Topic of the Week – January 2016 Handwashing Studies

Emerging infectious diseases. 2016 Feb; 22(2):233-41. doi: 10.3201/eid2202.151175.

Randomized Controlled Trial of Hospital-Based Hygiene and Water Treatment Intervention (CHoBI7) to Reduce Cholera. Authors: George CM, et al.

The risk for cholera infection is >100 times higher for household contacts of cholera patients during the week after the index patient seeks hospital care than it is for the general population. To initiate a standard of care for this high-risk population, we developed Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7), which promotes hand washing with soap and treatment of water. To test CHoBI7, we conducted a randomized controlled trial among 219 intervention household contacts of 82 cholera patients and 220 control contacts of 83 cholera patients in Dhaka, Bangladesh, during 2013-2014. Intervention contacts had significantly fewer symptomatic Vibrio cholerae infections than did control contacts and 47% fewer overall V. cholerae infections. Intervention households had no stored drinking water with V. cholerae and 14 times higher odds ofhand washing with soap at key events during structured observation on surveillance days 5, 6, or 7. CHoBI7 presents a promising approach for controlling cholera among highly susceptible household contacts of cholera patients.

Am J Trop Med Hyg. 2016 Jan 19. pii: 15-0335.

Beliefs, Behaviors, and Perceptions of Community-Led Total Sanitation and Their Relation to Improved Sanitation in Rural Zambia. Authors: Lawrence JJ, et al.

Inadequate hygiene and sanitation remain leading global contributors to morbidity and mortality in children and adults. One strategy for improving sanitation access is community-led total sanitation (CLTS), in which participants are guided into self-realization of the importance of sanitation through activities called “triggering.” This qualitative study explored community members’ and stakeholders’ sanitation, knowledge, perceptions, and behaviors during early CLTS implementation in Zambia. We conducted 67 in-depth interviews and 24 focus group discussions in six districts in Zambia 12-18 months after CLTS implementation. Triggering activities elicited strong emotions, including shame, disgust, and peer pressure, which persuaded individuals and families to build and use latrines and handwashing stations. New sanitation behaviors were also encouraged by the hierarchical influences of traditional leaders and sanitation action groups and by children’s opinions. Poor soil conditions were identified as barriers to latrine construction. Taboos, including prohibition of family members, in-laws, and opposite genders from using the same toilet, were barriers for using sanitation facilities. CLTS, through community empowerment and ownership, produced powerful responses that encouraged construction and use of latrines and handwashing practices. These qualitative data suggest that CLTS is effective for improving sanitation beliefs and behaviors in Zambia.

Int J Environ Res Public Health. 2016 Jan 14;13(1). pii: E129. doi: 10.3390/ijerph13010129.

Behavior Change without Behavior Change Communication: NudgingHandwashing among Primary School Students in Bangladesh. Authors: Dreibelbis R, et al.

Behavior change communication for improving handwashing with soap can be labor and resource intensive, yet quality results are difficult to achieve. Nudges are environmental cues engaging unconscious decision-making processes to prompt behavior change. In this proof-of-concept study, we developed an inexpensive set of nudges to encourage handwashing with soap after toilet use in two primary schools in rural Bangladesh. We completed direct observation of behaviors at baseline, after providing traditional handwashing infrastructure, and at multiple time periods following targeted handwashing nudges (1 day, 2 weeks, and 6 weeks). No additional handwashing education or motivational messages were completed.

Handwashing with soap among school children was low at baseline (4%), increasing to 68% the day after nudges were completed and 74% at both 2 weeks and 6 weeks post intervention. Results indicate that nudge-based interventions have the potential to improve handwashing with soap among school-aged children in Bangladesh and specific areas of further inquiry are discussed.

Arch Dis Child. 2016 Jan;101(1):42-50. doi: 10.1136/archdischild-2015-308875.

Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis. Authors: Willmott M, et al.

OBJECTIVE: To undertake a systematic review and meta-analysis to establish the effectiveness ofhandwashing in reducing absence and/or the spread of respiratory tract (RT) and/or gastrointestinal (GI) infection among school-aged children and/or staff in educational settings.

RESULTS: Eighteen cluster RCTs were identified; 13 school-based, 5 in child day care facilities or preschools. Studies were heterogeneous and had significant quality issues including small numbers of clusters and participants and inadequate randomisation. Individual study results suggest interventions may reduce children’s absence, RT infection incidence and symptoms, and laboratory confirmed influenza-like illness. Evidence of impact on GI infection or symptoms was equivocal.

CONCLUSIONS: Studies are generally not well executed or reported. Despite updating existing systematic reviews and identifying new studies, evidence of the effect of hand hygiene interventions on infection incidence in educational settings is mostly equivocal but they may decrease RT infection among children. These results update and add to knowledge about this crucial public health issue in key settings with a vulnerable population. More robust, well reported cluster RCTs which learn from existing studies, are required.

J Pediatr Gastroenterol Nutr. 2016 Jan;62(1):150-6. doi: 10.1097/MPG.0000000000000901.

Predictors of Stunting Among Children Ages 0 to 59 Months in a Rural Region of Armenia. Authors: Demirchyan A, et al.

OBJECTIVES: The prevalence of stunting in Armenia more than doubled since the 1990s. This study aimed to investigate the prevalence and the predictors of stunting among children younger than 5 years in a rural region of Armenia, Talin, targeted by the World Vision (WV) nutrition interventions.

CONCLUSIONS: The study findings suggest that although WV nutrition interventions have shown impact, there is also a nonnutritional pathway of child stunting in rural Armenia. Thus, antistunting interventions should include sanitation and hygienic measures along with adequate perinatal care and maternal and child nutrition to further reduce childhood stunting, ensuring long-term health benefits for children not only in rural Armenia but also in rural communities in other low/middle-income countries.

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