incidence of diarrhea than controls; those that received soap had a 56% lower incidence. There was no reduction in diarrhea in intervention households without a refrigerator. In 2001, households that received bleach and a vessel had a 71% lower incidence of diarrhea and children in households that received soap had a 35% lower incidence than controls. In 2001, the interventions were equally effective in households that had a refrigerator and those that did not. Both of these home-based interventions were ultimately effective in preventing diarrhea, but only households of slightly higher socioeconomic status changed their behavior quickly enough to benefit during the first summer.