A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline

Evaluating and Enhancing an Educational Intervention to Reduce Smallholder Farmers' Exposure to Pesticides in Uganda Through a Digital, Systematic Approach to Behavior Change: Protocol for a Cluster-Randomized Controlled Trial

BACKGROUND

Smallholder farmers receive educational interventions on safe pesticide handling by governmental agencies, industries, or nongovernmental organizations to reduce exposure risks. However, existing educational interventions have limited effects on changing behaviors. Targeting psychosocial determinants of behavior change in educational interventions through theory- and evidence-based approaches may enhance their effectiveness.

OBJECTIVE

We aim at describing the intervention development and study design of a 3-arm cluster-randomized controlled trial to assess the effects in improving safe pesticide handling and reducing pesticide exposure of (1) an existing educational intervention and (2) a newly developed SMS text messaging intervention based on the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) behavior change approach.

METHODS

We enrolled 539 Ugandan smallholder farmers in 12 clusters (subcounties). The clusters, each with 45 farmers, were randomly allocated to one of the three arms: (1) educational intervention, (2) educational intervention+RANAS-based SMS text messages, or (3) control group. The educational intervention comprised a 2-day workshop that targeted multiple aspects of safe pesticide handling, whereas the SMS text messages targeted the use of personal protective equipment (PPE) and were based on the RANAS approach. For intervention development in this study, this approach includes identifying psychosocial determinants of PPE use at baseline and selecting behavior change techniques to target them in SMS text messages. The primary outcomes of the study are (1) pesticide knowledge, attitude, and practice scores indicating performance throughout the educational intervention; and (2) frequency of PPE use. Secondary outcomes are the RANAS-based behavioral determinants of PPE use, the frequency of glove use, algorithm-based pesticide exposure intensity scores, and signs and symptoms of pesticide poisoning. The outcomes were assessed in structured interviews before the intervention (baseline) and at the 12-month follow-up. The effect of the interventions among the arms will be analyzed using the intervention arms and baseline measures as predictors and the follow-up measures as outcomes in linear multivariable mixed models including the clusters as random effects. The mediating psychosocial determinants of the interventions will be assessed in multiple mediation models.

RESULTS

The study was conducted from 2020 to 2021-baseline interviews were conducted in October 2020, and the educational intervention was delivered in November 2020. The RANAS-based SMS text messages were developed based on the baseline data for relevant behavioral determinants of PPE use and sent between February 2021 and September 2021. Follow-up interviews were conducted in October 2021. Overall, 539 farmers were enrolled in the study at baseline; 8.3% (45/539) were lost to follow-up by the end of the study.

CONCLUSIONS

This study will contribute to a better understanding of the effectiveness and behavior change mechanisms of educational interventions by using an experimental, cluster-randomized study design to improve pesticide handling among smallholder farmers.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) 18237656; https://doi.org/10.1186/ISRCTN18237656.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55238.

An overview of the Be Well Home Health Navigator Program to reduce contaminants in well water: Design and methods

BACKGROUND

The Be Well Home Health Navigator Program is a prospective, randomized controlled trial (RCT) implemented to compare a community health navigator program to usual care program to reduce contaminants in drinking water.

DESIGN AND SETTING

This 4-year two-armed RCT will involve well owners in Oregon that have private drinking water wells that contain arsenic, nitrate, or lead above maximum contaminant levels.

INTERVENTION

The intervention leverages the trusted relationship between Cooperative Extension Service (CES) Community Educators and rural well owners to educate, assist and motivate to make decisions and set actionable steps to mitigate water contamination. In this study, CES will serve as home health navigators to deliver: 1) individualized feedback, 2) positive reinforcement, 3) teach-back moments, 4) decision-making skills, 5) navigation to resources, 6) self-management, and 7) repeated contact for shaping and maintenance of behaviors. Usual care includes information only with no access to individual meetings with CES.

MEASURABLE OUTCOMES

Pre-specified primary outcomes include 1) adoption of treatment to reduce exposure to arsenic, nitrate, or lead in water which may include switching to bottled water and 2) engagement with well stewardship behaviors assessed at baseline, and post-6 and 12 months follow-up. Water quality will be measured at baseline and 12-month through household water tests. Secondary outcomes include increased health literacy scores and risk perception assessed at baseline and 6-month surveys.

IMPLICATIONS

The results will demonstrate the efficacy of a domestic well water safety program to disseminate to other CES organizations.

TRIAL REGISTRATION NUMBER

NCT05395663.

Assessing the Effectiveness of a Multicomponent Intervention on Hand Hygiene and Well-Being in Primary Health Care Centers and Schools Lacking Functional Water Supply in Protracted Conflict Settings: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Hand hygiene is crucial in health care centers and schools to avoid disease transmission. Currently, little is known about hand hygiene in such facilities in protracted conflict settings.

OBJECTIVE

This protocol aims to assess the effectiveness of a multicomponent hand hygiene intervention on handwashing behavior, underlying behavioral factors, and the well-being of health care workers and students. Moreover, we report our methodology and statistical analysis plan transparently.

METHODS

This is a cluster randomized controlled trial with 2 parallel arms taking place in 4 countries for 1 year. In Burkina Faso and Mali, we worked in 24 primary health care centers per country, whereas in Nigeria and Palestine, we focused on 26 primary schools per country. Facilities were eligible if they were not connected to a functioning water source but were deemed accessible to the implementation partners. Moreover, health care centers were eligible if they had a maternity ward and ≥5 employees, and schools if they had ≤7000 students studying in grades 5 to 7. We used covariate-constrained randomization to assign intervention facilities that received a hardware, management and monitoring support, and behavior change. Control facilities will receive the same or improved intervention after endline data collection. To evaluate the intervention, at baseline and endline, we used a self-reported survey, structured handwashing observations, and hand-rinse samples. At follow-up, hand-rinse samples were dropped. Starting from the intervention implementation, we collected longitudinal data on hygiene-related health conditions and absenteeism. We also collected qualitative data with focus group discussions and interviews. Data were analyzed descriptively and with random effect regression models with the random effect at a cluster level. The primary outcome for health centers is the handwashing rate, defined as the number of times health care workers performed good handwashing practice with soap or alcohol-based handrub at one of the World Health Organization 5 moments for hand hygiene, divided by the number of moments for hand hygiene that presented themselves during the patient interaction within an hour of observation. For schools, the primary outcome is the number of students who washed their hands before eating.

RESULTS

The baseline data collection across all countries lasted from February to June 2023. We collected data from 135 and 174 health care workers in Burkina Faso and Mali, respectively. In Nigeria, we collected data from 1300 students and in Palestine from 1127 students. The endline data collection began in February 2024.

CONCLUSIONS

This is one of the first studies investigating hand hygiene in primary health care centers and schools in protracted conflict settings. With our strong study design, we expect to support local policy makers and humanitarian organizations in developing sustainable agendas for hygiene promotion.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05946980 (Burkina Faso and Mali); https://www.clinicaltrials.gov/study/NCT05946980 and NCT05964478 (Nigeria and Palestine); https://www.clinicaltrials.gov/study/NCT05964478.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52959.

Absorbent hygiene products disposal behaviour in informal settlements: identifying determinants and underlying mechanisms in Durban, South Africa

BACKGROUND

Within South Africa, many low-income communities lack reliable waste management services. Within these contexts, absorbent hygiene product (AHP) waste, including nappies (diapers), are not recycled, and are often dumped, ending up in watercourses and polluting the local environment. The structural barriers to collection which have been well explored, however the behavioural determinants of safe disposal for AHPs remains poorly understood. The purpose of this study is to determine the psycho-social factors driving AHP disposal behaviour for caregivers, while identifying potential underlying mechanisms (such as mental health), which may be influencing disposal behaviour, with the intention of informing a future, contextually appropriate and sustainable, collection system.

METHODS

The cross-sectional study was conducted within three low-income communities located within eThekwini Municipality (Durban), South Africa. The study included a pre-study and a quantitative survey of 452 caregivers, utilising the RANAS approach of behaviour change. The quantitative questionnaire was based on the RANAS model to measure psycho-social factors underlying sanitary disposal of AHPs. Mental health was assessed using the Self-Reporting Questionnaire (SRQ-20). Statistical analysis involved regressing psycho-social factors onto disposal behaviour and exploring their interaction with mental health through a moderation model.

RESULTS

Our findings suggest that one third of caregivers do not dispose of nappies sanitarily, despite intent (86.9%). Regression analysis revealed ten psycho-social factors which significantly predict the desired behavioural outcome, the sanitary disposal of AHPs. Caregivers with poor mental health were less likely to dispose of AHP sanitarily, which reflects previous research linking poor mental health and the impairment of health-related daily activities, particularly within vulnerable groups. Specifically, several psycho-social factors underlying were moderated by poor mental health, the prevalence of sanitary disposal of AHPs depended on mental condition of caregiver.

CONCLUSIONS

Our findings confirmed the link between poor mental health and unsanitary AHPs disposal. This is especially relevant because poor mental health is common within South Africa. Addressing mental health problems within these communities is an essential step to providing sustainable waste management services. The findings informed an intervention strategy to implement a future collection system for these communities, and similar low-income or informal contexts within South Africa.

Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program

BACKGROUND

Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study.

OBJECTIVE

The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations.

METHODS

A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm).

RESULTS

A 47% reduction in urinary arsenic [geometric mean  ( GM ) = 13.2  to  7.0 μ g / g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM = 14.6  to  6.55 μ g / g creatinine) and 30% in the Intensive arm (GM = 11.2  to  7.82 μ g / g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%).

DISCUSSION

Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

Psychosocial factors associated with intention to pursue tertiary education among Malawian students: the moderating effect of mental health

BACKGROUND

In Sub Saharan Africa (SSA), approximately 9 million students are enrolled in tertiary education (TE), which is 4% of the total TE enrolment globally. Barriers to higher education in SSA are numerous: poverty, food insecurity, gender, and disability, while the COVID-19 pandemic has worsened the situation. Little is known about the psychosocial factors and underlying mechanisms associated with students' intention to apply for TE. Using a psychological theory of behaviour change, our study investigated the psychosocial and context factors associated with the application to TE.

METHODS

In a cross-sectional research study 821 interviews using researcher-administered questionnaires were conducted with secondary school students in rural and urban Blantyre, Malawi. A quantitative questionnaire based on the risks, attitudes, norms, abilities, and self-regulation (RANAS) model was used to assess psychosocial factors underlying application for TE. The Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and household hunger scale were used to assess mental health and hunger respectively.

RESULTS

More than half of the youth were at risk to develop depression (66.5%). Girls reported experiencing more depression symptoms than boys. Around 1 in every 5 interviewed youth lived in a home experiencing moderate or severe hunger. A higher intention to apply for TE was related to perceived vulnerability, affective beliefs (joy, happiness, excitement), injunctive (approval of others) and personal norms, self-efficacy, and commitment to apply. Factual knowledge about TE application was very limited. An intention to apply for TE and self-efficacy was positively associated with regular physical exercise, but negatively associated with mental health and hunger. However, mental health moderated the effects of physical exercise on the intention to apply for TE. We found significant differences between poor and good mental health groups on intention to apply for TE in perceived vulnerability, descriptive (behaviour of others) and personal norms, self-efficacy, maintenance self-efficacy and commitment factors. The results informed a behaviour change intervention strategy to increase students' intention to apply for TE.

CONCLUSIONS

Our research findings are an important contribution to the long-term strategy of achieving the Sustainable Development Goals (SDGs) and contribute to the inclusion of vulnerable students with impaired mental health in higher education in Malawi and beyond.

"People are now working together for a common good": The effect on social capital of participatory design for community-level sanitation infrastructure in urban informal settlements

Communities with higher levels of social capital perform better than communities with lower social capital in community-level water and sanitation interventions and have better health outcomes. Although research recommends bolstering social capital to improve intervention outcomes, few studies provide empirical evidence on the effect of intervention activities on social capital. This study aimed to evaluate the effect of participatory design and community engagement activities on social capital among urban informal settlements in Suva, Fiji and Makassar, Indonesia enrolled in the Revitalizing Informal Settlements and their Environments trial using the Short Adapted Social Capital Assessment Tool. We performed confirmatory factor analyses (CFA) to test tool performance and built structural equation models to assess intervention effect on CFA-informed, sub-scale scores for cognitive and structural social capital. Qualitative in-depth interviews in Fiji and Indonesia and focus group discussions in Fiji provided nuanced understanding of intervention effects on social capital from residents' perspectives. Results confirmed the hypothesized two-factor solution but revealed differences by country and by gender in Indonesia. The intervention appeared positively related to cognitive social capital among men and women in Indonesia and negatively related to cognitive and structural social capital among men and women in Fiji. While effect sizes were small and cluster-adjustment for a small number of settlements yielded non-significant effects, trends were consistent across models and bivariate analyses and were corroborated by qualitative findings. Several contextual factors may explain these results, including timing and duration of intervention activities and influence of COVID-19. Qualitative data suggested that the relationship between participatory design and social capital may be bidirectional, helping to explain why certain settlements appeared to be better equipped to benefit from intervention activities. Practitioners and program designers should carefully consider the social pre-conditions of communities in which they intend to work to optimize program outcomes and avoid unintended consequences.

Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda

BACKGROUND

Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach.

METHODS

We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability).

RESULTS

Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased.

CONCLUSIONS

Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

What works in sanitation promotion?

Promotion appears to be the least effective but is nevertheless often the only available, means to achieve increased access to sanitation services, especially at scale, in lower-income countries. A cursory examination of the history of past and present approaches to sanitation promotion, including sanitation marketing, community development, community-led total sanitation and public health, shows that they have a variety of features and characteristics which make them distinctive. Unfortunately, rigorous evaluation has not kept pace with this proliferation of approaches, so it is difficult to recommend any one approach over the others, based on empirical performance in a range of circumstances. However, I argue that a 'hybrid' approach which exhibits a number of salient features from all of the previous approaches is likely to be a good bet. I present a recent example of such a hybrid programme which proved to significantly increase the rate of improved sanitation coverage through promotion (without subsidy of any kind) at scale in Tanzania. I suggest other sanitation promotion programs may want to think about adopting similar practices in their own programming going forward.

Determinants of household safe drinking water practices in Kabul, Afghanistan: New insights from behavioural survey data

More than 2 billion people worldwide lack access to safe drinking water. Household water treatment (HWT) is an interim option for reducing the risk of water born disease. Understanding the factors that influence HWT behaviour is crucial for delivering successful interventions aimed at scaling relevant technologies, but the literature tends to emphasise psychological determinants with little consideration of socioeconomic and contextual factors. This article responds to this literature by using the COM-B model to examine the determinants of HWT practices through a comprehensive and context-sensitive behaviour definition. We informed this model through a cross-sectional survey design in which we collected data from 913 households in two peri‑urban neighbourhoods of Kabul, Afghanistan. Our findings from descriptive statistical and regression analysis highlight the importance of not only psychological but also socio-economic and contextual determinants of HWT behaviour: Especially the COM-B dimensions of reflective and automatic motivation, and physical opportunity - which are heavily influenced by local context and economic circumstances - had statistically significant associations with performing HWT. The practical significance of these dimensions was similarly pronounced. For example, an increase in the physical opportunity index by 0.1 units from an average value of 0.7 to 0.8 would be associated with a 7.7 percentage-point higher likelihood of HWT performance. These results suggest that the COM-B model can be utilised to systematically design interventions aimed at promoting HWT practices, while highlighting the need to broaden behavioural analyses of HWT and consider contextual factors to develop interventions that are tailored to the specific needs and obstacles of different communities.

The effect of a health extension program on improving water, sanitation, and hygiene practices in rural Ethiopia

BACKGROUND

To make basic primary health care services accessible, especially to the rural community, the government of Ethiopia launched the Health Extension Program (HEP) in 2004. Most of components of HEP are dedicated to hygiene and sanitation. Few studies have assessed the role of the Health Extension Program in improving water, hygiene, and sanitation (WASH) practices in Ethiopia. This study explored the role of health extension workers (HEWs) in influencing household water treatment practices, latrine ownership, latrine use and ownership, and the use of hand-washing facilities on the incidence of diarrheal diseases among the children under five years of age in rural Ethiopia.

METHODS

Using a cross sectional design, we conducted a national assessment that covered all nine regions of Ethiopia. We conducted face-to-face interviews among a sample of 6430 rural households using a structured questionnaire and an observation checklist to collect data from March 2018 to May 2019. Multilevel logistic regressions models were used to determine the relationships between the exposure of households to HEWs and WASH practice outcomes such as the use of water from an improved water source, household water treatment practices, availability of hand-washing and hand-washing with soap and water, availability of latrines, and use of latrines as well as the incidence of diarrheal diseases among children age 5 and younger. Our models were adjusted for covariates and confounders and P-values less than 5% were set to determine statistical significance.

RESULTS

We found that 72.7% of rural households had some type of latrine and 27.3% reported practicing open defecation. A total of 71.5% of rural households had access to drinking water from improved water sources, but only 9.4% reported practicing household water treatment. Exposure to HEWs was positively associated with household water treatment practices (AOR: 1.46; 95% CI = 1.01-2.10) and latrine availability (AOR: 1.44; 95% CI = 1.15-1.80). Among the households who were either visited by HEWs at their home or the that visited health posts to meet with the HEWs, being exposed to WASH health education by HEWs was significantly associated with the availability of a hand-washing facility (AOR: 5.14; 95% CI = 4.11-6.42) and latrine availability (AOR: 1.48; 95% CI = 1.10-2.01). However, we did not find a relationship between the incidence of diarrhea among children age 5 and under and exposure to HEWs (AOR: 2.09; 95% CI = 0.73- 6.62).

CONCLUSION

Our results show a significant association between exposure to the Health Extension Program/ HEWs and improved household water treatment practices, latrine construction, and the availability of hand-washing facilities in rural Ethiopia, suggesting the need to strengthen efforts to change WASH behavior through the Heath Extension Program. On the other hand, further investigation is needed regarding the spillover effect of latrine use practices and the reduction of the incidence of diarrheal diseases.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program

BACKGROUND

The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program.

METHODS

The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up.

RESULTS

Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water.

CONCLUSIONS

The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure.

TRIAL REGISTRATION

The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation

BACKGROUND

Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh.

METHODS

We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics.

RESULTS

The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion.

CONCLUSION

Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Assessment of factors related to individuals who were never treated during mass drug administration for lymphatic filariasis in Ambon City, Indonesia

Background

One challenge to achieving Lymphatic filariasis (LF) elimination is the persistent coverage-compliance gap during annual mass drug administration (MDA) and the risk of ongoing transmission among never treated individuals. Our analysis examined factors associated with individuals who were never treated during MDA.

Methods

Data were derived from two cross-sectional surveys conducted in Waihaong and Air Salobar Health Center in 2018 and 2019. We analyzed information from 1915 respondents aged 18+ years. The study outcome was individuals who self-reported never treatment during any round of MDA. All potential predictors were grouped into socio-demographic, health system, therapy and individual factors. Logistic regression analyses were used to examine factors associated with never treatment in any year of MDA.

Results

Nearly half (41%) of respondents self-reported they were never treated during any round of MDA. Factors associated with increased odds of never treatment were respondents working in formal sectors (aOR = 1.75, p = 0.040), living in the catchment area of Waihaong Health Center (aOR = 2.33, p = 0.029), and those perceiving the possibility of adverse events after swallowing LF drugs (aOR = 2.86, p<0.001). Respondents reporting difficulty swallowing all the drugs (aOR = 3.12, p<0.001) and having difficulties remembering the time to swallow the drugs (aOR = 1.53, p = 0.049) also had an increased odds of never treatment. The highest odds of never treatment were associated with respondents reporting almost none of their family members took LF drugs (aOR = 3.93, p<0.001). Respondents confident that they knew how to swallow LF drugs had a reduced odds (aOR = 0.26, p<0.001) of never treatment.

Conclusions

Efforts to reassure community members about adverse events, specific instructions on how to take LF drugs, and improving awareness that MDA participation is part of one’s contribution to promoting community health are essential drivers for uptake with LF drugs during MDA.

Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid Response Program to Reduce Diarrheal Diseases in Bangladesh

(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient (confirmed by bacterial culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm, p < 0.05). Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children) (Prevalence Ratio (PR) 0.35, 95% CI: 0.14-0.85) and for children under 5 years of age (PR: 0.27, 95% CI: 0.085-0.87) during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.

Factors Related to Family Health Behavior in Samosir District: A Mix-Methods Study

BACKGROUND: Non-communicable and communicable diseases remain a problem in Indonesia, where both are closely related to unhealthy behavior. Family health behavior affects the health status of the family and community. AIM: The study aims to examine the factors related to family health behavior in the Samosir district. METHODS: This study used a mixed-method approach with an explanatory sequential design. The respondents were 187 families who were selected through multi-stage random sampling. In-depth interviews were conducted with six informants: Samosir Health Department staff, Community Health Center staff, and religious or community leaders. The study was conducted in ten villages across three sub-districts. The instrument passed the validity and reliability tests and met triangulation. The Ethics Committee of the Faculty of Public Health, Universitas Indonesia has approved ethical clearance. Univariate and multivariate analysis with logistic regression (CI 95%) were used for quantitative data, while content analysis was used for qualitative data. RESULTS: In Samosir District, family health behavior (consisting of eating vegetables and fruits, not smoking at home, washing hands with soap and water, and using clean water) was low (12.8 %). Attitudes, income, and the availability and affordability of health care facilities all have a significant correlation with family health behavior, according to multivariate analysis. In content analysis, attitudes, economy, community characteristics, infrastructure, and access were discovered to be related to family health behavior. CONCLUSIONS: Health promotion strategies such as health education, community empowerment, and cross-sectoral collaboration must be thoroughly implemented to address the factors related to family health behavior because they can increase family health behavior through family empowerment.

Contextual and psychosocial factors influencing caregiver safe disposal of child feces and child latrine training in rural Odisha, India

Child feces are an important source of fecal exposure in household environments. Typically, one of two behaviors is necessary to mitigate this risk: either caregivers dispose of their children’s feces into a latrine or children learn how to use a latrine. Although past studies have examined factors associated with these two behaviors collectively (i.e. “safe disposal”), there is a need to separately analyze these distinctive practices to better inform programming. This study aims to quantitatively examine contextual and psychosocial factors influencing caregiver safe disposal and, separately, child latrine training. We surveyed 791 primary female caregivers, who reported on 906 children <5 years old, across 74 villages in rural Odisha, India. At their last defecation event, 38% of children used the latrine and another 10% had their feces safely disposed of into the latrine. Since caregiver safe disposal was rare, we instead assessed safe disposal intention. We used linear regression and multilevel mixed effects models to examine contextual and psychosocial factors. For contextual factors, we found caregivers had stronger safe disposal intention when they came from wealthier households and had greater informational support, but weaker intention when their latrine was near the household. Caregivers more intensely practiced latrine training with their child when they themselves used the latrine for defecation, the latrine was fully intact, and they had greater instrumental support. For psychosocial factors, caregivers had stronger safe disposal intention when their households expected them to practice safe disposal, they felt strongly committed to the behavior, and had a plan for what to do when faced with a water shortage. Caregivers more intensely taught their child how to use the latrine when they believed their child was at risk of becoming sick if they practiced open defecation (OD); viewed child OD as unbeneficial; liked teaching their child; personally felt it was important for the child’s father to help; felt confident in their ability to teach their child; and had greater action control over their training practice. Interestingly, caregivers put less effort into latrine training when they felt more concerned for their child’s safety when the child defecated outside. These findings underscore the critical need to separately assess unique child feces management (CFM) practices and also provide a road map for practitioners on the types of behavior change strategies to consider in their CFM programming.

Psychosocial Determinants of Hand Hygiene, Facemask Wearing, and Physical Distancing During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

BACKGROUND

Hand hygiene, facemask wearing, and physical distancing play a crucial role in the prevention of the COVID-19 pandemic. Identifying the key psychosocial determinants of these precautionary behaviors contributes to effective intervention and policymaking for COVID-19 and future pandemics.

PURPOSE

This study aimed to systematically review and meta-analyze available evidence on psychosocial determinants of the general population's practice of three precautionary behaviors, based on the Risk, Attitudes, Norms, Abilities, and Self-regulation (RANAS) framework.

METHODS

Literature was identified by searching seven databases and relevant review papers. Observational and experimental studies targeting the general population (≥18 years) published between January 2020 to September 2021 were included. Pooled effect sizes were calculated with the inverse-variance method using random-effects models.

RESULTS

A total of 51 studies (64 samples) were included in the qualitative synthesis, of which 30 studies (42 samples) were included in the meta-analysis. RANAS-based constructs including knowledge, pros attitudes, and perceived norms were identified as significant determinants of all three behaviors in the meta-analysis. Perceived susceptibility and cons attitudes showed no significant associations with any behaviors. Perceived severity, perceived control, self-efficacy, and behavioral intention were significantly associated with one or two behaviors. Country (western vs. eastern hemispheres) significantly moderated the effects of certain risk and ability factors.

CONCLUSIONS

More research is needed with respect to the intention-behavior relationship, self-regulatory and reflexive factors of precautionary behaviors, as well as the exploration of the potential moderating effect of sociodemographic factors.

The COVID-19 Health Protocol among University Students: Case Studies in Three Cities in Indonesia

The COVID-19 pandemic has caused lifestyle changes for everyone and led to the practice of regulated health protocols for preventing the spreading or severity of the COVID-19 pandemic. This study examines the differences in health protocols and health practices among university students. The designed online survey was conducted among 292 university students in three cities in Indonesia, i.e., Yogyakarta, Semarang, and Surakarta. A forced-entry multivariate regression was conducted using all RANAS (risk, attitude, norms, ability-self-regulation) sub-factors as independent variables and health protocol obtained from PCA as the dependent variable. The results showed that the students' health protocol and health practices were practiced with varying frequency. A face mask covering the chin and nose was the most practiced health protocol, while reducing mobilization by maintaining distance was the most violated health protocol among students. We also found that four health protocol practices are highly correlated, i.e., handwashing in public spaces, physical distancing, frequency of using the mask, and avoiding crowded places. In addition, three significant psychological factors were identified, which were positively associated with the student's health protocol practice, i.e., belief about time (attitude) (OR: 0.119; CI: -0.054-0.136; p ≤ 0.05), personal norm (norm) (OR: 0.232; CI: 0.149-0.539; p ≤ 0.01), and action control (self-regulation) (OR: 0.173; CI: 0.046-0.427; p ≤ 0.05), where the personal norm is the most significant one. Finally, to minimize the COVID-19 transmission among students, especially when they back to onsite learning, it was important to create students' sense of ethical self-obligation to follow and practice standard health hygiene correctly and regularly.

A novel theatre-based behaviour change approach for influencing community uptake of schistosomiasis control measures

Background

Appropriate behaviour change with regard to safe water contact practices will facilitate the elimination of schistosomiasis as a public health concern. Various approaches to effecting this change have been trialled in the field but with limited sustainable outcomes. Our case study assessed the effectiveness of a novel theatre-based behaviour change technique (BCT), in combination with cohort awareness raising and capacity training intervention workshops.

Methodology

Our study was carried out in four rural communities in the Mwanza region of Tanzania and in the semi-urban town of Kemise, Ethiopia. We adapted the Risk, Attitude, Norms, Ability and Self-regulation (RANAS) framework and four phases using a mixed methods approach. Participatory project phase engagement and qualitative formative data were used to guide the design of an acceptable, holistic intervention. Initial baseline (BL) data were collected using quantitative questionnaire surveys with 804 participants in Tanzania and 617 in Ethiopia, followed by the theatre-based BCT and capacity training intervention workshops. A post-intervention (PI) survey was carried out after 6 months, with a participant return rate of 65% in Tanzania and 60% in Ethiopia.

Results

The intervention achieved a significant improvement in the knowledge of schistosomiasis transmission being associated with poorly managed sanitation and risky water contact. Participants in Tanzania increased their uptake of preventive chemotherapy (males: BL, 56%; PI, 73%, females: BL, 43%; PI, 50%). There was a significant increase in the selection of sanitation (Tanzania: BL, 13%; PI, 21%, Ethiopia: BL, 63%; PI, 90%), safe water and avoiding/minimising contact with infested waters as prevention methods in Tanzania and Ethiopia. Some of the participants in Tanzania followed on from the study by building their own latrines.

Conclusions

This study showed that substantial positive behaviour changes in schistosomiasis control can be achieved using theatre-based BCT intervention and disease awareness training. With the appropriate sensitisation, education and stakeholder engagement approaches, community members were more open to minimising risk-associated contact with contaminated water sources and were mobilised to implement preventive measures.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05421-5.

Does Poor Mental Health Impair the Effectiveness of Complementary Food Hygiene Behavior Change Intervention in Rural Malawi?

Mental disorders have the potential to affect an individual's capacity to perform household daily activities such as water, sanitation, and hygiene (food hygiene inclusive) that require effort, time, and strong internal motivation. However, there is limited detailed assessment about the influence of mental health on food hygiene behaviors at household level. We conducted a follow-up study to detect the effects of mental health on food hygiene behaviors after food hygiene intervention delivery to child caregivers in rural Malawi. Face-to-face interviews, based on the Risk, Attitude, Norms, Ability, and Self-regulations (RANAS) model, were conducted with 819 participants (control and intervention group) to assess their handwashing and food hygiene-related behaviors. Mental health was assessed using the validated Self-Reporting Questionnaire. Study results showed a significant negative relationship between mental health and handwashing with soap behavior (r = -0.135) and keeping utensils in an elevated place (r = -0.093). Further, a significant difference was found between people with good versus poor mental health on handwashing with soap behavior (p = 0.050) among the intervention group. The results showed that the influence of the intervention on handwashing with soap behavior was mediated by mental health. Thus, integration of mental health in food hygiene interventions can result in improved outcomes for caregivers with poor mental health.

Household-level sanitation in Ethiopia and its influencing factors: a systematic review

BACKGROUND

Within the past two decades, Ethiopia has achieved one of the fastest reductions of open defecation worldwide. This change can be attributed to the implementation of a national sanitation strategy that focused on facilitating community demand for latrine adoption and use of basic self-constructed latrines but less on other preconditions of hygienic sanitation. Recognition of sanitation by policymakers also catalyzed primary research in this area. As such, the synthesis of the available evidence is both warranted and possible. In this article, we thus decided to assess available primary evidence on the household-level sanitation in Ethiopia and its influencing factors.

METHODS

We searched primary studies that present findings on the role of factors influencing household-level sanitation outcomes in Ethiopia. We typologically classified sanitation outcomes analyzed in identified literature and computed pooled estimates for the most prevalent ones (measures of latrine availability and use). We characterized thematic types (themes and sub-themes) of influential sanitation drivers and used network analysis to examine the relational patterns between sanitation outcomes and their influencing factors.

FINDINGS

We identified 37 studies that met our inclusion criteria-all but one published after 2009. The general latrine coverage pooled across 23 studies was 70% (95% CI: 62-77%), the share of improved latrines pooled across 15 studies was 55% (95% CI: 41-68%), and latrine use pooled across 22 studies was 72% (95% CI: 64-79%). Between-study heterogeneity was high, and no time trends were identified. The identified sanitation outcomes were classified into eight types and factors reported to influence these outcomes were classified into 11 broader themes and 43 more specific sub-themes. Factors around the quality of latrines represented the most frequent sub-theme of consequential drivers. We found that the available research focused predominantly on outcomes concerning the initial adoption and use of basic latrines, emulating the main focus of national sanitation strategy. By contrast, research on drivers of the sustainability of sanitation change and, in particular, on the upgrading of latrines, has been rare despite its urgency. There is a high need to redirect the focus of sanitation research in Ethiopia towards understanding these factors on both the demand and supply side.

A systematic review and meta-analysis on the preventive behaviors in response to the COVID-19 pandemic among children and adolescents

Purpose

The purpose of this review was to synthesize the empirical evidence of relevant studies related to preventive behaviors in response to the COVID-19 pandemic among children and adolescents. Further to this, we aimed to identify the demographic, psychological, and social and environmental correlates of such behaviors.

Methods

Following PRISMA guidelines, eligible literature was identified by searching seven databases (PsycINFO, PubMed, MEDLINE, EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov website) and reference list of included studies and relevant review papers from 1^st Jan 2020 to 28^th Feb 2021. The standardized mean difference and correlation coefficients r were extracted to estimate the effect sizes. Analyses were conducted using R software.

Results

Of the 35,271 original papers, 23 eligible studies were included in the qualitative synthesis and all these studies were of moderate-to-high quality, of which 17 studies were further included into the quantitative analysis. Children and adolescents (6–20 yrs.) showed a poorer practice of COVID-19 preventive behaviors compared to younger adults (21–59 yrs.) with a small-to-medium effect size (SMD = -.25, 95%CI = -.41 to -.09). For the demographic correlates, children and adolescents’ COVID-19 preventive practice was found to be significantly associated with gender (r = .14, 95%CI = .10 to .18), while not with age (r = -.02, 95%CI = -.14 to .10). Narratively, knowledge was found to be consistently and significantly correlated. For the psychological correlates, small-to-medium overall effects were identified for the association with attitudes (r = .26, 95%CI = .21 to .31) and perceived severity (r = .16, 95%CI = .01 to .30). For the family and social correlates, a non-significant association was identified between family economic status and COVID-19 preventive behaviors (r = .004, 95%CI = -.12 to .12).

Conclusions

Interventions and relevant policies of promoting children and adolescent’s preventive measures should be a priority. Further, empirical studies identifying the demographic, psychological, and family and social correlates of children and adolescents’ preventive behaviors are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13585-z.

Process Evaluation of “The Hygienic Family” Intervention: A Community-Based Water, Sanitation, and Hygiene Project in Rural Malawi

Process evaluations of environmental health interventions are often under-reported and under-utilized in the development of future programs. The “Hygienic Family” intervention targeted improvements in hygiene behaviors of caregivers with under five-year-old children in rural Malawi. Delivered through a combination of open days, cluster meetings, household visits, and prompts, data were collected from two intervention areas for ten months. A process evaluation framework provided indicators that were measured through intervention implementation and expenditure reports, focus groups discussions, interviews, and household surveys. The collected data assessed the intervention fidelity, dose, reach, acceptability, impact, and cost. Results indicated that all planned hygiene promotion messages were delivered, and study participants were better reached primarily through household visits (78% attended over 75% of the intervention) than cluster meetings (57% attended over 75% of the intervention). However, regression found that the number of household visits or cluster meetings had no discernible effect on the presence of some household hygiene proxy indicators. Intervention implementation cost per household was USD 31.00. The intervention delivery model provided good fidelity, dose, and reach and could be used to strengthen the scope of child health and wellbeing content. The intensive face-to-face method has proven to be effective but would need to be adequately resourced through financial support for community coordinator remuneration.

Do health risk perceptions motivate water - and health-related behaviour? A systematic literature review

Health-related risk perceptions are important determinants of health behaviours and components of behaviour change theories. What someone thinks or feels will motivate or hinder their intention or hesitancy to implement a certain behaviour. Thus, a perceived potential risk to our health and well-being can influence our health-promoting and/or health-seeking behaviour. We aimed to review and synthesize available peer-reviewed literature to better understand the links between water and health-related risk perceptions and behaviours. We conducted the first systematic review of peer-reviewed literature on risk perceptions and behaviours in the context of water and health, published between 2000 and 2021. A total of 187 publications met the inclusion criteria. We extracted data relating to study characteristics and categorized our results according to the major themes emerging from the literature, namely drinking water, sanitation, hygiene and wasterelated topics, health risk factors, diseases and mental health implications, and preventative measures. Our review shows that the literature has grown over the past twenty years, reporting information from different countries belonging to different income groups around the globe, conducted in various settings and contexts, among different target populations, from various disciplinary angles, using different methods, theories and approaches. Our review provides evidence of health risk perceptions determining behaviour particularly related to drinking water sources and water safety. Evidence on disease prevention, health seeking, variations and changes in perception and behaviour over space, geography, socioeconomic differences and time, and the relevance of cultural context is provided. Our review shows that risk perception studies are vital for WASH governance in terms of policy, raising awareness, education and behaviour change. In order to make risk perception and behaviour studies even more relevant to effective public health planning and health messaging, future research needs to increasingly focus on early culturally sensitive interventions and changes in perceptions and behaviours over time.

How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq

This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq–a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

Changes in the use of mobile devices during the crisis: Immediate response to the COVID-19 pandemic

We analyze the smartphone usage behavior of individuals against the background of the spread of the coronavirus disease (COVID-19) to classify usage behaviors and examine the factors that lead to change. Specifically, we examine the differences in smartphone usage between the first wave and the second wave of the epidemic in Japan. On average, the frequency of use increased, especially during the first wave of the epidemic. Next, we classify the changes in usage behavior and examine the differences between individuals whose smartphone usage time increased and those whose usage time decreased. Our analysis using personal characteristics as explanatory variables suggests that demographic variables may explain behavioral changes. We were able to classify the factors into three categories: positive factors that promote an increase in usage time, negative factors that promote a decrease, and variation factors that promote fluctuations.

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

INTRODUCTION

Achieving 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.

METHODS

An 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.

RESULTS

The 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.

CONCLUSION

Open 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.

Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial

BACKGROUND

Uptake of Government-promoted sanitation remains a challenge in India. We aimed to investigate a low-cost, theory-driven, behavioural intervention designed to increase latrine use and safe disposal of child faeces in India.

METHODS

We did a cluster-randomised controlled trial between Jan 30, 2018, and Feb 18, 2019, in 66 rural villages in Puri, Odisha, India. Villages were eligible if not adjacent to another included village and not designated by the Government to be open-defecation free. All latrine-owning households in selected villages were eligible. We assigned 33 villages to the intervention via stratified randomisation. The intervention was required to meet a limit of US$20 per household and included a folk performance, transect walk, community meeting, recognition banners, community wall painting, mothers' meetings, household visits, and latrine repairs. Control villages received no intervention. Neither participants nor field assessors were masked to study group assignment. We estimated intervention effects on reported latrine use and safe disposal of child faeces 4 months after completion of the intervention delivery using a difference-in-differences analysis and stratified results by sex. This study is registered at ClinicalTrials.gov, NCT03274245.

FINDINGS

We enrolled 3723 households (1807 [48·5%] in the intervention group and 1916 [51·5%] in the control group). Analysis included 14 181 individuals (6921 [48·8%] in the intervention group and 7260 [51·2%] in the control group). We found an increase of 6·4 percentage points (95% CI 2·0-10·7) in latrine use and an increase of 15·2 percentage points (7·9-22·5) in safe disposal of child faeces. No adverse events were reported.

INTERPRETATION

A low-cost behavioural intervention achieved modest increases in latrine use and marked increases in safe disposal of child faeces in the short term but was unlikely to reduce exposure to faecal pathogens to a level necessary to achieve health gains.

FUNDING

The Bill & Melinda Gates Foundation and International Initiative for Impact Evaluation.

Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India

BACKGROUND

Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child's feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices.

METHODS

The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child's feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs' hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback.

DISCUSSION

This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure.

TRIAL REGISTRATION

This trial is registered at ISRCTN: ISRCTN15831099.

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.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

Incorporating qualitative research methods into the monitoring and evaluation of neglected tropical disease programmes: a scoping literature review

This publication addresses the limited use of qualitative methods in neglected tropical disease (NTD) programmes. It describes a scoping literature review conducted to inform the development of a guide to inform the use of rapid qualitative assessments to strengthen NTD mass drug administration (MDA) programmes. The review assessed how qualitative methods are currently used by NTD programmes and identified qualitative approaches from other health and development programmes with the potential to strengthen the design of MDA interventions. Systematic review articles were reviewed and searched using key terms conducted on Google Scholar and PubMed. Results show that methods used by NTD programmes rely heavily on focus group discussions and in-depth interviews, often with time-consuming analysis and limited information on how results are applied. Results from other fields offered insight into a wider range of methods, including participatory approaches, and on how to increase programmatic uptake of findings. Recommendations on how to apply these findings to NTD control are made. The topic of human resources for qualitative investigations is explored and a guide to improve MDAs using qualitative methods is introduced. This guide has direct applicability across the spectrum of NTDs as well as other public health programmes.

Kukaa Salama (Staying Safe): study protocol for a pre/post-trial of an interactive mHealth intervention for increasing COVID-19 prevention practices with urban refugee youth in Kampala, Uganda

INTRODUCTION

With over 82.4 million forcibly displaced persons worldwide, there remains an urgent need to better describe culturally, contextually and age-tailored strategies for preventing COVID-19 in humanitarian contexts. Knowledge gaps are particularly pronounced for urban refugees who experience poverty, overcrowded living conditions and poor sanitation access that constrain the ability to practise COVID-19 mitigation strategies such as physical distancing and frequent hand washing. With over 1.4 million refugees, Uganda is sub-Saharan Africa's largest refugee hosting nation. More than 90 000 of Uganda's refugees live in Kampala, most in informal settlements, and 27% are aged 15-24 years old. There is an urgent need for tailored COVID-19 responses with urban refugee adolescents and youth. This study aims to evaluate the effectiveness of an 8-week interactive informational mobile health intervention on COVID-19 prevention practices among refugee and displaced youth aged 16-24 years in Kampala, Uganda.

METHODS AND ANALYSIS

We will conduct a pre-test/post-test study nested within a larger cluster randomised trial. Approximately 385 youth participants will be enrolled and followed for 6 months. Data will be collected at three time points: before the intervention (time 1); immediately after the intervention (time 2) and at 16-week follow-up (time 3). The primary outcome (self-efficacy to practise COVID-19 prevention measures) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health practices; food and water security; COVID-19 vaccine acceptability) will be evaluated using descriptive statistics and regression analyses.

ETHICS AND DISSEMINATION

This study has been approved by the University of Toronto Research Ethics Board, the Mildmay Uganda Research Ethics Committee, and the Uganda National Council for Science & Technology. The results will be published in peer-reviewed journals, and findings communicated through reports and conference presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04631367).

Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program)

Diarrheal disease remains a leading cause of child mortality, globally. In the Democratic Republic of the Congo (DRC), each year there are an estimated 45 million episodes of diarrhea in children under five years of age. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to develop theory-driven, evidence-based approaches to reduce diarrheal diseases among young children. The REDUCE prospective cohort study in Walungu Territory in Eastern DRC took guidance from the risks, attitudes, norms, abilities, and self-regulation model, the integrated behavioral model for water, sanitation, and hygiene (WASH), and other behavior change theories to identify psychosocial factors associated with WASH behaviors. Psychosocial factors were measured among 417 caregivers at baseline and caregiver responses to child mouthing of dirty fomites and handwashing with soap was assessed by 5-hour structured observation at the 6-month follow-up. Caregivers who agreed that their child could become sick if they put dirt in their mouth (perceived susceptibility) and caregivers that agreed they could prevent their child from playing with dirty things outside (self-efficacy) were significantly more likely to stop their child from mouthing a dirty fomite. Higher perceived susceptibility, self-efficacy, and disgust, and lower dirty reactivity, were associated with higher handwashing with soap behaviors. This study took a theory-driven and evidence-based approach to identify psychosocial factors to target for intervention development. The findings from this study informed the development of the REDUCE Baby WASH Modules that have been delivered to over 1 million people in eastern DRC.

Justice and sanitation well-being: an analysis of frameworks in the context of slippage, based on findings from Shravasti, Uttar Pradesh, India

Access to safe drinking water and adequate sanitation is considered as a basic human right. Swachh Bharat Mission - Gramin (Rural), launched by the Government of India in 2014, is hailed as an attempt towards that direction. On 2nd October 2019, India was declared free from open defecation, with rural households having full toilet coverage. However, despite Government claims, the existing literature indicates the presence of slippage: where households practice open defecation despite having access to toilets. Equating progress in sanitation interventions with mere toilet provision presents a partial assessment of sanitation. To address the gap, the 'Sanitation Well-being' framework, based on Amartya Sen's concept of justice, has been proposed. It identifies slippage as an outcome of various underlying factors across the sanitation life-cycle. The framework provides a lens to analyse existing frameworks and secondary data sets and finds that they do not capture the dynamism inherent in the sector. The efficacy of the framework has been tested in the rural district of Shravasti, Uttar Pradesh, India, through the rapid rural appraisal method. Through our investigation, we found that slippage exists in the field, and that the framework is a feasible instrument to assess sanitation as a comprehensive phenomenon.

Financial, institutional, environmental, technical, and social (FIETS) aspects of water, sanitation, and hygiene conditions in indigenous - rural Indonesia

Background

There is increasing recognition of the complexity underlying WASH conditions in developing countries. This article explores the complexity by assessing the vulnerability of a specific area to poor WASH conditions using a qualitative approach.

Methods

We present our findings for the district of East Sumba in Indonesia. This area is known as one of the poorest regions in Indonesia with inadequate WASH services, indigenous belief that hinder the practice of WASH-related behaviours, and has a high rate of children malnutrition. All the factors that contribute to poor WASH conditions were discussed through the lens of the Financial, Institutional, Environmental, Technological, and Social (FIETS) framework. We then summarised the factors and visualized the “system” using a mind map which shows how factors are interconnected and helps to find the root causes of poor WASH conditions.

Results

There are three main challenges that inhibit the improvement of WASH conditions in this area: inadequate institutional capacity, water scarcity, and poor socio-economic conditions. We found that a village leader is the most important actor who influences the sustainability of WASH services in this area and healthcare workers are influential WASH promoters. This study also shows how culture shapes people’s daily lives and institution performance, and influences the current WASH conditions in East Sumba. The mind map shows there is an overlap and interconnection between FIEST aspects and WASH conditions in the study area.

Conclusion

WASH conditions are influenced by many factors and are often interconnected with each other. Understanding this complexity is necessary to improve WASH conditions and sustain adequate WASH services in developing countries. Finally, WASH interventions have to be considerate of the prevailing cultural practices and should involve multidisciplinary stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11800-x.

Water, sanitation and hygiene (WASH) behaviour change research: why an analysis of contingencies of reinforcement is needed

Diarrheal disease associated with poor water, sanitation and hygiene (WASH) kills more than one million people every year. Safe WASH practices have the potential to greatly reduce these statistics but behaviour change interventions in the field have yielded little success to date. Currently, there is an emphasis on addressing cognitive processes to bring about changes in behaviour. In this review, a case is made for the benefits of a contingency-based perspective, focusing on the contextual antecedents and consequences of behaviour. The role of contingencies of reinforcement, not explored in previous WASH literature, is discussed as an explanatory framework for designing behaviour change strategies. A proper use of contrived reinforcers is recommended to counterbalance the natural reinforcers of convenience associated with risk practices. Recognising the role of consequences in the acquisition and maintenance of behaviour is an important step in the search for the answers urgently needed in the WASH field.

Does COVID-19 Promote Self-Service Usage among Modern Shoppers? An Exploration of Pandemic-Driven Behavioural Changes in Self-Collection Users

Due to health concerns related to COVID-19, shoppers have learned to minimise social contact by adopting various contactless self-service technologies to fulfil their consumption needs. This study explores shoppers' behavioural changes in relation to self-service, using the special research context of e-commerce self-collection services. By synthesising insights from the health psychology literature, this study proposes an affective-cognitive-social perspective to explain the pandemic-driven behavioural changes of self-collection users. The survey instrument is used for online data collection (n = 500), and a combined (descriptive and quantitative) method is adopted for data analysis. Our results suggest that, although with a relatively weak predictive power, the affective and cognitive appraisals of health risks lead to the reinforced usage of self-collection service. This also applies to the factors of action/coping planning and subjective norm. This study theoretically contributes to the self-service literature and creates managerial implications for retailers and logistics operators.

Midstream Players Determine Population-Level Behavior Change: Social Marketing Research to Increase Demand for Lead-Free Components in Pitcher Pumps in Madagascar

Lead (Pb) exposure through water contamination is an important issue at the intersection of public health and water, sanitation, and hygiene (WASH). Behavior-change programs designed to address this pressing problem rarely take a behavioral-science-informed approach, nor do they consider the role of intermediate players who often influence and support behavior change. Social marketing segments the population and focuses on the consumer/user throughout program development and implementation. To illustrate the social marketing process, this cross-sectional, qualitative design study investigates the use of Pb in the construction and maintenance of household pitcher pumps for potable water in Madagascar. A sample of 18 technicians were interviewed on their current practices, motivators, barriers, and communication channels for knowledge exchange. The results reveal the importance of peers, those considered experts or "market mavens", and the need for information on the dangers of Pb as an outdated practice for any future intervention. This study advances the notion of a design shift within engineering WASH projects, whereby social/behavioral approaches are used to consider the needs, concerns, and current behaviors of the consumer. We also advocate for engaging intermediate players who often influence behavior change in the rollout of an engineering innovation.

Environmental Issues Are Health Issues

Abstract. Increasing demands on ecosystems, decreasing biodiversity, and climate change are among the most pressing environmental issues of our time. As changing weather conditions are leading to increased vector-borne diseases and heat- and flood-related deaths, it is entering collective consciousness: environmental issues are human health issues. In public health, the field addressing these issues is known as environmental health. This field addresses both the effects people have on their environment as well as the effects of the environment on people. Psychology, as a discipline concerned with explaining, predicting, and changing behavior has much to contribute to these issues because human behavior is key in promoting environmental health. To date, however, an integrative view of environmental health in psychology is lacking, hampering urgently needed progress. In this paper, we review how the environment and human health are intertwined, and that much can be gained through a systemic view of environmental health in psychology. Based on a review of the literature, we suggest that psychologists unite efforts to promote an integrative science and practice of environmental health psychology, and jointly address environmental-health related behavior. The research agenda for this field will include integrating behavior change theory and intervention approaches. Thereby, psychology can potentially make an important contribution to sustained environmental health for generations to come.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review

BACKGROUND

Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear.

OBJECTIVES

To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change.

METHODS

We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising.

RESULTS

Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'.

CONCLUSIONS

Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice

BACKGROUND

Delivery of high quality, at-scale, and sustained services is a major challenge in the water, sanitation, and hygiene (WASH) sector, made more challenging by a dearth of evidence-based models for adaption across contexts in low- and middle-income countries.

OBJECTIVE

We aim to describe the value of implementation science (IS) for the WASH sector and provide recommendations for its application.

METHODS

We review concepts from the growing field of IS-defined as the "scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services"-and we translate their relevance to WASH research, learning, and delivery.

DISCUSSION

IS provides a suite of methods and theories to systematically develop, evaluate, and scale evidence-based interventions. Though IS thinking has been applied most notably in health services delivery in high-income countries, there have been applications in low-income settings in fields such as HIV/AIDS and nutrition. Expanding the application of IS to environmental health, specifically WASH interventions, would respond to the complexity of sustainable service delivery. WASH researchers may want to consider applying IS guidelines to their work, including adapting pragmatic research models, using established IS frameworks, and cocreating knowledge with local stakeholders. https://doi.org/10.1289/EHP7762.

Public Perception and Hand Hygiene Behavior During COVID-19 Pandemic in Indonesia

Hand hygiene practices are important not only during the corona virus disease 2019 (COVID-19) pandemic, but also critical to prevent the possible spread of other infectious diseases. This study aims to examine the current hand hygiene behaviors during the COVID-19 pandemic, post pandemic behavior intentions, and the relationship between behavior, psychosocial and contextual factors. A cross-sectional online survey was conducted from 28 May to 12 June 2020, with 896 valid responses obtained from Indonesian citizens over 18 years old. The survey questions included demographic characteristics, individual practices, risk perceptions, attitude, norm factors and ability factors related to hand hygiene during the COVID-19 pandemic. Descriptive analysis, chi square and multiple logistic regression tests were used to analyse the data. The results showed that 82.32% of female respondents and 73.37% male respondents reported handwashing practice 8 times or more per day during COVID-19 pandemic. Participants who perceived themselves at higher risk of contracting SARS-CoV-2 (OR 7.08, 2.26-22.17), had less negative perception toward the practice (OR 1.93, 1.32-2.82), perceived handwashing as an effective preventive measure (OR 1.77, 1.23-2.54), were female (OR 1.71, 1.21-2.41), perceived a more supportive norm (OR 1.68, 1.15-2.44) and noticed more barriers in access to handwashing facilities (OR 1.57, 1.05-2.36) were more likely to engage in hand hygiene practice more frequently during the pandemic. In conclusion, the majority of respondents did increase their frequency of hand hygiene practices during COVID-19 pandemic. In line with previous studies in other pandemic contexts, sex, perceived susceptibility and effectiveness are important predictors of hand hygiene practices, which are similar to findings from previous studies in other pandemic contexts. Addressing social norm related to the perceived hand hygiene practices of friends and important people is a potential health promotion strategy by creating hand hygiene norms in the community.

Norms and Social Network-Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial

BACKGROUND

Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings.

OBJECTIVE

The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India.

METHODS

Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for "our well-being"). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people's sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals.

RESULTS

We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context.

CONCLUSIONS

Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24407.

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Mental model-based repeated multifaceted (MRM) intervention design: a conceptual framework for improving preventive health behaviors and outcomes

Objective

Field interventions employed to improve preventive health behaviors and outcomes generally use well-established approaches; however, recent studies have reported that health education and promotional interventions have little to no impact on health behaviors, especially in low- and middle-income countries. We aimed to develop a conceptual framework to improve intervention designs that would internalize these concerns and limitations.

Results

We identified three major experimental design- and implementation-related concerns associated with mental models, including the balance between the treatment and control groups, the treatment group’s willingness to adopt suggested behaviors, and the type, length, frequency, intensity, and sequence of treatments. To minimize the influence of these aspects of an experimental design, we proposed a mental model-based repeated multifaceted (MRM) intervention design framework, which represents a supportive intervention design for the improvement of health education and promotional programs. The framework offers a step-by-step method that can be used for experimental and treatment design and outcome analysis, and that addresses potential implementation challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05516-9.

Planning for the health impacts of climate change: Flooding, private groundwater contamination and waterborne infection - A cross-sectional study of risk perception, experience and behaviours in the Republic of Ireland

The frequency and severity of flooding events will increase over the coming decades due to global climate change. While close attention has typically been paid to infrastructural and environmental outcomes of flood events, the potential adverse human health consequences associated with post-event consumption from private groundwater sources have received minimal attention, leading to a poor understanding of private well users' preparedness and the drivers of positive behavioural adoption. The current study sought to quantify the capacity of private well users to cope with flood-triggered contamination risks and identify the social psychological determinants of proactive attitudes in the Republic of Ireland, using a cross-sectional questionnaire incorporating two distinct models of health behaviour, the Health Belief Model and Risk-Attitude-Norms-Ability-Self Regulation model. Adoption of healthy behaviours prior to flooding was evaluated with respect to respondents' risk exposure, risk experience and risk perception, in addition to systematic supply stewardship under normal conditions. Associations between adoption of protective behaviours and perception, experience and socio-demographic factors were evaluated through multinomial and multiple logistic regressions, while a multi-model inferential approach was employed with the predictors of health behaviour models. Findings suggest that floods are not considered likely to occur, nor were respondents worried about their occurrence, with 72.5% of respondents who reported previous flooding experience failing to adopt protective actions. Prior experience of well water contamination increased adoption of proactive attitudes when flooding occurred (+47%), with a failure to adopt healthy behaviours higher among rural non-agricultural residents (136%). Low levels of preparedness to deal with flood-related contamination risks are a side-effect of the general lack of appropriate well stewardship under normal conditions; just 10.1% of respondents adopted both water treatment and frequent testing, in concurrence with limited risk perception and poor awareness of the nexus between risk factors (e.g. floods, contamination sources) and groundwater quality. Perceived risk, personal norms and social norms were the best predictors of protective behaviour adoption and should be considered when developing future awareness campaigns.