Hygiene Promotion Interventions Research Articles

Hand hygiene intervention in the prevention of healthcare associated infections

Abstract Background Healthcare associated infections are a major cause of morbidity and mortality in intensive care units. Observance hand hygiene is singled out as a key element in interruption of these infections. The present study aimed to assess whether hand hygiene intervention program in intensive care unit at the Sahloul University Hospital of Sousse is able to decrease healthcare associated infections. Methods We carried out a pre-experimental study among patients hospitalized in seven intensive care units at the Sahloul University Hospital of Sousse during two distinct periods of 3 months, the first in 2019 and the second in 2021. During these two periods, we monitored only patients hospitalized in the ICU for more than 48 hours and incidence of healthcare associated infections was compared. Healthcare associted infections were defined as infections occurred at least 48 hours after admission to the intensive care units. The hand hygiene promotion intervention, done during the year 2020, was based on 3 axes (training sessions, procedures writing and professional practicesevaluation). Results Incidence of healthcare associated infections decreased significantly in post-intervention (p = 0.000). The decrease of Ventilator-associated pneumonia was significantly higher than other types of infections(p = 0.042). Extended Spectrum B-Lactamase Producing Enterobacteriaceae infections and Ceftazidim resistant Pseudomonas Aeruginosa infections decreased significantly in after intervention (p = 0.000). Conclusions The results of our study showed that improved hand hygiene resulted in a reduction in healthcare associated infections. Key messages • Observance hand hygiene is singled out as a key element in interruption of healthcare associated infections. • Improved hand hygiene resulted in a reduction in healthcare associated infections.

Hygiene Promotion Interventions and Their Effectiveness in Protecting Public Health in Rohingya Refugee Settlements in Bangladesh

This paper examines the effectiveness of hygiene promotion interventions in protecting public health within the Rohingya refugee settlements in Bangladesh. The study focuses on various strategies implemented to improve hygiene practices and reduce the incidence of waterborne diseases among the refugee population. Key interventions include the distribution of hygiene kits, handwashing campaigns, construction and maintenance of sanitation facilities, and educational programs tailored to the cultural context of the Rohingya community. Through a mixed-methods approach involving quantitative surveys, qualitative interviews, and observational data, the study assesses changes in hygiene behaviors, knowledge, attitudes, and practices (KAP), as well as health outcomes. The findings indicate significant improvements in hygiene practices, such as increased handwashing with soap, greater use of latrines, and better water storage practices, alongside a notable reduction in diarrheal disease incidence. The paper also highlights the critical role of community engagement, cultural sensitivity, and continuous monitoring in enhancing the effectiveness and sustainability of hygiene interventions. These insights contribute to the broader understanding of public health strategies in humanitarian settings and provide valuable recommendations for future hygiene promotion efforts in similar contexts.

Preservation and Handling Practices of Household Drinking Water in Ahmedabad city with special reference to Bacterial Contamination and Diarrheal Episode in Children: A Cross Sectional Study

Background: Safe drinking water is essential for healthy human life. Presence of coliform organism, E. coli in particular, has been found to be the most specific bacteriological indicator of faecal contamination. Studying their preservation and handling practices of household drinking water, its contamination and diarrheal episodes in children is very necessary for hygiene promotion intervention. Methods: This cross-sectional study was conducted at urban field practice area of community medicine department B.J.M.C, Ahmedabad in year 2020-2021. Total 168 Drinking water samples were collected from each household and tested at microbiology department. Information regarding household characteristics, preservation and handling practices of drinking water were gathered from mother using pre-tested and pre-designed proforma. Data were entered in Microsoft excel and analysed using Epi-info Software. Result: Out of 168 households studied, 165(98.2%) households used matka / earthen pot and 161(95.8%) used narrow necked covered container to preserve drinking water. Only in 10 (5.8%) households’ water was filtered with folded cotton cloth at the time of collection. 101 (60%) water containers did have tap while 67 (39.8%) didn’t have it. 4/168 (2.3%) samples were bacteriologically not acceptable for drinking purpose. Conclusion: Narrow necked coveredmatka (earthen pot) was the most commonly used container to preserve drinking water. Though prevalence of bacterial contamination and ADD episodes in under five child were low due to pre-treated piped water supply, diarrhoeal morbidity is more in household where broad necked, non tapped containers used. Education of mother has positive impact on preservation and handling practices of drinking water. Keywords: Preservation, Handling, Drinking water, Coliform, Diarrheal episode, Under 5 children

BabyWASH and diarrhea prevention practices following multimedia educational intervention in hard-to-reach areas of the Afar and Somali regions of Ethiopia: a mixed-method endline evaluation

BackgroundWater, sanitation, and hygiene (WASH) interventions, which are specifically targeted towards young children—known as “BabyWASH”—reduce exposure to environmental contamination and prevent microbial burden in their play and feeding environments. The purpose of this endline study was to evaluate the effectiveness and potential sustainability of a multimedia educational intervention in influencing key BabyWASH and diarrhea prevention practices in four hard-to-reach woredas (i.e. administrative districts) of the Afar and Somali regions of Ethiopia.MethodsA mixed-method, comparative cross-sectional study was conducted, which included 457 household surveys, 16 key informant interviews, and 8 focus group discussions. The multimedia educational intervention comprised: broadcasting radio talk shows and radio spot messages, capacity-building training for community health workers and community leaders, community mobilization campaigns, and the distribution of promotional print media materials. Propensity score matching analysis was used to estimate the effect of the multimedia educational intervention on key BabyWASH and diarrhea prevention attitudes and practices, which was then triangulated with qualitative findings.ResultsThe multimedia intervention had a significant positive impact on good BabyWASH and diarrhea prevention practices, including appropriate practices of child feces disposal (t-test = 5.17; p < 0.001), handwashing with soap or ash (t-test = 8.85; p < 0.001), maintaining separate playgrounds for young children (t-test = 2.83; p < 0.001), washing of child’s body, hands, and faces (t-test = 15.78; p < 0.001), and food hygiene practices (t-test = 2.74; p < 0.05). The findings of the qualitative assessment also revealed that the multimedia intervention packages and the approaches used were successful in influencing key BabyWASH and diarrhea prevention behaviors in the intervention implementation woredas. In addition, providing capacity building training to local actors and community leaders and recording radio talk shows and sharing them with community members were recognized as effective intervention implementation strategies.ConclusionThe endline evaluation found that the multimedia educational intervention improved awareness, perception, and practice of BabyWASH and diarrhea prevention behaviors in intervention woredas compared to control woredas. Sanitation and hygiene promotion interventions in pastoralist settings can be effective when using locally and contextually appropriate intervention strategies. However, considerations for integrating both behavioral and structural components in WASH interventions is essential.

Personal characteristics associated with handwashing behaviour among Japanese university students studying abroad: Prospective observational studies

BackgroundHand hygiene is recommended to travellers to prevent common travel-related illnesses such as diarrhoea and respiratory infection. For effective hygiene promotion interventions, we aimed to identify the personal characteristics associated with handwashing behaviour. MethodsProspective observational studies consisting of pre- and post-travel surveys were conducted among Japanese university students studying abroad between 2016 and 2018 (n = 825; 6–38 travel days). Associations of age, sex, study major, and overseas travel experience with handwashing behaviour (5-point scale) were evaluated using ordinal logistic regression models, with adjustment for destination, travel duration, and psychological factors (risk perception of diarrhoea and concern about hygiene). ResultsAmong the participants in our analysis (n = 629), 28.0 % washed their hands before every meal while abroad. The male sex and no overseas travel experience were associated with decreased frequency of infrequent handwashing, even after adjusting for all potential confounding factors, whereas the study major was not associated. The adjusted odds ratios (95 % confidence intervals) were 0.74 (0.56–0.99) for men vs. women and 0.69 (0.52–0.93) for no overseas travel experience vs. overseas travel experience but not to the current destination. ConclusionsThe lack of overseas travel experience correlated with handwashing frequency in both men and women. In addition to the travel destination, the male sex and no overseas travel experience should be highlighted in pretravel hand hygiene interventions.

Impact of hygiene promotion intervention on acute childhood diarrhea: evidence from a cluster-randomized trial in refugee communities in Gambella Region, Ethiopia

Abstract Background: Diarrheal illnesses are mainly linked with poverty, and hygiene promotion programs can significantly reduce childhood diarrhea when interventions are tested in stable communities. However, there is no sufficient evidence in emergency context. Methods: A cluster-randomized controlled trial was conducted in Teirkidi and Pugnido refugee camps. Intention to treat was applied in analyses of the results of this trial. Logistic, poison regression and generalized estimating equation (GEE) models were used to evaluate changes in cluster-level hygiene behaviors and period prevalence and incidence of diarrhea with its confidence intervals (95% CI) and p &amp;lt; 0.05 significant cutoff point. Results: The reported diarrhea episodes were 1,307 (15.6 episodes per 100 person-weeks observation) among the intervention households and 1,619 (18.9 episodes per 100 person-weeks observation) in the control households. Under-five children living in households that received hygiene promotion had a 15% [p &amp;lt; 0.001; adjusted IRR: 0.85, 95% CI: 0.79 0.92] and a lower incidence of diarrhea compared with children living in control households. Conclusion: The study confirms that hygiene promotion intervention significantly reduces the incidence rate of childhood diarrhea in refugee camps. Hence, gains in the reduction of childhood diarrhea can be achieved in refugee camps through an enhanced hygiene promotion program.

Contextual and psychological factors influencing open defecation free status: an exploratory qualitative study in rural South Western Uganda

IntroductionAchieving the Open defecation free (ODF) status remains a major challenge in Uganda, yet it contributes significantly to child health improvement. Literature on social, cultural and behavioral aspects that influence the ODF status in rural Uganda is limited. The study therefore, explored perceived factors influencing the ODF status in rural South Western Uganda.MethodsAn exploratory study employing qualitative techniques and based on deductive analysis between month December 2020 and January 2021 was conducted. Seven Focus Group Discussions (FGDs and three Key Informant Interviews (KIs) were conducted in Kabale District, southwestern Uganda. Focus Group Discussion participants were mothers and fathers having children of 2 years and below while KIIs included local community leaders and health extension workers. Data was analyzed using a categorization matrix derived from the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model which is comprised of contextual and psychological factors. Text was further categorized into high and low statements for attainment of ODF status.ResultsThe contextual factors influencing the Open Defecation Free status behavior included; farming activities far from home, financial constraints, rainy seasons, collapsible soft soils, and alcohol use. Psychological factors influencing ODF status included; perceived health risk for typhoid disease, low perceived severity for lack of ODF components, negative attitude of less value attached to ODF components, and a feeling of time wastage practicing ODF status behavior. The perception that the community has the ability to attain the ODF status was high. Although, the capability to maintain ODF was low when it comes to replacement of ODF component if stolen or destroyed.ConclusionOpen Defecation Free status is influenced by contextual and psychological factors. Therefore, it’s crucial for sanitation promotors to always identify such context specific factors in order to design sanitation and hygiene promotion interventions to address the ODF free status related challenges.

Impact of Multiple Hygienic Interventions on Caregivers’ Behaviors in a Conflict Setting, Yemen: Cluster-Randomized Controlled Trial

Background Several household hygiene programs have been implemented by the Ministry of Public Health and Population and international nongovernment organizations to reduce the risk factors related to child morbidity and mortality in Yemen. However, no research has been conducted to assess the impact of such interventions on caregivers’ hygiene behavior. We therefore carried out a cluster-randomized controlled trial to assess whether such interventions could improve caregivers’ hygiene behavior. Objective The study aims to identify the impact of hygiene promotion interventions on mothers’ practices related to water, sanitation, and hygiene. Methods A 6-month cluster-randomized controlled trial was conducted in Hufash District of Al-Mahweet Province in Yemen from May to October 2015. In total, 20 villages were randomly selected and assigned to an intervention arm that received hygiene promotional interventions and a control arm. In total, 358 households were interviewed at baseline and the endpoint. A logistic regression model was fitted to data, and the adjusted odds ratio (AOR) was used to estimate the effect size of the intervention. Results The intervention made significant improvements in caregivers’ handwashing after using a latrine (AOR 2.6, 95% CI 1.75-3.90) and before feeding the baby (AOR 1.8, 95% CI 1.14-2.92), safe disposal of child feces (AOR 2.0, 95% CI 1.35-2.53), covering of remaining food (AOR 1.1, 95% CI 1.08-1.19), cleaning of cooking utensils (AOR 1.27, 95% CI 1.08-1.51), and cleanness of drinking water storage containers (AOR 1.3, 95% CI 1.17-1.46). However, the intervention had no effect on caregivers’ handwashing practices after cleaning child feces, before preparing food, and before eating a meal, as well as no improvement in cleanness of the floor of the kitchen. Conclusions The findings from this trial reveal the important role that hygiene promotion can play in improving caregivers’ behaviors that could lead to better child health in high-risk communities where access to primary health care is limited. Trial Registration ClinicalTrials.gov NCT03810430; https://clinicaltrials.gov/show/NCT03810430

Urban Water Access and Use in the Kivus: Evaluating Behavioural Outcomes Following an Integrated WASH Intervention in Goma and Bukavu, Democratic Republic of Congo.

Increasing the availability and reliability of community water sources is a primary pathway through which many water supply interventions aim to achieve health gains in communities with limited access to water. While previous studies in rural settings have shown that greater access to water is associated both with increased overall consumption of water and use of water for hygiene related activities, there is limited evidence from urban environments. Using data collected from 1253 households during the evaluation of a community water supply governance and hygiene promotion intervention in the cities of Goma and Bukavu, Democratic Republic of Congo, we conducted a secondary analysis to determine the impact of these interventions on household water collection and use habits. Using multiple and logistic regression models we compared differences in outcomes of interest between households in quartiers with and without the intervention. Outcomes of interest included litres per capita day (lpcd) of water brought to the household, lpcd used at the household, and lpcd used for hygiene-related activities. Results demonstrated that intervention households were more likely to use community tapstands than households located in comparison quartiers and collected on average 16.3 lpcd of water, compared with 13.5 lpcd among comparison households (adj. coef: 3.2, 95 CI: 0.84 to 5.53, p = 0.008). However, reported usage of water in the household for domestic purposes was lower among intervention households (8.2 lpcd) when compared with comparison households (9.4 lpcd) (adj. coef: −1.11, 95 CI: −2.29 to 0.07), p = 0.066) and there was no difference between study groups in the amount of water allocated to hygiene activities. These results show that in this setting, implementation of a water supply governance and hygiene promotion intervention was associated with a modest increase in the amount of water being bought to the household, but that this did not translate into an increase in either overall per capita consumption of water or the per capita amount of water being allocated to hygiene related activities.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial.

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

The effect of hand hygiene promotion programs during epidemics and pandemics of respiratory droplet-transmissible infections on health outcomes: a rapid systematic review

BackgroundPublic health strategies in the context of respiratory droplet-transmissible diseases (such as influenza or COVID-19) include intensified hand hygiene promotion, but a review on the effectiveness of different ways of promoting hand hygiene in the community, specifically for this type of infections, has not been performed. This rapid systematic review aims to summarize the effectiveness of community-based hand hygiene promotion programs on infection transmission, health outcomes and behavioral outcomes during epidemic periods in the context of respiratory droplet-transmissible diseases. We also included laboratory-confirmed health outcomes for epidemic-prone disease during interepidemic periods.MethodsWe searched for controlled experimental studies. A rapid systematic review was performed in three databases and a COVID-19 resource. Following study selection (in which studies performed in the (pre-)hospital/health care setting were excluded), study characteristics and effect measures were synthesized, using meta-analyses of cluster-RCTs where possible. Risk of bias of each study was assessed and the certainty of evidence was appraised according to the GRADE methodology.ResultsOut of 2050 unique references, 12 cluster-RCTs, all in the context of influenza, were selected. There were no controlled experimental studies evaluating the effectiveness of hand hygiene promotion programs in the context of COVID-19 that met the in−/exclusion criteria. There was evidence that preventive hand hygiene promotion interventions in interepidemic periods significantly decreased influenza positive cases in the school setting. However, no improvement could be demonstrated for programs implemented in households to prevent secondary influenza transmission from previously identified cases (epidemic and interepidemic periods).ConclusionsThe data suggest that proactive hand hygiene promotion interventions, i.e. regardless of the identification of infected cases, can improve health outcomes upon implementation of such a program, in contrast to reactive interventions in which the program is implemented after (household) index cases are identified.

Determinants of intention to improve oral hygiene behavior among students based on the theory of planned behavior: A structural equation modelling analysis.

The prevalence of oral hygiene behaviors (OHB) is very low among school children in Ethiopia. However, the determinants of student's readiness/intention to perform those behaviors have been remained unstudied. This study aimed to identify the determinants of oral hygiene behavioral intention (OHBI) among preparatory school students based on the theory of planned behavior (TPB). An institution-based cross-sectional study was conducted among 393 students. A 98-item self-administered questionnaire was used to evaluate oral hygiene knowledge (OHK), oral hygiene behavior (OHB), and OHBI based on TPB variables [attitude (ATT), subjective norms (SN) and perceived behavioral control (PBC)]. Descriptive statistics and structural equation modeling analysis (SEM) were employed to confirm relationships and associations among study variables. A p-value of less than 0.05 and a 95% confidence interval were used to declare statistical significance. A total of 393 students were participated with a response rate of 97.5%. The mean age of the participants (54% females) was 18 (± 1.3) with an age range of 16 to 24. The TPB model was well fitted to the data and explained 66% of the variance in intention. ATT (β = 0.38; 95% CI, (0.21, 0.64)), SN (β = 0.33; 95% CI, (0.05, 0.83)) and PBC (β = 0.29; 95% CI, (0.13, 0.64)) were significant predictors of OHBI, where ATT was the strongest predictor of OHBI. The TPB model explained a large variance in the intention of students to improve their OHB. All TPB variables were significantly and positively linked to stronger intent, as the theory suggests. Furthermore, these results suggest that the model could provide a framework for oral hygiene promotion interventions in the study area. Indeed, these interventions should focus on changing the attitudes of students towards OHB, creation of positive social pressure, and enabling students to control over OHB barriers.

The determinants of handwashing behaviour in domestic settings: An integrative systematic review.

Hygiene promotion interventions are likely to be more effective if they target the determinants of handwashing behaviour. Synthesis of the evidence on the determinants of handwashing behaviour is needed to enable practitioners to use evidence in hygiene promotion programming. To identify, define and categorise the determinants of handwashing behaviour in domestic settings and to appraise the quality of this evidence. We conducted an integrative review, searching three databases for terms related to handwashing and behaviour change determinants. Studies were summarised and their quality assessed against a pre-defined set of criteria for qualitative, quantitative and mixed-method studies. Data on determinants were extracted and classified according to a predefined theoretical taxonomy. The effect of each association between a determinant and handwashing behaviour was summarised and weighted based on the quality of evidence provided. Determinants that were reported more than three times were combined into a meta-association and included in the main analysis. Sub-analyses were done for studies conducted during outbreaks or humanitarian crises. Seventy-eight studies met the criteria. Of these, 18% were graded as 'good quality' and 497 associations between determinants and handwashing behaviour were extracted. We found that 21% of these associations did not clearly define the determinant and 70% did not use a valid or reliable method for assessing determinants and/or behaviour. Fifty meta-associations were included in the main analysis. The determinants of handwashing that were most commonly reported were knowledge, risk, psychological trade-offs or discounts, characteristic traits (like gender, wealth and education), and infrastructure. There was insufficient data to draw conclusions about the determinants of behaviour in outbreaks or crises. This review demonstrates that our understanding of behavioural determinants remains sub-optimal. We found that there are limitations in the way behavioural determinants are conceptualised and measured and that research is biased towards exploring a narrow range of behavioural determinants. Hygiene promotion programmes are likely to be most successful if they use multi-modal approaches, combining infrastructural improvement with 'soft' hygiene promotion which addresses a range of determinants rather than just education about disease transmission.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection.

Cost and effectiveness of water, sanitation and hygiene promotion intervention in Ghana: the case of four communities in the Brong Ahafo region

Knowledge of cost and effectiveness of Ghana's main hygiene promotion intervention (HPI), Community-Led Total Sanitation (CLTS), is critical for policy direction. Cost and resultant effect of HPI is examined using a case study of four communities. Surveys were conducted with 300 households, CLTS implementers and relevant agencies during the study period (May 2012 to February 2014). The HPI produced marginal but statistically significant effect (8%, p < 0.001). Improvement in hygiene behaviour was statistically associated with both government investments (p < 0.001) and household investments (p < 0.001). Actual HPI cost is US$ 90 per household: US$ 51 and 39 from government and households respectively. Cost-effectiveness of the HPI is US$ 106.42 per capita of improved hygiene behaviour.

Drinking Water Supply, Sanitation, and Hygiene Promotion Interventions in Two Slum Communities in Central Uganda.

Poor water, sanitation, and hygiene (WASH) continue to contribute to the high prevalence of diarrhoeal diseases in low-income countries such as Uganda particularly in slums. We implemented a 3-year WASH project in two urban slums in Uganda with a focus on safe drinking water and improvement in sanitation. The project implemented community and school interventions in addition to capacity building initiatives. Community interventions included home improvement campaigns, clean-up exercises, water quality assessment, promotion of drinking safe water through household point-of-use chlorination, promotion of hand washing, and support towards solid waste management. In schools, the project supported health clubs and provided them with “talking compound” messages. The capacity building initiatives undertaken included training of youth and community health workers. Project evaluation revealed several improvements in WASH status of the slums including increase in piped water usage from 38% to 86%, reduction in use of unprotected water sources from 30% to 2%, reduction in indiscriminate disposal of solid waste from 18% to 2%, and increase in satisfaction with solid waste management services from 40% to 92%. Such proactive and sustainable community interventions have the potential to not only improve lives of slum inhabitants in developing countries but also create lasting impact.

Evaluating the effectiveness of a community-based hygiene promotion program in a rural Salvadoran setting.

There has been considerable progress in the reduction of diarrheal disease among children under five through health and nutrition interventions. However, diarrheal disease is still the second leading cause of child death worldwide. There is growing recognition that comprehensive hygiene behavior improvements should be integral to prevention efforts, but the effectiveness of different approaches for hygiene promotion is still being established. Hygiene risk practices vary across settings, suggesting that prevention strategies should be adapted to local contexts using community-based approaches. We planned, implemented, and evaluated a hygiene promotion intervention using the hygiene cluster framework. The two-year, multi-level intervention was implemented by local health promoters who were involved in identifying and addressing disease transmission risks at the household, school, and community levels. The intervention was evaluated using a quasi-experimental pretest-posttest design with repeated follow-up assessments to determine changes in hygiene knowledge and behavior. A household survey instrument was administered at three time points in the intervention ( n = 480) and comparison ( n = 271) communities to assess two hygiene knowledge and eleven hygiene behavior outcome variables. We used one-way analysis of variance with post hoc analysis using Tukey's HSD for multiple comparisons to examine change and differences over time. We also fit a linear regression model to identify statistically significant differences. Study results demonstrated improvements in the areas of: knowledge of disease transmission and key times for handwashing, water container hygiene, sanitation practices, personal hygiene and food hygiene. The hygiene cluster framework is useful for hygiene promotion intervention planning and evaluation, and we recommended continued testing of this framework across contexts. We also recommend local community participatory approaches, as well as in-depth formative behavioral assessments by hygiene cluster that also consider environmental barriers to behavior change.

A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh

To pilot two intensive hand hygiene promotion interventions, one using soap and one using a waterless hand sanitizer, in low-income housing compounds in Dhaka, Bangladesh and assess subsequent changes in handwashing behaviour and hand microbiology. Fieldworkers randomized 30 housing compounds: 10 received handwashing promotion with free soap, 10 received handwashing promotion with free waterless hand sanitizer and 10 were non-intervention controls. Fieldworkers assessed handwashing behaviour by structured observation and collected hand rinse specimens. At baseline, compound residents washed their hands with soap 26% of the time after defecation and 30% after cleaning a child's anus but <1% at other times. Compared with baseline, residents of soap intervention compounds were much more likely to wash their hands with soap after faecal contact (85-91%), before preparing food (26%) and before eating (26%). Compounds that received waterless hand sanitizer cleansed their hands more commonly than control compounds that used soap (10.4%vs. 2.3%), but less commonly than soap intervention compounds used soap (25%). Post-intervention hand rinse samples from soap and sanitizer compounds had lower concentrations of faecal indicator bacteria compared with baseline and control compounds. Waterless hand sanitizer was readily adopted by this low-income community and reduced hand contamination but did not improve the frequency of handwashing compared with soap. Future deployments of waterless hand sanitizers may improve hand hygiene more effectively by targeting settings where soap and water is unavailable.

A Systematic Review of Community Handwashing Interventions Leading to Changes in Hygiene Behavior in the Developing World

A B S T R A C T Background: Educational interventions in hygienic practices have shown to be cost effective methods of controlling diarrhea and other diseases spread through poor hygiene. Hand washing is one method of breaking the chain of transmission between household contacts, and especially between mother and child. Effective interventions to promote this behavior should be expanded and encouraged in the developing world. Objectives: To determine the extent and credibility of intervention studies done to promote uptake of improved hand washing behaviors in communities. To assess these interventions on their results in terms of behavior change, and identify factors contributing to their success or failure. Methods: The investigators searched the databases SCOPUS, EMBASE (1980-2010), and Pubmed for English papers written about hygiene promotion interventions in developing countries. Interventions included were community based control trials examining the effectiveness of increased hygiene education through measured behavior change. Only studies measuring behavior change using structured observation or demonstration of hand washing skills were used. Results: The search terms: hand washing, health education, hygiene promotion, behavior change, and diarrhea were used, resulting in a total of 330 titles. The investigators scanned the titles and abstracts to narrow down to 13 hygiene interventions measuring behavior change. Only five control trial interventions met the observation measurement criteria. Behavior change measurements were compiled and compared based on the length of intervention and the degree of change noted with each study.Conclusion: Encouraging uptake of hand washing behavior is possible using educational interventions to promote improved hygiene. The most significant impacts were seen from interventions running for longer periods of time. More robust and long term control trials are necessary to gather conclusive data on the sustainability of behavior change after educational interventions. Statistically sound methods of measurement of hand washing behavior change should be encouraged in future studies.

The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial

To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households. Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars. The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (-1%, 95% CI -2%/+0.3%), or the control arm (+0.4%, 95% CI -1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation. The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.