Publications by authors named "Robert Dreibelbis"

56 Publications

How does sanitation influence people's quality of life? Qualitative research in low-income areas of Maputo, Mozambique.

Soc Sci Med 2021 Mar 21;272:113709. Epub 2021 Jan 21.

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom. Electronic address:

Preventing infectious disease has often been the primary rationale for public investment in sanitation. However, broader aspects of sanitation such as privacy and safety are important to users across settings, and have been linked to mental wellbeing. The aim of this study is to investigate what people most value about sanitation in low-income areas of Maputo, Mozambique, to inform a definition and conceptual model of sanitation-related quality of life. Our approach to qualitative research was rooted in economics and applied the capability approach, bringing a focus on what people had reason to value. We undertook 19 in-depth interviews and 8 focus group discussions. After eliciting attributes of "a good life" in general, we used them to structure discussion of what was valuable about sanitation. We applied framework analysis to identify core attributes of sanitation-related quality of life, and used pile-sorting and triad exercises to triangulate findings on attributes' relative importance. The five core attributes identified were health, disgust, shame, safety, and privacy. We present a conceptual model illustrating how sanitation interventions might improve quality of life via changes in these attributes, and how changes are likely to be moderated by conversion factors (e.g. individual and environmental characteristics). The five capability-based attributes are consistent with those identified in studies of sanitation-related insecurity, stress and motives in both rural and urban areas, which is supportive of theoretical generalisability. Since two people might experience the same toilet or level of sanitation service differently, quality of life effects of interventions may be heterogeneous. Future evaluations of sanitation interventions should consider how changes in quality of life might be captured.
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http://dx.doi.org/10.1016/j.socscimed.2021.113709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938219PMC
March 2021

Hand hygiene intervention to optimize helminth infection control: Design and baseline results of Mikono Safi-An ongoing school-based cluster-randomised controlled trial in NW Tanzania.

PLoS One 2020 9;15(12):e0242240. Epub 2020 Dec 9.

Mwanza Intervention Trials Unit, Mwanza, Tanzania.

Introduction: Soil transmitted helminths (STH) can affect over 50% of children in some parts of Tanzania. Control measures involve annual deworming campaigns in schools, but re-infection is rapid. This paper presents the design and baseline survey results of an ongoing school-based cluster-randomised controlled trial in Kagera region, NW Tanzania. The trial aims to determine whether the effect of routine deworming on the prevalence of Ascaris lumbricoides and Trichuris trichiura infections among school aged children can be sustained when combined with a behaviour change intervention promoting handwashing with water and soap.

Methods: As part of the trial, a total of 16 schools were randomised to receive the intervention (N = 8) or as controls (N = 8). Randomisation was stratified per district and restricted to ensure pre-trial STH prevalence was balanced between study arms. The combination intervention to be tested comprises class-room based teacher-led health education, improvement of handwash stations, coloured nudges to facilitate handwashing and parental engagement sessions. The impact evaluation involves two cross-sectional surveys conducted at baseline and endline. The objectives of the baseline survey were: (i) to confirm whether the deworming campaign was successful, and identify and treat students still infected about 2 weeks after deworming, (ii) to document any baseline differences in STH prevalence between trial arms, and (iii) to assess handwashing behaviours, and access to water and sanitation at school and home. We randomly sampled 35 students per class in Grades 1-6 (an average of 200 children per school), stratified to ensure equal representation between genders. Assenting students were interviewed using a structured questionnaire and asked to provide a stool specimen.

Results: Results of the baseline survey conducted about 2 weeks after deworming shows balanced demographic and STH prevalence data across trial arms. We observed a low prevalence of ascariasis (< 5%) as expected; however, the prevalence of trichuriasis was still about 35% in both arms.

Conclusion: The randomisation procedure was successful in achieving a balanced distribution of demographic characteristics and helminth infections between trial arms. The intervention is being rolled out. The current deworming treatment regimen may need to be revised with regards to the treatment of trichuriasis.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242240PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725373PMC
January 2021

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial.

Int J Public Health 2020 Dec 3;65(9):1699-1709. Epub 2020 Nov 3.

Disease Control Department, School of Hygiene and Tropical Medicine London, London, UK.

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.
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http://dx.doi.org/10.1007/s00038-020-01514-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717050PMC
December 2020

COVID-19: urgent actions, critical reflections and future relevance of 'WaSH': lessons for the current and future pandemics.

J Water Health 2020 Oct;18(5):613-630

Environmental and Health Research Unit, South African Medical Research Council, Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa; ‡ Authors in alphabetical order.

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.
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http://dx.doi.org/10.2166/wh.2020.162DOI Listing
October 2020

Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria.

BMC Pregnancy Childbirth 2020 Oct 6;20(1):589. Epub 2020 Oct 6.

Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.

Background: Newborns delivered in healthcare facilities in low- and middle-income countries are at an increased risk of healthcare associated infections. Facility-based studies have focused primarily on healthcare worker behaviour during labour & delivery with limited attention to hygiene practices in post-natal care areas and largely ignore the wide variety of actors involved in maternal and neonatal care.

Methods: This exploratory mixed-methods study took place in six healthcare facilities in Nigeria where 31 structured observations were completed during post-natal care, discharge, and the first 6 hours after return to the home. Frequency of hand hygiene opportunities and hand hygiene actions were assessed for types of patient care (maternal and newborn care) and the role individuals played in caregiving (healthcare workers, cleaners, non-maternal caregivers). Qualitative interviews with mothers were completed approximately 1 week after facility discharge.

Results: Maternal and newborn care were performed by a range of actors including healthcare workers, mothers, cleaners and non-maternal caregivers. Of 291 hand hygiene opportunities observed at health facilities, and 459 observed in home environments, adequate hand hygiene actions were observed during only 1% of all hand hygiene opportunities. Adequate hand hygiene prior to cord contact was observed in only 6% (1/17) of cord contact related hand hygiene opportunities at healthcare facilities and 7% (2/29) in households. Discharge advice was infrequent and not standardised and could not be remembered by the mother after a week. Mothers reported discomfort around telling non-maternal caregivers to practice adequate hand hygiene for their newborn.

Conclusions: In this setting, hand hygiene practices during post-natal care and the first 6 hours in the home environment were consistently inadequate. Effective strategies are needed to promote safe hand hygiene practices within the post-natal care ward and home in low resource, high-burden settings. Such strategies need to target not just mothers and healthcare workers but also other caregivers.
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http://dx.doi.org/10.1186/s12884-020-03282-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541299PMC
October 2020

How to set up government-led national hygiene communication campaigns to combat COVID-19: a strategic blueprint.

BMJ Glob Health 2020 08;5(8)

Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, England.

While large-scale changes in population behaviour are required to reduce the transmission of the severe acute respiratory syndrome coronavirus 2 virus, the emergency context is not conducive to the sort of careful communications planning that would normally be required to meet such a task. Rapid strategic communications planning in a pandemic by governments is, however, possible and necessary. Steps include setting up a dedicated communications task force, mobilising partners and resources, developing a creative brief and theory of change and overseeing the creation, testing, roll out and revision of content. In this short guide, we argue that a minimum of strategic planning can be undertaken rapidly, and that good use can be made of simple principles of behaviour change, even during pandemics. Our aim here is to provide a blueprint that governments and their partners, especially in low-income settings, can follow to design, coordinate and resource national communications efforts to combat the COVID-19 pandemic immediately and for the longer term.
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http://dx.doi.org/10.1136/bmjgh-2020-002780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412616PMC
August 2020

Determinants of clean birthing practices in low- and middle-income countries: a scoping review.

BMC Public Health 2020 May 1;20(1):602. Epub 2020 May 1.

Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Background: Infection is a leading cause of maternal and newborn mortality in low- and middle-income countries (LMIC). Clean birthing practices are fundamental to infection prevention efforts, but these are inadequate in LMIC. This scoping study reviews the literature on studies that describe determinants of clean birthing practices of healthcare workers or mothers during the perinatal period in LMIC.

Methods: We reviewed literature published between January 2000 and February 2018 providing information on behaviour change interventions, behaviours or behavioural determinants during the perinatal period in LMIC. Following a multi-stage screening process, we extracted key data manually from studies. We mapped identified determinants according to the COM-B behavioural framework, which posits that behaviour is shaped by three categories of determinants - capability, opportunity and motivation.

Results: Seventy-eight studies were included in the review: 47 observational studies and 31 studies evaluating an intervention. 51% had a household or community focus, 28% had a healthcare facility focus and 21% focused on both. We identified 31 determinants of clean birthing practices. Determinants related to clean birthing practices as a generalised set of behaviours featured in 50 studies; determinants related specifically to one or more of six predefined behaviours - commonly referred to as "the six cleans" - featured in 31 studies. Determinants of hand hygiene (n = 13) and clean cord care (n = 11) were most commonly reported. Reported determinants across all studies clustered around psychological capability (knowledge) and physical opportunity (access to resources). However, greater heterogeneity in reported behavioural determinants was found across studies investigating specific clean birthing practices compared to those studying clean birthing as a generalised set of behaviours.

Conclusions: Efforts to combine clean birthing practices into a single suite of behaviours - such as the "six cleans"- may simplify policy and advocacy efforts. However, each clean practice has a unique set of determinants and understanding what drives or hinders the adoption of these individual practices is critical to designing more effective interventions to improve hygiene behaviours and neonatal and maternal health outcomes in LMIC. Current understanding in this regard remains limited. More theory-grounded formative research is required to understand motivators and social influences across different contexts.
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http://dx.doi.org/10.1186/s12889-020-8431-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195776PMC
May 2020

Reducing hand recontamination of healthcare workers during COVID-19.

Infect Control Hosp Epidemiol 2020 Jul 6;41(7):870-871. Epub 2020 Apr 6.

World Health Organization Consultant, Glasgow, United Kingdom.

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http://dx.doi.org/10.1017/ice.2020.111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7167489PMC
July 2020

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

Int J Hyg Environ Health 2020 06 25;227:113512. Epub 2020 Mar 25.

London School of Hygiene and Tropical Medicine, Department of Disease Control, Keppel Street, UK. Electronic address:

Background: 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.

Purpose: To identify, define and categorise the determinants of handwashing behaviour in domestic settings and to appraise the quality of this evidence.

Methods: 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1016/j.ijheh.2020.113512DOI Listing
June 2020

Risk factors for child food contamination in low-income neighbourhoods of Maputo, Mozambique: An exploratory, cross-sectional study.

Matern Child Nutr 2020 10 12;16(4):e12991. Epub 2020 Mar 12.

Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.

In low- and middle-income countries, food may be a critical transmission route for pathogens causing childhood diarrhoea, but basic food hygiene is often overlooked in public health strategies. Characterising child food contamination and its risk factors could help prioritise interventions to reduce foodborne diarrhoeal disease, especially in low-income urban areas where the diarrhoeal disease burden is often high. This cross-sectional study comprised a caregiver questionnaire coupled with food sampling, and food preparation observations, among the study population of an ongoing sanitation trial in Maputo. The aim was to determine the prevalence of child food contamination and associated risk factors. The prevalence of Enterococcus spp., as an indicator of faecal contamination, was estimated in food samples. Risk factor analyses were performed through zero-inflated negative binomial regression on colony counts. A modified hazard analysis and critical control point approach was used to determine critical control points (CCPs) that might effectively reduce risk. Fifty-eight linked caregiver questionnaires and food samples were collected, and 59 food preparation observations were conducted. The prevalence of enterococci in child foods exceeding 10 colony forming units per gram was 53% (95% confidence interval [40%, 67%]). Risk factors for child food contamination were identified, including type of food, food preparation practices, and hygiene behaviours. CCPs included cooking/reheating of food and food storage and handling. This exploratory study highlights the need for more research into diarrhoeagenic pathogens and foodborne risks for children living in these challenging urban environments.
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http://dx.doi.org/10.1111/mcn.12991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507538PMC
October 2020

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

Am J Trop Med Hyg 2020 05;102(5):1116-1123

Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.

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.
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http://dx.doi.org/10.4269/ajtmh.19-0629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204591PMC
May 2020

Impact of an intervention to improve pit latrine emptying practices in low income urban neighborhoods of Maputo, Mozambique.

Int J Hyg Environ Health 2020 05 18;226:113480. Epub 2020 Feb 18.

Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA. Electronic address:

Safe fecal sludge management (FSM) - the hygienic emptying, transport, and treatment for reuse or disposal of fecal sludge - is an essential part of safely managed sanitation, especially in towns and cities in low- and middle-income countries with limited sewer coverage. The need for safe and affordable FSM services has become more acute as cities grow and densify. Hygienic pit-emptying uses equipment that limits direct human exposure with fecal sludge and hygienic transport conveys fecal sludge offsite for treatment. We evaluated whether a program of on-site sanitation infrastructure upgrades and FSM capacity development in urban Maputo, Mozambique resulted in more hygienic pit-emptying and safe transportation of fecal sludge. We compared reported emptying practices among multi-household compounds receiving sanitation upgrades with control compounds, both from the Maputo Sanitation (MapSan) trial at 24-36 months after the intervention. Intervention compounds (comprising 1-40 households, median = 3) received a subsidized pour-flush latrine to septic tank system that replaced an existing shared latrine; control compounds continued using existing shared latrines. We surveyed compound residents and analyzed available municipal data on FSM in the city. Due to the recent construction of the intervention, emptying was more frequent in control compounds: 5.6% (15/270) of intervention compounds and 30% (74/247) of controls had emptied their on-site sanitation system in the previous year. Among those compounds which had emptied a sanitation facility in the previous year, intervention compounds were 3.8 (95% CI: 1.4, 10) times more likely to have to done so hygienically. Results suggest that the construction of subsidized pour-flush sanitation systems increased hygienic emptying of fecal sludge in this setting. Further gains in hygienic emptying in urban Maputo may be limited by affordability and physical accessibility.
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http://dx.doi.org/10.1016/j.ijheh.2020.113480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184672PMC
May 2020

Child handwashing in an internally displaced persons camp in Northern Iraq: A qualitative multi-method exploration of motivational drivers and other handwashing determinants.

PLoS One 2020 3;15(2):e0228482. Epub 2020 Feb 3.

Department for Disease Control, London School of Hygiene and Tropical Medicine, London, England, United Kingdom.

Background: Children in humanitarian situations are particularly vulnerable to diseases such as diarrhoea. Handwashing with soap can greatly reduce transmission but handwashing rates are often low and traditional interventions ineffective. To aid future intervention design, this study aims to understand the determinants of child handwashing and the key motivational drivers of children's behaviour within a specific humanitarian setting.

Methods: In an internally displaced persons camp in Northern Iraq we conducted a series of 36 friendship-paired interviews with children aged 7-12 years, six semi-structured caregiver interviews, and three semi-structured hygiene promoter interviews. Perceived determinants of child handwashing were explored qualitatively, and motivational drivers were explored quantitatively with children in a rating exercise. Qualitative data were analysed thematically, using an inductive approach, and logistic regression analyses of motive rating data were performed to determine the predicted probabilities of motives being rated as important.

Results: Access to soap and water was perceived to be high across all participant groups. Children, caregivers and hygiene promoters all perceive the determinants of child handwashing to be associated with familial role, environmental factors pertaining to location and quality of handwashing materials and facilities, and level of exposure to hygiene promotion, and children also attribute their handwashing to social norms. We find that children in this context are motived most by play and nurture.

Conclusions: Provision of soap and water alone is not sufficient to encourage children to practice handwashing with soap in a humanitarian context. Our findings suggest that equal consideration should be given to the quality and location of handwashing materials and facilities and social norms could be leveraged to promote and enhance child handwashing. Motive-based interventions targeting play or nurture may be a promising approach and are likely most effective when used in conjunction, along with other motivational drivers such as affiliation and love.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228482PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996827PMC
May 2020

The Safe Start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: a study protocol for a cluster randomized controlled trial.

BMC Infect Dis 2019 Dec 19;19(1):1066. Epub 2019 Dec 19.

Disease Control Department, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, UK.

Background: Symptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya.

Methods: This is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean.

Results: The primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination.

Conclusion: To our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children.

Trial Registration: The trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114).
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http://dx.doi.org/10.1186/s12879-019-4657-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6923833PMC
December 2019

The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial.

BMC Public Health 2019 Dec 16;19(1):1680. Epub 2019 Dec 16.

Disease Control Department, London School of Hygiene and Tropical Medicine, Kepple Street, London, UK.

Background: Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level.

Methods: In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level.

Results: 20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality - between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035).

Conclusion: Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure.

Trial Registration: ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.
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http://dx.doi.org/10.1186/s12889-019-7833-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916048PMC
December 2019

Factors perceived to facilitate or hinder handwashing among primary students: a qualitative assessment of the Mikono Safi intervention schools in NW Tanzania.

BMJ Open 2019 11 28;9(11):e030947. Epub 2019 Nov 28.

Department of Disease Control, London School of Hygiene and Tropical Medicine (LSHTM), London, UK.

Objective: To qualitatively assess the effects of a multi-modal school-based water, sanitation and hygiene (WASH) intervention on handwashing behaviour among primary students in North Western (NW) Tanzania.

Design: The study was a qualitative assessment of barriers and facilitators to handwashing among students attending primary schools participating in the Mikono Safi Trial (Kiswahili for 'Clean Hands), a cluster-randomised trial assessing the impact of a school-based WASH intervention on selected soil transmitted helminth infections. Data collection methods included in-depth interviews with teachers, focus group discussions and friendship pair interviews with students collected between April and October 2018. The Capability-Opportunity-Motivation and Behaviour model was used to inform data collection and analysis.

Setting: The study was conducted in four purposively selected intervention schools in three districts of Kagera region, NW Tanzania (Bukoba urban, Bukoba rural and Muleba districts).

Participants: Participants comprised 16 purposively selected teachers aged between 23 and 52 years and 100 students aged 7-15 years RESULTS: The Mikono Safi intervention increased students' reported capability and motivation to wash their hands with soap at key times, particularly after visiting the toilet. Improvements in students' handwashing knowledge and skills were reported by both teachers and students, and motivation for handwashing was enhanced by emotional drivers such as disgust, fear and nurture. Newly established handwashing stations improved the physical opportunity to wash hands, although the availability of water and the provision of soap was not always consistent (eg, due to internal organisational shortcomings or during the dry season). Students and teachers were actively engaged in intervention implementation which created a school community that valued and supported improved hand hygiene.

Conclusion: The intervention was successful in improving capability and motivation for handwashing. Handwashing opportunity was also greatly improved, although the supply with water and soap was sometimes interrupted, calling for much stronger multi-sectoral collaboration to improve access to water at schools.

Trial Registration Number: ISRCTN45013173; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-030947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924754PMC
November 2019

Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya.

Am J Trop Med Hyg 2020 01;102(1):220-222

Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Complementary food hygiene is important to reduce infant exposures to enteric pathogens; however, interventions to improve food hygiene in low- and middle-income countries often ignore the larger context in which childcare occurs. In this study, we explore on observational and qualitative information regarding childcare in an informal community in Kenya. Our findings demonstrate that behaviors associated with food contamination, such as hand feeding and storing food for extended periods, are determined largely by the larger social and economic realities of primary caretakers. Data also show how caregiving within an informal settlement is highly dynamic and involves multiple individuals and locations throughout the day. Findings from this study will help inform the development and implementation of food hygiene interventions in informal urban communities.
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http://dx.doi.org/10.4269/ajtmh.19-0279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947802PMC
January 2020

A localized sanitation status index as a proxy for fecal contamination in urban Maputo, Mozambique.

PLoS One 2019 25;14(10):e0224333. Epub 2019 Oct 25.

Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America.

Sanitary surveys are used in low- and middle-income countries to assess water, sanitation, and hygiene conditions, but have rarely been compared with direct measures of environmental fecal contamination. We conducted a cross-sectional assessment of sanitary conditions and E. coli counts in soils and on surfaces of compounds (household clusters) in low-income neighborhoods of Maputo, Mozambique. We adapted the World Bank's Urban Sanitation Status Index to implement a sanitary survey tool specifically for compounds: a Localized Sanitation Status Index (LSSI) ranging from zero (poor sanitary conditions) to one (better sanitary conditions) calculated from 20 variables that characterized local sanitary conditions. We measured the variation in the LSSI with E. coli counts in soil (nine locations/compound) and surface swabs (seven locations/compound) in 80 compounds to assess reliability. Multivariable regression indicated that a ten-percentage point increase in LSSI was associated with 0.05 (95% CI: 0.00, 0.11) log10 fewer E. coli/dry gram in courtyard soil. Overall, the LSSI may be associated with fecal contamination in compound soil; however, the differences detected may not be meaningful in terms of public health hazards.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224333PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814227PMC
March 2020

Behaviour settings theory applied to domestic water use in Nigeria: A new conceptual tool for the study of routine behaviour.

Soc Sci Med 2019 08 8;235:112398. Epub 2019 Jul 8.

Environmental Health Group, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.

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.
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http://dx.doi.org/10.1016/j.socscimed.2019.112398DOI Listing
August 2019

Hygiene During Childbirth: An Observational Study to Understand Infection Risk in Healthcare Facilities in Kogi and Ebonyi States, Nigeria.

Int J Environ Res Public Health 2019 04 11;16(7). Epub 2019 Apr 11.

Disease Control Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.

: Infections acquired during labour and delivery are a significant cause of maternal and child morbidity and mortality. Adherence to hand hygiene protocols is a critical component of infection prevention strategies, but few studies have closely examined the hand hygiene of health care providers with sufficient detail to understand infection risks and prioritize prevention strategies. : This observational study was conducted in six healthcare facilities in Nigeria. In each, five women were observed from the onset of labour through to delivery of the placenta. Hand hygiene infection risk was estimated for all procedures requiring aseptic technique compared against adherence to proper hand hygiene protocol and potential recontamination events. : Hands were washed with soap and sterile gloves applied with no observed recontamination before only 3% of all observed procedures requiring aseptic technique. There was no significant difference in hygiene compliance between midwives and doctors nor facilities or states. Adherence to proper hygiene protocol was observed more in morning compared to afternoon and night shifts. : This study highlights that hand hygiene remains a barrier to delivering high-quality and safe care in health facilities. Improving hygiene practices during labour and delivery will require strategies that extend beyond infrastructure provision.
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http://dx.doi.org/10.3390/ijerph16071301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479678PMC
April 2019

A mixed-methods study of women's sanitation utilization in informal settlements in Kenya.

PLoS One 2019 21;14(3):e0214114. Epub 2019 Mar 21.

Edward J. Bloustein School of Planning & Public Policy, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, United States of America.

While access to safe sanitation is a global issue, there are large disparities in access. Women living in informal settlements, in particular, are disproportionately affected by lack of access to sanitation. Without adequate sanitation, these women may resort to unsafe strategies to manage their sanitation needs, but limited research has focused specifically on this issue. Qualitative and quantitative data were collected from women in the Mathare informal settlement in Nairobi, Kenya in 2016. A latent class analysis (LCA) using the quantitative data yielded five distinct sanitation profiles (SP) among women in Mathare. In-depth interviews and sanitation walks with women added further detail about the characteristics of and motivations underlying each profile. Women's sanitation profiles in these settlements are complex. A majority of women in this study utilized an unsafe method of disposal at least once in a 24-hour period that increased their risk of direct exposure to waste and harmful pathogens.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214114PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428280PMC
December 2019

Enteric Pathogen Diversity in Infant Foods in Low-Income Neighborhoods of Kisumu, Kenya.

Int J Environ Res Public Health 2019 02 12;16(3). Epub 2019 Feb 12.

Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA 52246, USA.

Pediatric diarrheal disease remains the second most common cause of preventable illness and death among children under the age of five, especially in low and middle-income countries (LMICs). However, there is limited information regarding the role of food in pathogen transmission in LMICs. For this study, we examined the frequency of enteric pathogen occurrence and co-occurrence in 127 infant weaning foods in Kisumu, Kenya, using a multi-pathogen PCR diagnostic tool, and assessed household food hygiene risk factors for contamination. Bacterial, viral, and protozoan enteric pathogen DNA and RNA were detected in 62% of the infant weaning food samples collected, with 37% of foods containing more than one pathogen type. Multivariable generalized linear mixed model analysis indicated type of infant food best explained the presence and diversity of enteric pathogens in infant food, while most household food hygiene risk factors considered in this study were not significantly associated with pathogen contamination. Specifically, cow's milk was significantly more likely to contain a pathogen (adjusted risk ratio = 14.4; 95% confidence interval (CI) 1.78⁻116.1) and more likely to have higher number of enteric pathogen species (adjusted risk ratio = 2.35; 95% CI 1.67⁻3.29) than porridge. Our study demonstrates that infants in this low-income urban setting are frequently exposed to diarrhoeagenic pathogens in food and suggests that interventions are needed to prevent foodborne transmission of pathogens to infants.
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http://dx.doi.org/10.3390/ijerph16030506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388216PMC
February 2019

Shared Sanitation Management and the Role of Social Capital: Findings from an Urban Sanitation Intervention in Maputo, Mozambique.

Int J Environ Res Public Health 2018 10 11;15(10). Epub 2018 Oct 11.

Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.

Shared sanitation-sanitation facilities shared by multiple households-is increasingly common in rapidly growing urban areas in low-income countries. However, shared sanitation facilities are often poorly maintained, dissuading regular use and potentially increasing disease risk. In a series of focus group discussions and in-depth interviews, we explored the determinants of shared sanitation management within the context of a larger-scale health impact evaluation of an improved, shared sanitation facility in Maputo, Mozambique. We identified a range of formal management practices users developed to maintain shared sanitation facilities, and found that management strategies were associated with perceived latrine quality. However-even within an intervention context-many users reported that there was no formal system for management of sanitation facilities at the compound level. Social capital played a critical role in the success of both formal and informal management strategies, and low social capital was associated with collective action failure. Shared sanitation facilities should consider ways to support social capital within target communities and identify simple, replicable behavior change models that are not dependent on complex social processes.
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http://dx.doi.org/10.3390/ijerph15102222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210686PMC
October 2018

Women's sanitation practices in informal settlements: A multi-level analysis of factors influencing utilisation in Nairobi, Kenya.

Glob Public Health 2019 05 12;14(5):663-674. Epub 2018 Oct 12.

a Edward J. Bloustein School of Planning & Public Policy, Rutgers , The State University of New Jersey , New Brunswick , USA.

For decades, countries throughout the world have failed to meet sanitation-related development goals. Access to safe sanitation is undeniably linked to improved health outcomes; yet, 2.4 billion people, globally, still lack access. The persistent failure to meet sanitation goals suggests that our understanding of the factors that influence sustainable sanitation access and utilisation is incomplete. Despite growing availability of toilets in informal settlements, there is evidence that women, in particular, may adopt other strategies for managing their sanitation needs. Empirical data documenting the motivations underlying such practices in sub-Saharan Africa are limited. This study uses cross-sectional data collected in 2016 from women in Mathare Valley Informal Settlement in Nairobi, Kenya. Boosted and logistic regressions were used to investigate which factors were associated with women's common sanitation patterns. Lack of privacy and insecurity at toilets and neighbourhood disorganisation emerged as important factors - particularly for women who reported regularly using buckets or plastic bags for urination/defecation. These findings suggest that availability of toilets may not be enough to eliminate sanitation-related health risks in informal settlements. Future interventions may need to address other barriers to sanitation access if sustainable gains in this important public health area are to be achieved.
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http://dx.doi.org/10.1080/17441692.2018.1534256DOI Listing
May 2019

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya.

Hum Resour Health 2018 10 4;16(1):53. Epub 2018 Oct 4.

Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.

Background: Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation.

Methods: This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B.

Results: In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement.

Motivation: Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities.

Conclusions: In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.
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http://dx.doi.org/10.1186/s12960-018-0318-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172748PMC
October 2018

Collective Efficacy: Development and Validation of a Measurement Scale for Use in Public Health and Development Programmes.

Int J Environ Res Public Health 2018 09 28;15(10). Epub 2018 Sep 28.

Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.

Impact evaluations of water, sanitation, and hygiene interventions have demonstrated lower than expected health gains, in some cases due to low uptake and sustained adoption of interventions at a community level. These findings represent common challenges for public health and development programmes relying on collective action. One possible explanation may be low collective efficacy (CE)-perceptions regarding a group's ability to execute actions related to a common goal. The purpose of this study was to develop and validate a metric to assess factors related to CE. We conducted this research within a cluster-randomised sanitation and hygiene trial in Amhara, Ethiopia. Exploratory and confirmatory factor analyses were carried out to examine underlying structures of CE for men and women in rural Ethiopia. We produced three CE scales: one each for men and women that allow for examinations of gender-specific mechanisms through which CE operates, and one 26-item CE scale that can be used across genders. All scales demonstrated high construct validity. CE factor scores were significantly higher for men than women, even among household-level male-female dyads. These CE scales will allow implementers to better design and target community-level interventions, and examine the role of CE in the effectiveness of community-based programming.
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http://dx.doi.org/10.3390/ijerph15102139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211028PMC
September 2018

Child's play: Harnessing play and curiosity motives to improve child handwashing in a humanitarian setting.

Int J Hyg Environ Health 2019 03 13;222(2):177-182. Epub 2018 Sep 13.

Department for Disease Control, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK.

In humanitarian emergency settings there is need for low cost and rapidly deployable interventions to protect vulnerable children, in- and out-of-school, from diarrhoeal diseases. Handwashing with soap can greatly reduce diarrhoea but interventions specifically targeting children's handwashing behaviour in humanitarian settings have not been tested. Traditional children's handwashing promotion interventions have been school-focused, resource-intensive and reliant on health-based messaging. However, recent research from non-humanitarian settings and targeting adults suggests that theory-based behaviour change interventions targeting specific motives may be more effective than traditional handwashing interventions. In this proof-of-concept study we test, for the first time, the distribution of a modified soap bar, designed to appeal to the motives of play and curiosity, in a household-level, rapidly deployable, handwashing promotion intervention for older children in a humanitarian setting - an internally displaced persons camp in Iraqi Kurdistan. Out of five total blocks within the camp, one was assigned to intervention and one to control. 40 households from each assigned block were then randomly chosen for inclusion in the study and the practice of handwashing with soap at key times was measured at baseline and four weeks after intervention delivery. Children in intervention households received transparent soaps with embedded toys, delivered within a short, fun, and interactive household session with minimal, non-health-based, messaging. The control group received plain soap delivered in a short standard, health-based, hygiene promotion session. At the 4-week follow-up, children in the intervention group were 4 times more likely to wash their hands with soap after key handwashing occasions than expected in the counterfactual (if there had been no intervention) based on the comparison to children in the control group (adjusted RR = 3.94, 95% CI 1.59-9.79). We show that distributing soaps with toys embedded inside, in a rapidly deployable intervention, can improve child handwashing behaviour in a humanitarian emergency context. Further studies are needed to determine the longer-term behavioural and health impact of such an intervention when delivered at a greater scale in a humanitarian context.
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http://dx.doi.org/10.1016/j.ijheh.2018.09.002DOI Listing
March 2019

Social Influence on Handwashing with Soap: Results from a Cluster Randomized Controlled Trial in Bangladesh.

Am J Trop Med Hyg 2018 10;99(4):934-936

Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom.

We analyzed data from a cluster-randomized controlled trial conducted among 20 schools in Rajshahi, Bangladesh, to explore the role of social influence on handwashing with soap (HWWS) in a primary school setting. Using data collected through covert video cameras outside of school latrines, we used robust Poisson regression analysis to assess the impact of social influence-defined as the presence of another person near the handwashing location-on HWWS after a toileting event. In adjusted analyses, we found a 30% increase in HWWS when someone was present, as compared with when a child was alone (Prevalence ratio 1.30; 95% confidence interval: 1.14-1.47, < 0.001). The highest prevalence of HWWS was found when both child(ren) and adult(s) were present or when just children were present (64%). Our study supports the conclusion that the presence of another individual after a toileting event can positively impact HWWS in a primary school setting.
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http://dx.doi.org/10.4269/ajtmh.17-0903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159569PMC
October 2018

Shared latrines in Maputo, Mozambique: exploring emotional well-being and psychosocial stress.

BMC Int Health Hum Rights 2018 07 25;18(1):30. Epub 2018 Jul 25.

London School of Hygiene and Tropical Medicine, Department of Disease Control, Kepple Street, London, UK.

Background: Approximately 18% of Sub-Saharan Africa's urban population relies on shared sanitation facilities, which are shared by one or more households. While there is growing recognition of sanitation's relationship with stress and well-being - particularly among women - most research has focused on rural populations and the transition from open defecation and/or unimproved latrines to private shared sanitation. This study explores sanitation-related stressors among users of both improved and unimproved shared sanitation facilities.

Methods: This study was nested within the larger MapSan health impact trial (Trial Registration: NCT02362932). Participants were recruited from the control arm of the trial (Traditional Latrine (TL) users) and intervention arm, which received one of two improved shared sanitation facilities - Shared Latrines (SL) shared by up to 20 individuals and Community Sanitation Blocks (CSBs) shared by more than 20 individuals. Sampling was informed by a life stage perspective to reflect diversity in sanitation needs and experiences within the population. Data included 96 in-depth interviews, 7 focus group discussions, and 25 unstructured observations. Data collection and analysis followed a Grounded Theory approach, which was used to identify the key domains of sanitation-related stress among participants. A semi-structured tool was applied to all female interview transcripts to assess the frequency and severity of key stressors.

Results: Participants reported stress due to: lack of safety; lack of privacy; disgust about the latrine condition; and collective action failure in terms of managing the latrine, often causing neighborhood conflict or unhygienic sanitation conditions. Fewer SL and CSB users reported specific stress domains and - with the exception of perceived safety - reported fewer severe stressors. The leading cause of stress reduction due to the intervention was decreased disgust followed by increased privacy and safety.

Conclusions: Our data suggest that "improved", shared facilities can reduce stress when proper maintenance and management systems are in place. Private, shared sanitation only had limited impact on users' perceptions of safety, particularly at night, suggesting that safety concerns extend beyond the physical latrine structure. Our research demonstrates that factors including latrine location and neighborhood violence are important determinants of safety perceptions and corresponding psychosocial stress.
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http://dx.doi.org/10.1186/s12914-018-0169-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060455PMC
July 2018

Access to Household Water Quality Information Leads to Safer Water: A Cluster Randomized Controlled Trial in india.

Environ Sci Technol 2018 05 17;52(9):5319-5329. Epub 2018 Apr 17.

School of Civil and Environmental Engineering , Georgia Institute of Technology , 790 Atlantic Drive , Atlanta , Georgia 30332 , United States.

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 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.
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http://dx.doi.org/10.1021/acs.est.8b00035DOI Listing
May 2018