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Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Davies et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: This multicountry analysis aimed to assess the prevalence of key hygiene prevention behaviours and their determinants, associated with international non-governmental organisation (WaterAid) hygiene behaviour change programmes for COVID-19 prevention. The goal of this analysis is to inform future outbreak preparedness and pandemic response in low and middle-income countries., Design: Cross-sectional study., Setting: Households in seven countries where WaterAid implemented a first-phase COVID-19 response programme in 2020 (Ethiopia, Ghana, Nepal, Nigeria, Rwanda, Tanzania and Zambia)., Participants: 3033 adults (1469 men and 1564 women, alternately sampled from one household to the next to maintain gender balance) in specific programme areas (211 villages) surveyed between October and November 2020., Primary Outcome Measures: Self-reported primary outcomes were: a composite measure of HWWS for prevention of respiratory infection/COVID-19 (total of 5 key moments); respondent increased HWWS behaviour after the COVID-19 pandemic; respondent always wears a mask in public spaces; respondent always practices physical distancing in public spaces., Results: Most respondents (80%) reported increasing their handwashing behaviour after the pandemic, but practice of HWWS at COVID-19-specific prevention moments was low. Mask wearing (58%) and physical distancing (29%) varied substantially between countries. Determinants of key behaviours were identified, including age and socioeconomic status, perceived norms, self-regulation and the motive of protecting others. Incidence rate ratios or odds ratios and 95% CIs for a range of psychosocial determinants for each of the four primary outcomes are reported., Conclusions: These findings highlight that leveraging behaviour-specific emotional drivers and norms, reducing common barriers and promoting targeted messages about specific behaviours and actions individuals can take to reduce risk are necessary to support large-scale behaviour change. Learning from the COVID-19 response to more effectively integrate novel behaviours into existing health promotion will be vital for disease prevention and outbreak resilience., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Guardian Waiting Shelters (GWSs) are an essential component of the Malawi's health care system as they serve as a temporary home for patient guardians while taking care of their relatives admitted to the hospital, and expectant mothers. Although GWSs play a crucial role in Malawi's healthcare system, past studies have primarily concentrated on maternity waiting homes, neglecting the role and importance of GWSs. The study examines GWS management structures and conditions, as well as guardian satisfaction and perception of health risks related to GWS use. In this explanatory sequential mixed methods design, we assessed 12 GWSs from southern region of Malawi. Qualitative data included interviews (n = 149) and focus group discussions with patient guardians (n = 72), interviews with GWS caretakers (n = 5), representatives from Hospital Management (n = 12) and Hospital Advisory Committees (n = 11). Lack of guidelines and standards for GWSs resulted in creating a customized facility checklist to quantitatively assess infrastructure present at GWSs (n = 12). Descriptive statistics and qualitative thematic analysis were utilized for data analysis, and a problem tree analysis was used to triangulate and summarize the findings. A total of 249 participants participated in the study. Each GWS had an average of 100 users daily, primarily adult females (71%). No one was accountable for GWS operation and maintenance due to the lack of a management hierarchy. GWS infrastructure conditions were poor, with inadequate functional sleeping rooms, insufficient access to water, sanitation and hygiene facilities. Notably, 50% of the GWSs lacked water access, and a quarter had non-functional toilets. Guardians felt unsafe and at risk of disease transmission when staying within GWS. Study findings highlight lack of clear, consistent GWS ownership as a root cause of challenges in GWSs. Clear policy and operational standards must be established for effective management and smooth functioning of GWSs., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Panulo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Observational evidence suggests that household floors may be an important domain for the transmission of enteric and parasitic infections. However, little work has been done to investigate how household floors can become contaminated with human and animal faeces. This study uses a mixed methods approach to postulate the proximal and distal determinants of household floor contamination with faeces in groups of rural villages in 3 counties in Kenya (Bungoma, Kwale and Narok). Quantitative data was collected through a household census and analysed descriptively and using mixed effects logistic regression models. Qualitative data was collected through unstructured observations of daily routines and in-depth interviews. These data were analysed thematically with case memos produced for routine activities that were hypothesised to be determinants of floor contamination. Possible proximal determinants of floor contamination included; (1) animal contact with floors; (2) child faeces disposal, and; (3) floor cleaning routines. Distal determinants are suggested to be rooted in the socioeconomic, environmental, and cultural context in which households were located and included; (1) the type and number of animals owned by households; (2) presence/absence of dedicated shelters for housing animals at night, which impacted whether sleeping or cooking areas were exposed to animals; (3) Accessibility of inside spaces to poultry and other roaming animals; (4) ownership of an improved floor; (5) ability of animals to access neighbours compounds; (6) seasonal changes in weather. These results will be of use in identifying the contexts in which faecal contamination of domestic floors may be contributing towards transmission of enteric and parasitic infections and in designing effective interventions to prevent this exposure., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Introduction: Environmental hygiene and food safety are important determinants of child stunting. This research aims to explore the relationship between child stunting and household hygiene practices and behaviours, including the availability of water, sanitation and hygiene (WASH) facilities; the use of safe food and good quality drinking water (especially when used for complementary feeding); hygienic practices in food transport, storage and preparation and the control of cross-contamination from animals, their produce and waste., Methods and Analysis: This study is part of a wider observational study which aims to investigate the interdisciplinary factors contributing to child stunting using a 'whole child' paradigm. The observational study recruits women during pregnancy in Hyderabad, India, Lombok, Indonesia and Kaffrine, Senegal, and dyads (ie, 500 mother-infant pairs per country) are followed longitudinally up to 24 months after birth. Within the interdisciplinary niche, the study here has developed tools to investigate the potential exposure pathways to environmental pathogen contamination of foods and water. Holistic WASH and food safety data collection tools have been developed to explore exposure pathways at the household level, including: (1) survey questionnaires; (2) spot-checks; (3) biological sampling of drinking water, food and domestic surfaces and (4) direct observation. An integrated analytical approach will be used to triangulate the evidence in order to examine the relationships between child stunting, WASH and food safety behaviours., Ethics and Dissemination: Ethical approval of the study was granted by the ethics committee of the LSHTM, RVC, ILRI, ICMR, IIPHG, SEAMEO-RECFON, University of Cheikh Anta Diop. Findings of the study will be disseminated through publication in peer-reviewed journals, relevant international conferences, public engagement events, and policy-maker and stakeholder events., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Hand hygiene is an important measure to prevent disease transmission., Objective: To summarise current international guideline recommendations for hand hygiene in community settings and to assess to what extent they are consistent and evidence based., Eligibility Criteria: We included international guidelines with one or more recommendations on hand hygiene in community settings-categorised as domestic, public or institutional-published by international organisations, in English or French, between 1 January 1990 and 15 November 2021., Data Sources: To identify relevant guidelines, we searched the WHO Institutional Repository for Information Sharing Database, Google, websites of international organisations, and contacted expert organisations and individuals., Charting Methods: Recommendations were mapped to four areas related to hand hygiene: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures. Recommendations were assessed for consistency, concordance and whether supported by evidence., Results: We identified 51 guidelines containing 923 recommendations published between 1999 and 2021 by multilateral agencies and international non-governmental organisations. Handwashing with soap is consistently recommended as the preferred method for hand hygiene across all community settings. Most guidelines specifically recommend handwashing with plain soap and running water for at least 20 s; single-use paper towels for hand drying; and alcohol-based hand rub (ABHR) as a complement or alternative to handwashing. There are inconsistent and discordant recommendations for water quality for handwashing, affordable and effective alternatives to soap and ABHR, and the design of handwashing stations. There are gaps in recommendations on soap and water quantity, behaviour change approaches and government measures required for effective hand hygiene. Less than 10% of recommendations are supported by any cited evidence., Conclusion: While current international guidelines consistently recommend handwashing with soap across community settings, there remain gaps in recommendations where clear evidence-based guidance might support more effective policy and investment., Competing Interests: Competing interests: None declared., (© World Health Organization 2023. Licensee BMJ.)

Background: Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs., Methods: In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414., Findings: 26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I 2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I 2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I 2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I 2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence., Interpretation: Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease., Funding: Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO., Competing Interests: Declaration of interests IR and SB report grants from the Reckitt Global Hygiene Institute during the conduct of the study. OC reports grants from the UK Foreign, Commonwealth, and Development Office (FCDO) and the Bill & Melinda Gates Foundation during the conduct of the study. JW reports grants from UK FCDO during the conduct of the study. MB reports grants from the Bill & Melinda Gates Foundation during the conduct of the study. RD reports a donation from Reckitt, outside the submitted work. MCF reports consulting fees from Reckitt, outside the submitted work. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding., Methods: A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation., Results: The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02-1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91-6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours., Conclusion: Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other., (© 2022. The Author(s).)

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., (© Watson et al.)

Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care., (© 2022. The Author(s).)

Introduction: Many children in developing countries grow up in environments that lack stimulation, leading to deficiencies in early years of development. Several efficacy trials of early childhood care and education (ECCE) programmes have demonstrated potential to improve child development; evidence on whether these effects can be sustained once programmes are scaled is much more mixed. This study evaluates whether an ECCE programme shown to be effective in an efficacy trial maintains effectiveness when taken to scale by the Government of Ghana (GoG). The findings will provide critical evidence to the GoG on effectiveness of a programme it is investing in, as well as a blueprint for design and scale-up of ECCE programmes in other developing countries, which are expanding their investment in ECCE programmes., Methods and Analysis: This study is a cluster randomised controlled trial, in which the order that districts receive the programme is randomised. A minimum sample of 3240 children and 360 schools will be recruited across 72 district school cohort pairs. The primary outcomes are (1) child cognitive and socioemotional development measured using the International Development and Early Learning Assessment tool, the Strengths and Difficulties Questionnaire, and tasks from the Harvard Laboratory for Development Studies; (2) child health (measured using height/weight for age, height-for-weight Z scores). Secondary outcomes include (1) maternal mental health, (using Kessler-10 and Warwick Edinburgh Mental Wellbeing Scale) and knowledge of ECCE practices; (2) teacher knowledge, motivation and teaching quality (measured with classroom observation); (3) parental investment (using the Family Care Index and Home Observation Measurement of the Environment and the Child-Parent Relationship Scale); (4) water, sanitation, and hygiene (WASH) practices; (5) acute malnutrition (using mid-upper arm circumference). We will estimate unadjusted and adjusted intent-to-treat effects., Ethics and Dissemination: Study protocols have been approved by ethics boards at the University College London (21361/001), Yale University (2000031549) and Ghanaian Health Service Ethics Review Committee (028/09/21). Results will be made available to participating communities, funders, the wider public and other researchers through peer-reviewed journals, conference presentations, social and print media and various community/stakeholder engagement activities., Trial Registration Number: ISRCTN15360698, AEARCTR-0008500., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions-all of which may also be rapidly evolving., Methods: We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings-one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed., Results: Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered., Conclusion: Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes., (© 2022. The Author(s).)

Objectives: To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children., Methods: In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children's independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children's independent toothbrushing behaviour at home., Results: Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857)., Conclusions: Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children's uptake of independent hygiene behaviours.

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

Rationale: Many behaviours relevant to public health are part of everyday routines. However, few tools exist to study such behaviours. Here we re-introduce the behaviour setting, an ecological psychological concept developed in the 1950s, as an approach to the study of routine behaviour. The setting concept bridges theoretical and applied approaches in sociology, psychology and social practice; its components include stage, infrastructure, props, roles, norms, competencies, objectives and resultant routines., Methods: We applied settings theory to health-related water use behaviour in rural Nigeria. We captured the dimensions of water use behaviour settings in 23 households at varying distances from newly-introduced kiosks selling purified water., Results: We found that routines concerning drinking, laundering, dish washing and handwashing were stable in their settings, varying little between households or by type of water source. Hygiene routines were suboptimal but drinking water was carefully segregated. The majority of water use behaviour was governed, not by an immediate desire to maximise health, but by long-established routines embedded in the social, technical and physical environment. Water kiosks are making only marginal improvements to the quantity and quality of water being used in homes., Conclusions: Improving public health will require the disruption of settings, for example, through bringing water infrastructure directly to the home, through the sale of new props that facilitate hygienic routines, or in the disruption of gender roles via the promotion of new norms. Settings are an ecologically valid, meso-level theoretical approach that link social and techno-physical environmental factors to behaviour. They provide a comprehensive framework within which to judge avenues for changing routine behaviours. The behaviour settings tool we developed was easy to use, provided a systematic means of capturing the determinants of routine behaviour, and the findings offered insight into methods for disrupting such behaviour., (Copyright © 2019. Published by Elsevier Ltd.)

Household-specific feedback on the microbiological safety of drinking water may result in changes to water management practices that reduce exposure risks. We conducted a randomized, controlled trial in India to determine if information on household drinking water quality could change behavior and improve microbiological quality as indicated by Escherichia coli counts. We randomly assigned 589 participating households to one of three arms: (1) a messaging-only arm receiving messaging on safe water management ( n = 237); (2) a standard testing arm receiving the same messaging plus laboratory E. coli testing results specific to that household's drinking water ( n = 173); and (3) a test kit arm receiving messaging plus low-cost E. coli tests that could be used at the household's discretion ( n = 179). Self-reported water treatment increased significantly in both the standard testing arm and the test kit arm between baseline and follow-up one month later. Mean log 10 E. coli counts per 100 mL in household stored drinking water increased in the messaging-only arm from 1.42 to 1.87, while decreasing in the standard testing arm (1.38 to 0.89, 65% relative reduction) and the test kit arm (1.08 to 0.65, 76% relative reduction). Findings indicate that household-specific water quality information can improve both behaviors and drinking water quality.

Inadequate hand hygiene is estimated to result in nearly 300,000 deaths annually, with the majority of deaths being among children younger than 5 years. In an effort to promote handwashing with soap and water treatment behaviors among highly susceptible household members of cholera patients, we recently developed the Cholera-Hospital-Based Intervention-for-7-Days (CHoBI7); chobi means picture in Bengali. This 1-week handwashing with soap and water treatment intervention is delivered by a promoter in the hospital and the home to cholera patients and their household members. In our randomized controlled trial of this intervention, we observed a significant reduction in symptomatic cholera infections during the 1-week intervention period compared to the control arm and sustained high uptake of observed handwashing with soap behaviors up to 12 months postintervention. The aim of the present study was to assess the underlying mechanism of change that led to the high handwashing with soap behavior observed among participants who received the CHoBI7 intervention. Handwashing with soap was measured using 5-hour structured observation, and psychosocial factors were assessed using a structured questionnaire among 170 intervention and 174 control household members enrolled in the CHoBI7 trial. To investigate potential mediators of the CHoBI7 intervention effect, mediation models were performed. Response efficacy was found to mediate the intervention's effect on habit formation for handwashing with soap at the 1-week follow-up, and disgust, convenience, and cholera awareness were mediators of habit maintenance at the 6- to 12-month follow-up. These results support the use of theory-driven approaches for the development and implementation of handwashing with soap interventions.