A simple index to measure hygiene behaviours

Water, sanitation and hygiene (WASH) index for primary healthcare facilities: Towards achieving WASH security

This study focused on designing a WASH Index for assessing the status of WASH in Primary Healthcare Facilities (PHCs) especially for low- and middle-income countries. To assess the effectiveness of the WASH Index in evaluating the WASH in PHCs, PHCs were selected from 70 Local Government Areas (LGA) across 3 Southwestern States in Nigeria. The WASH index comprises of the five Joint Monitoring Programme service ladders as outlined in the World Health Organization Global Baseline Report for monitoring basic WASH services in health care facilities: water, sanitation, hygiene, waste management and environmental cleaning. The 5 service elements (termed as components) assessed were based on 10 indicators and 30 sub-indicators. The results of the WASH Index of the PHCs were compared statistically on LGA and State basis with emphasis on the status of WASH facilities. The study concludes that the result would further provide baseline information on the status of WASH in PHCs in the selected States in the quest to achieve the Sustainable Development Goals (SDGs). This study recommends that the WASH Index could be adopted an assessment tool for evaluating WASH in PHCs in other to ensure communication of results to policy makers and other relevant stakeholders, for effective monitoring healthcare facilities.

Infection, nutritional status, and body composition: Associations at birth and 6 months postnatally in Soweto, South Africa

INTRODUCTION

The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life.

METHODS

Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis.

RESULTS

The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (β = -1.77) and lower FM (β = -0.61), and conversely with higher FFM (β = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (β = 0.66), HAZ (β = 1.14), and WHZ (β = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (β = 1.21).

DISCUSSION

Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities.

Personal and Household Hygiene Measures for Preventing Upper Respiratory Tract Infections among Children: A Cross-Sectional Survey of Parental Knowledge, Attitudes, and Practices

Personal and household hygiene measures are important for preventing upper respiratory tract infections (URTIs) and other infectious diseases, including coronavirus disease 2019 (COVID-19). An online survey recruited 414 eligible parents in Hong Kong to study their hygiene knowledge, attitudes, and practices (KAPs) regarding the prevention of URTIs among their children. The average knowledge score was high (10.2/12.0), but some misconceptions were identified. The majority of the participants agreed that good personal hygiene (93.5%) and good environmental hygiene (92.8%) can prevent URTIs. The average score for hand hygiene practices was high (3.78/4.00), but only 56.8% of the parents always performed hand hygiene before touching their mouths, noses, or eyes. In terms of environmental hygiene, only some household items were disinfected with disinfectants (door handles in 69.8% of the households, toilet seats in 60.4% of the households, the floor in 42.8% of the households, dining chairs in 24.2% of the households, and dining tables in 20.5% of the households). A higher knowledge score was associated with parents having tertiary educational levels or above, working as healthcare professionals, living in private residential flats or staff quarters, or having household incomes of HKD 70,000 or above. The results of multiple regression analyses also indicated that parents who were healthcare professionals and with higher household income had a better parental knowledge of hygiene measures after adjusting the attitude score. For hand hygiene, parents who achieved higher attitude scores obtained higher practice scores. Under the fifth wave of the COVID-19 epidemic, there were some misconceptions regarding hygiene among parents. Any health promotion program should target parents regarding taking proper personal and household hygienic measures, especially for those who had relatively lower socio-economic status and/or from a non-healthcare background. Motivating attitudes toward hand hygiene can lead to better practices.

Characterizing Behaviors Associated with Enteric Pathogen Exposure among Infants in Rural Ecuador through Structured Observations

The relative importance of environmental pathways that results in enteropathogen transmission may vary by context. However, measurement of contact events between individuals and the environment remains a challenge, especially for infants and young children who may use their mouth and hands to explore their environment. Using a mixed-method approach, we combined 1) semistructured observations to characterize key behaviors associated with enteric pathogen exposure and 2) structured observations using Livetrak, a customized software application, to quantify the frequency and duration of contacts events among infants in rural Ecuador. After developing and iteratively piloting the structured observation instrument, we loaded the final list of prompts onto a LiveTrak pallet to assess environmental exposures of 6-month infants (N = 19) enrolled in a prospective cohort study of diarrheal disease. Here we provide a detailed account of the lessons learned. For example, in our field site, 1) most mothers reported washing their hands after diaper changes (14/18, 77.8%); however only a third (4/11, 36.4%) were observed washing their hands; 2) the observers noted that animal ownership differed from observed animal exposure because animals owned by neighboring households were reported during the observation; and 3) using Livetrak, we found that infants frequently mouthed their hands (median = 1.9 episodes/hour, median duration: 1.6 min) and mouthed surroundings objects (1.8 episodes/hour, 1.9 min). Structured observations that track events in real time, can complement environmental sampling, quantitative survey data and qualitative interviews. Customizing these observations enabled us to quantify enteric exposures most relevant to our rural Ecuadorian context.

Social and geographic inequalities in water, sanitation and hygiene access in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe

INTRODUCTION

Many refugees face challenges accessing water, sanitation, and hygiene (WASH) services. However, there is limited literature on WASH access for refugee populations, including for menstrual health services. Unmet WASH access needs may therefore be hidden, amplifying morbidity and mortality risks for already vulnerable refugee populations. The aim of this study was therefore to quantitatively analyze WASH access among refugee camps, with a focus on households with women of reproductive age.

METHODS

This was a cross-sectional study that utilized the Standardized WASH Knowledge, Attitude and Practice (KAP) Survey. A total of 5632 household questionnaires were completed by the United Nations Refugee Agency in 2019 in 21 refugee camps and settlements in Bangladesh, Kenya, South Sudan, Uganda, and Zimbabwe. WASH access (14 items) and social and geographic stratifiers were analyzed at the household-level including the refugee camp, country of the settlement, having women of reproductive age, members with disability/elderly status, and household size. We calculated frequencies, odds ratios, and performed bivariate and multivariate analyses to measure inequalities. We developed a Female WASH Access Index to characterize WASH access for households with women of reproductive age.

RESULTS

Most refugee households had high levels of access to improved water (95%), low levels of access to waste disposal facility (64%) and sanitation privacy (63%), and very low access to basic sanitation (30%) and hand hygiene facility (24%). 76% of households with women of reproductive age had access to menstrual health materials. WASH access indicators and the Female WASH Access Index showed large inequalities across social and geographic stratifiers. Households with disabled or elderly members, and fewer members had poorer WASH access. Households with women of reproductive age had lower access to basic sanitation.

CONCLUSIONS

Large inequalities in WASH access indicators were identified between refugee sites and across countries, in all metrics. We found high levels of access to improved water across most of the refugee camps and settlements studied. Access to basic hygiene and sanitation, sanitation privacy, waste disposal, and menstrual health materials, could be improved across refugee sites. Households with women of reproductive age, with 4+ members, and without members with disability/elderly status were associated with higher WASH access. The female WASH access index piloted here could be a useful tool to quickly summarize WASH access in households with women of reproductive age.

Water, sanitation and hygiene (WaSH) practices and diarrhoea prevalence among children under five years in a tribal setting in Palghar, Maharashtra, India

Providing safe drinking water, sanitation and hygiene (WaSH) in geographically isolated settings is a global public health priority. Prevalence of WaSH practices among mothers and diarrhoea among their children (birth to 59 months) was studied in nine randomly selected tribal villages of Mokhada in Palghar, Maharashtra, India. A community-based cross-sectional survey among 577 mother-child pairs was performed. Participants were recruited from the anganwadi list of enrolled children through household visits. WaSH index was used for assessing WaSH practices. Well was the major (47%) drinking water source. Almost 70% treated and covered the stored drinking water. Nearly 75% of the mothers used soap for washing hands before food and 35% after defecation. Open drains and open defecation were observed in 99% and 50% of households, respectively. The median score for drinking water index was 3 (interquartile range (IQR) = 2), personal hygiene index (PHI) was 2 (IQR = 2), household hygiene index (HHI) was 2 (IQR = 1) and composite index (CI) was 6 (IQR = 2). Prevalence of diarrhoea among children was found to be 33.4% and was significantly associated with poor HHI (p = .007), PHI (p < .001) and CI (p < .001). Measures to provide basic WaSH resources combined with efforts to create awareness would ensure improved WaSH practices and prevent diarrhoea.

Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: results from the Soweto Baby WASH study

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (β = -2.24) and 6 months (β = -0.96); a decrease in WAZ at 1 month (β = -1.21), 6 months (β = -1.57), and 12 months (β = -1.92); and finally, with WHZ scores at 12 months (β = -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (β = 0.53) and WAZ (β = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained.

Development and reliability of a quantitative personal hygiene assessment tool

Personal hygiene practices, including facewashing and handwashing, reduce transmission of pathogens, but are difficult to measure. Using color theory principles, we developed and tested a novel metric that generates quantitative measures of facial and hand cleanliness, proxy indicators of personal hygiene practices. In this cross-sectional study, conventional qualitative cleanliness metrics (e.g., presence or absence of nasal and ocular discharge, dirt under nails or on finger pads and palms) were also recorded. We generated Gwet’s agreement coefficients to determine the inter-rater reliability of novel and conventional metrics between various rating groups, where appropriate, including two non-blinded raters, non-blinded vs. blinded raters, three blinded raters, and blinded vs. computer raters. Inter-rater reliability of the novel metric was high across all rating groups, ranging from 0.98 (95% CI: 0.97, 0.99) to 0.90 (95% CI: 0.90, 0.91) for facial cleanliness, and 0.97 (95% CI: 0.96, 0.98) to 0.92 (95% CI: 0.91, 0.93) for hand cleanliness. Our novel metric generates more nuanced data than conventional qualitative metrics, and allows for quantifiable assessments of facial and hand cleanliness.

Bayesian network modelling of hierarchical composite indicators

The water, sanitation and hygiene (WaSH) sector has witnessed the development of multiple tools for multidimensional monitoring. Hierarchical and composite indicator (CI)-based conceptual frameworks provide one illustrative example. However, this approach does not address the existing interrelationship of the indicators they comprise. Bayesian networks (BNs) are increasingly being exploited to assess WaSH issues and to support planning and decision-making processes. Here, we aim to evaluate the validity, reliability and feasibility of BNs in replicating an existing CI-based conceptual framework. We adopt a data-driven approach and propose a semi-automatic methodology. As a pilot study, we used the regional monitoring initiative Rural Water Supply and Sanitation Information System (SIASAR). Data from two different countries are processed and analysed to calibrate and validate the model and the method. The major findings show: i) the model inference capacity improves when structure is provided to the networks (according to the CI-based framework); ii) key components that explain a pre-defined objective variable are reduced and quantified (implying important advantages in data updating); and iii) interlinkages among these components can be identified (which might enhance multi- and trans-disciplinary actions). We conclude that BNs accurately replicate the CI-based conceptual framework, with great potential for a wider application.

Postnatal depression and infant growth in an urban area of Bangladesh

Postnatal depression (PND) has been a common depressive mental disorder among the mothers in a low-income country like Bangladesh where stunting, underweight and wasting are prevalent among infants. The present prospective cohort study was carried out among 297 non-depressed and 103 depressed mothers (ages 18-36 years) to find the association between post natal depression and growth of infants. Data were collected by face to face interview through semi-structured questionnaires and anthropometric measurements were taken with proper anthropometric techniques and calibrated instruments. Postnatal depression was assessed by the Edinburgh Postnatal Depression Scale and infants' physical growth was assessed by Z score of weight, length and Mid-Upper Arm Circumference (MUAC). The overall prevalence of post natal depression was found 22% [95% CI, 21.71-30.29]. Infants of depressed mothers were found iller in comparison with the infants of non-depressed mothers (p < 0.001) which could result in growth retardation of infants. According to the MUAC level, infants of depressed mothers were more at risk of malnutrition (p < 0.001). Early detection of postpartum depression, implementation of interventions, prevention or treatment of maternal depressive disorders and effective strategies will not only ameliorate the impact of PND among mothers but also facilitates infant growth.

Impact of wastewater-irrigation on in-household water contamination. A cohort study among urban farmers in Ahmedabad, India

This cohort study explores the contribution of wastewater irrigation, in the context of WASH (Water, Sanitation, Hygiene), on in-household water contamination among urban farming households in Ahmedabad, India. Drinking water samples of 204 households in four peri-urban farming communities were collected from the point-of-source (PoS) and point-of-use (PoU) of each household four times over the 12-month follow-up period. Next to the quantification of E. coli, three household surveys (baseline, hygiene and farm) were conducted. Additionally, an observational spot-check was undertaken in bi-monthly intervals throughout the follow-up period. Significant positive differences in water quality between PoS and PoU samples were identified in 78% of households. During the monsoon, the peak of contamination, only 6% of households had access to safe drinking water at PoU. The Average Treatment Effect (ATE) of wastewater irrigation indicates an adverse effect on in-household water contamination, larger in effect size than the mitigation effect of access to sanitation or personal hygiene. To control transmission of fecal pathogens, effective barriers are required for wastewater irrigation similar to the necessity of ensuring access to sanitation and practicing adequate hygiene behavior.

Investigating individual and social behaviour of the Northern bald ibis (Geronticus eremita): behavioural variety and welfare

The Northern bald ibis (Geronticus eremita) (NBI) is one of the most threatened birds in the world. Intense conservation efforts have been undertaken and several research projects on the species are being done in Morocco and in Europe. Observing animal behaviour has been proved to be an efficient and non-invasive technique to assess the animal welfare, with the performance of a wide array of natural behaviours being one of the mostly used indicators of good mental and physical well-being. The aim of this study was to investigate the behaviour of a flock of 14 zoo-living NBI of different ages. The study focused on the variety of species-specific individual and social behaviours, in the light of reintroduction of the study juveniles in the wild. Per subject, 20 10-min. sessions were done. A continuous focal animal sampling method was used to collect individual and social behaviours. Behavioural data have been compared between adults and juveniles. Moreover, a Behavioural Variety Index (BVI) has been proposed and calculated based on previous literature describing natural ibis behaviours. The BVI might help in the evaluation of the variety of behaviours performed by each individual and the monitoring of the diversity of the behavioural repertoire of zoo animals. Our results showed that the birds performed species-specific behaviours and no abnormal behaviour was reported. Moreover, the BVI highlighted a good behavioural variety as each bird performed approximately 78% of the natural behaviours described in the Northern bald ibis and in close relative species. Our findings seem to suggest the presence of qualitative and quantitative similarities between the behavioural repertoires of the study ibises and those described in wild conspecifics, suggesting a good welfare of the colony. Finally, the BVI proposed in the current study seems to be a useful and practical tool to test behavioural diversity in zoo animals.

Impact of Wastewater-Irrigated Urban Agriculture on Diarrhea Incidence in Ahmedabad, India

BACKGROUND

Urbanization and water scarcity are placing pressure on urban food security. Globally, wastewater irrigation is a common feature of urban agriculture; however, high pathogen densities of wastewater pose disease risk for farming households.

OBJECTIVES

(a) Compare Escherichia coli concentrations of groundwater, surface, and wastewater. (b) Estimate the household diarrheal disease risk between the irrigation sources.

MATERIALS AND METHODS

This 12-month case-cohort study was undertaken in 187 households from four communities, selected purposively based on the irrigation water type, in urban Ahmedabad. The study included two communities utilizing surface water and one each using groundwater and wastewater. Households were visited bimonthly during each visit self-report health information was collected by health diary method. Water samples were analyzed for E. coli using the most probable number method.

RESULTS

Average E. coli concentrations, per 100 mL, in all the three water sources, were exceeding the international irrigation water standard and measured 3.04 × 104, 9.28 × 105, and 4.02 × 109 for groundwater, surface, and wastewater, respectively. The incidence of diarrhea in the groundwater area was 7.92 episodes/1,000 person-weeks, while the wastewater and surface water group had incidences of 13.1 and 13.4 episodes/1,000 person-weeks. A positive correlation between irrigation water quality and incidence of diarrhea was documented. The average treatment effect of wastewater quality obtained was 2.73.

CONCLUSION

Large proportions of Ahmedabad's farming population rely on water unsuitable for irrigation, inducing significant adverse health effects for farming households. This warrants an urgent need of introducing the concept of urban agriculture to the local civic authorities.

Effects of n-3 long-chain PUFA supplementation to lactating mothers and their breastfed children on child growth and morbidity: a 2 × 2 factorial randomized controlled trial in rural Ethiopia

Background

Recurrent infections and inflammation contribute to growth faltering in low-income countries. n-3 (ω-3) Long-chain polyunsaturated fatty-acids (LC-PUFAs) may improve immune maturation, resistance to infections, and growth in young children who are at risk.

Objective

We evaluated the independent and combined effects of fish oil (500 mg n-3 LC-PUFAs/d) supplementation to lactating mothers and their breastfed children, aged 6-24 mo, on child morbidity, systemic inflammation, and growth in southwest Ethiopia.

Design

A 4-arm double-blind randomized controlled trial was conducted by enrolling 360 mother-infant pairs with infants 6-12 mo old. Study arms were both the lactating mother and child receiving fish oil intervention (MCI), only the lactating mother receiving fish oil intervention and child receiving placebo control (MI), only the child receiving intervention and mother receiving placebo control (CI), and both mother and child receiving a placebo supplement or control (C). The primary study outcome was linear growth using monthly changes in length-for-age z score. Anthropometric measurements were taken monthly, and hemoglobin, C-reactive protein, and blood LC-PUFAs were measured at baseline and after 6 and 12 mo of follow-up. Weekly morbidity surveillance was conducted throughout the study.

Results

Fish-oil supplementation significantly increased blood n-3 LC-PUFA concentration (P < 0.01) and decreased the arachidonic acid:(docosahexaenoic acid + eicosapentaenoic acid) ratio (P < 0.001) in all intervention arms. No significant intervention effect was found on linear growth, morbidity, or systemic inflammation. Compared to the control group, a small positive effect on monthly changes in weight-for-length z scores was found in the CI arm (effect size: 0.022/mo; 95% CI: 0.005, 0.039/mo; P = 0.012) and the MCI arm (effect size: 0.018/mo; 95% CI: 0.001, 0.034/mo; P = 0.041).

Conclusions

n-3 LC-PUFA supplementation of lactating mothers and children did not affect child linear growth and morbidity in a low-income setting. n-3 LC-PUFA supplementation given directly to children modestly increased relative weight gain. This trial was registered at clinicaltrials.gov as NCT01817634.

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

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

Exploring geographic distributions of high-risk water, sanitation, and hygiene practices and their association with child diarrhea in Uganda

Background

High-risk water, sanitation, and hygiene (WASH) practices are still prevalent in most low-income countries. Because of limited access to WASH, children may be put at an increased risk of diarrheal diseases.

Objectives

This study aims to 1) develop a new measure of WASH-induced burden, the WASH Resource Index (WRI), and estimate its correlation with child diarrhea and an additive index of high-risk WASH practices; 2) explore the geographic distribution of high-risk WASH practices, child diarrhea, and summary indices at the cluster level; and 3) examine the association between the WRI and child diarrhea at the individual level.

Design

A sample of 7,019 children from the Uganda Demographic and Health Survey 2011 were included in this study. Principal component analysis was used to develop a WRI, and households were classified as WASH poorest, poorer, middle, richer, and richest. A hot spot analysis was conducted to assess whether and how high-risk WASH practices and child diarrhea were geographically clustered. A potential association between the WRI and child diarrhea was examined through a nested regression analysis.

Results

High-risk WASH practices were clustered at geographically distant regions from Kampala. The 2-week prevalence of child diarrhea, however, was concentrated in Eastern and East Central regions where high-risk WASH practices were not prevalent. At the individual level, none of the high-risk WASH practices were significantly associated with child diarrhea. Being in the highest WASH quintile was, however, significantly associated with 24.9% lower prevalence of child diarrhea compared to being in the lowest quintile (p<0.05).

Conclusions

Only a weak association was found between the WRI and child diarrhea in this study. Future research should explore the potential utility of the WRI to examine WASH-induced burden.

Spot-checks to measure general hygiene practice

A variety of hygiene behaviors are fundamental to the prevention of diarrhea. We used spot-checks in a survey of 761 households in Burundi to examine whether something we could call general hygiene practice is responsible for more specific hygiene behaviors, ranging from handwashing to sweeping the floor. Using structural equation modeling, we showed that clusters of hygiene behavior, such as primary caregivers' cleanliness and household cleanliness, explained the spot-check findings well. Within our model, general hygiene practice as overall concept explained the more specific clusters of hygiene behavior well. Furthermore, the higher general hygiene practice, the more likely children were to be categorized healthy (r = 0.46). General hygiene practice was correlated with commitment to hygiene (r = 0.52), indicating a strong association to psychosocial determinants. The results show that different hygiene behaviors co-occur regularly. Using spot-checks, the general hygiene practice of a household can be rated quickly and easily.

Entamoeba histolytica and Entamoeba dispar infection in Mexican school children: genotyping and phylogenetic relationship

BACKGROUND

This study aimed to determine the frequency of Entamoeba histolytica and Entamoeba dispar infection in school children in the community of Tlaltizapan, in order to understand the dynamics of infection within the school and family spheres of this population. Amoebiasis is an unsolved public health problem and an endemic disease in Mexico. The incidence rate varies depending on the state; the most affected states show the highest numbers of new cases of amoebiasis per year. Previously, we reported the molecular frequency of infection with E. histolytica and/or E. dispar in other rural communities of the state of Morelos.

METHODS

Children from 3 schools were studied to estimate the frequency of intestinal parasites through microscopic examination of fresh stool samples. The number of studied individuals were 309 school children. The molecular characterization of E. histolytica or E. dispar was carried out by Polymerase Chain Reaction (PCR) using species-specific primers to amplify short tandem repeats (STR) in non-coding sequences associated with the tRNA gene; the amplified fragments were sequenced and analyzed.

RESULTS

Eight different genotypes were obtained from E. dispar isolates with the molecular marker NKD3-D5. None of the cases in which the species E. histolytica was detected developed symptoms attributable to an invasive process of disease. Moreover, the parasitized condition appeared to have no significant impact on the development or nutritional status of affected children. Genotype 1, which corresponds to the reference strain E. dispar SAW760, considered a non-pathogenic amoeba, was the most prevalent.

CONCLUSIONS

The comparison of the genotypes of Entamoeba species did not show a correlation between children and their relatives. In this community, the species Entamoeba dispar genotype 1 was the most widespread. Based on the indicators of growth, development and nutrition status, the studied community seems to be reasonably adapted to constant exposure to intestinal parasites, since there were no evidences of a serious impact of the parasitized condition on the children's health.

Water, sanitation and hygiene in wetlands. A case study from the Ewaso Narok Swamp, Kenya

Wetlands can be both a blessing and a curse. They are beneficial sources of safe water and nutrition and places from which humans derive their livelihoods. At the same time, wetlands are known to be sources of disease-causing microorganisms and invertebrates that can threaten human health. Safe water, sanitation and personal hygiene (WASH) are crucial preconditions for the prevention of disease transmission. And of special importance for people living in wetlands, depending on and being exposed to them. WASH should be prioritized especially in those wetlands that are subject to intensive use, that have a poor sanitation infrastructure, and which at the same time only provide limited water resources. However, despite this critical importance, WASH in wetlands is not well characterized in literature. This study therefore aimed at providing insights into the water, sanitation and hygiene conditions and behavioural determinants of households in wetlands by presenting the case of a rural wetland in East Africa. The mixed method approach included a broad set of empirical data collected during a household survey (n=400), an observational WASH assessment (n=397) and in-depth interviews (n=20) conducted from January to March 2015 in Ewaso Narok Swamp in Kenya. Different user groups of the wetland were targeted. The study in Ewaso Narok Swamp showed that wetland users' water supply and storage, sanitation and personal hygiene conditions were inadequate for large parts of the community and significantly differed between groups. Whereas the WASH conditions of people working in the service sector were rather positive, for pastoralists, they were correspondingly negative. The WASH behaviour was also perceived to be inadequate influenced by a variety of determining factors. The observational index as applied in this study indicated to be a valuable, rapid and efficient tool for assessing domestic WASH and for detecting differences between different groups in wetlands. Combined with the quantitative and qualitative data, the approach served as a very helpful model to develop a multi-layered understanding of WASH conditions and related behaviour. The people in the researched wetland use by far less improved water sources and sanitation facilities than the nationwide average for rural populations. Since Ewaso Narok Swamp serves as a model case for the domestic WASH conditions in a rural wetland in semiarid East Africa, this fact make the study relevant not only at a national, but also at an international level. The results underline the previously formulated need of an integrative approach that first and foremost complements wetland management by public health interventions. In order to improve WASH conditions and to change behaviour in the long term, interventions should include the provision of clean water and sanitation infrastructure, as well as widespread health education. The approach proved to be useful for wetland environments and will be integrated into the development of a health impact assessment tool for wetlands. Moreover, it can be adopted in other contexts.

Personal hygiene among military personnel: developing and testing a self-administered scale

OBJECTIVE

Good personal hygiene (PH) behavior is recommended to prevent contagious diseases, and members of military forces may be at high risk for contracting contagious diseases. The aim of this study was to develop and test a new questionnaire on PH for soldiers.

METHODS

Participants were all male and from different military settings throughout Iran. Using a five-stage guideline, a panel of experts in the Persian language (Farsi) developed a 21-item self-administered questionnaire. Face and content validity of the first-draft items were assessed. The questionnaire was then translated and subsequently back-translated into English, and both the Farsi and English versions were tested in pilot studies. The consistency and stability of the questionnaire were tested using Cronbach's alpha and the test-retest strategy. The final scale was administered to a sample of 502 military personnel. Explanatory and confirmatory factor analyses evaluated the structure of the scale. Both the convergent and discriminative validity of the scale were also determined.

RESULTS

Cronbach's alpha coefficients were >0.85. Principal component analysis demonstrated a uni-dimensional structure that explained 59 % of the variance in PH behaviors. Confirmatory factor analysis indicated a good fit (goodness-of-fit index = 0.902; comparative fitness index = 0.923; root mean square error of approximation = 0.0085).

CONCLUSIONS

The results show that this new PH scale has solid psychometric properties for testing PH behaviors among an Iranian sample of military personnel. We conclude that this scale can be a useful tool for assessing PH behaviors in military personnel. Further research is needed to determine the scale's value in other countries and cultures.

Association of food-hygiene practices and diarrhea prevalence among Indonesian young children from low socioeconomic urban areas

Background

Information on the part that poor food-hygiene practices play a role in the development of diarrhea in low socioeconomic urban communities is lacking. This study was therefore aimed at assessing the contribution of food-hygiene practice to the prevalence of diarrhea among Indonesian children.

Methods

A cross-sectional study was conducted among 274 randomly selected children aged 12–59 months in selected low socioeconomic urban areas of East Jakarta. The prevalence of diarrhea was assessed from 7-day records on frequency and consistency of the child’s defecation pattern. Food-hygiene practices including mother’s and child’s hand washing, food preparation, cleanliness of utensils, water source and safe drinking water, habits of buying cooked food, child’s bottle feeding hygiene, and housing and environmental condition were collected through home visit interviews and observations by fieldworkers. Thirty-six practices were scored and classified into poor (median and below) and better (above median) food-hygiene practices. Nutritional status of children, defined anthropometrically, was measured through height and weight.

Results

Among the individual food-hygiene practices, children living in a house with less dirty sewage had a significantly lower diarrhea prevalence compared to those who did not [adjusted odds ratio (OR) 0.16, 95% confidence interval (CI) = 0.03-0.73]. The overall food-hygiene practice score was not significantly associated with diarrhea in the total group, but it was in children aged < 2 years (adjusted OR 4.55, 95% CI = 1.08-19.1).

Conclusions

Overall poor mother’s food-hygiene practices did not contribute to the occurrence of diarrhea in Indonesian children. However, among children < 2 years from low socioeconomic urban areas they were associated with more diarrhea.

Using child health outcomes to identify effective measures of handwashing

We assessed which practical handwashing indicators were independently associated with reduced child diarrhea or respiratory disease. Fieldworkers collected 33 indicators of handwashing at baseline in 498 households in 50 villages in rural Bangladesh. Community monitors visited households monthly and asked standard questions about diarrhea and symptoms of respiratory illness among children under 5 years of age. In multivariate analysis, three handwashing indicators were independently associated with less child diarrhea-mothers reporting usually washing hands with soap before feeding a child, mothers using soap when asked to show how they usually washed their hands after defecation, and children having visibly clean finger pads. Two indicators were independently associated with fewer respiratory infections-mothers allowing their hands to air dry after the handwashing demonstration and the presence of water where the respondents usually wash hands after defecation. These rapid handwashing indicators should be considered for inclusion in handwashing assessments.

Hygiene: new hopes, new horizons

Although promotion of safe hygiene is the single most cost-effective means of preventing infectious disease, investment in hygiene is low both in the health and in the water and sanitation sectors. Evidence shows the benefit of improved hygiene, especially for improved handwashing and safe stool disposal. A growing understanding of what drives hygiene behaviour and creative partnerships are providing fresh approaches to change behaviour. However, some important gaps in our knowledge exist. For example, almost no trials of the effectiveness of interventions to improve food hygiene in developing countries are available. We also need to figure out how best to make safe hygiene practices matters of daily routine that are sustained by social norms on a mass scale. Full and active involvement of the health sector in getting safe hygiene to all homes, schools, and institutions will bring major gains to public health.

Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh

Background

We analyzed data from the baseline assessment of a large intervention project to describe typical handwashing practices in rural Bangladesh, and compare measures of hand cleanliness with household characteristics.

Methods

We randomly selected 100 villages from 36 districts in rural Bangladesh. Field workers identified 17 eligible households per village using systematic sampling. Field workers conducted 5-hour structured observations in 1000 households, and a cross-sectional assessment in 1692 households that included spot checks, an evaluation of hand cleanliness and a request that residents demonstrate their usual handwashing practices after defecation.

Results

Although 47% of caregivers reported and 51% demonstrated washing both hands with soap after defecation, in structured observation, only 33% of caregivers and 14% of all persons observed washed both hands with soap after defecation. Less than 1% used soap and water for handwashing before eating and/or feeding a child. More commonly people washed their hands only with water, 23% after defecation and 5% before eating. Spot checks during the cross sectional survey classified 930 caregivers (55%) and 453 children (28%) as having clean appearing hands. In multivariate analysis economic status and water available at handwashing locations were significantly associated with hand cleanliness among both caregivers and children.

Conclusions

A minority of rural Bangladeshi residents washed both hands with soap at key handwashing times, though rinsing hands with only water was more common. To realize the health benefits of handwashing, efforts to improve handwashing in these communities should target adding soap to current hand rinsing practices.

Hands, water, and health: fecal contamination in Tanzanian communities with improved, non-networked water supplies

Almost half of the world's population relies on non-networked water supply services, which necessitates in-home water storage. It has been suggested that dirty hands play a role in microbial contamination of drinking water during collection, transport, and storage. However, little work has been done to evaluate quantitatively the association between hand contamination and stored water quality within households. This study measured levels of E. coli, fecal streptococci, and occurrence of the general Bacteroidales fecal DNA marker in source water, in stored water, and on hands in 334 households among communities in Dar es Salaam, Tanzania, where residents use non-networked water sources. Levels of fecal contamination on hands of mothers and children were positively correlated to fecal contamination in stored drinking water within households. Household characteristics associated with hand contamination included mother's educational attainment, use of an improved toilet, an infant in the household, and dissatisfaction with the quantity of water available for hygiene. In addition, fecal contamination on hands was associated with the prevalence of gastrointestinal and respiratory symptoms within a household. The results suggest that reducing fecal contamination on hands should be investigated as a strategy for improving stored drinking water quality and health among households using non-networked water supplies.

Estimating the scope of household water treatment in low- and medium-income countries

For populations without reliable access to safe drinking water, household water treatment (HWT) provides a means of improving water quality and preventing disease. We extracted data on reported HWT practices from 67 national surveys and reports on the scope of HWT. An estimated 33.0% of the households (1.1 billion people) in these countries report treating their drinking water at home. The practice is widespread in the Western Pacific (66.8%) and Southeast Asia (45.4%) regions, and it is less common in the Eastern Mediterranean (13.6%) and Africa (18.2%). Boiling is the most dominant method with 21.0% of the study households (598 million people) using the method. Despite being at higher risk of waterborne disease because of lower coverage of improved water sources, African and rural households are less likely to practice HWT or use microbiologically adequate methods. Validation of the household surveys and further analysis of these data could help optimize HWT practices.

Cancer and obesity: effect of bariatric surgery

Recent international cancer prevention guidelines recommend weight loss, where appropriate, for the purpose of cancer risk reduction. However, limited research associates voluntary weight loss to subsequent cancer incidence because of the difficulty of achieving long-term weight loss maintenance among large participant groups. Bariatric surgery has demonstrated long-term sustained weight loss, and as a result, patients after bariatric surgery represent an ideal population to explore the relationship between long-term, voluntary weight loss and cancer incidence. This paper briefly reviews cancers that have shown to be associated with overweight and obesity and looks at studies that demonstrate reduced total mortality after bariatric surgery. Reduced cancer mortality and incidence as well as reduced cancer-related physician visits after bariatric surgery are presented. Study limitations and future research questions related to cancer and bariatric surgery are briefly discussed.

Choice of environmental components for a longitudinal birth cohort study

Various aspects of the environment of the mother and child may have major influences on the health and development of the child. Long-term influences can even affect chronic diseases of adulthood. Here we describe the major psychosocial and physical environmental factors that should be measured in longitudinal birth cohort studies.

Height for age increased while body mass index for age remained stable between 1968 and 2007 among Guatemalan children

Promotion of optimal growth while preventing the emergence of obesity in childhood requires an understanding of the dynamics over time of linear growth and weight for height. To assess long-term secular trends in height-for-age and BMI for age in children <6 y old, we analyzed a series of cross-sectional surveys conducted between 1968 and 2007 in 4 villages in eastern Guatemala. We used height and weight of children <6 y old (n = 507, 606, 627, 704, 526, and 502 for survey years 1968, 1972, 1977, 1988, 1997, and 2005-7, respectively) to compute height-for-age Z-score (HAZ) and BMI-for-age Z-score (BMIZ) based on WHO growth standards. HAZ was -2.73 +/- 1.12 (mean +/- SD) in 1968 and -1.16 +/- 1.16 in 2005-7 (P < 0.001). The prevalence of stunting (HAZ <-2.0) was 73.0% in 1968 and 23.1% in 2005-7 (P < 0.001). Among children 57-63 mo old, HAZ in 2005-7 was 1.20 (95% CI, 0.79, 1.62) SD units higher than in 1968, corresponding to 5.6 cm in boys and 5.7 cm in girls. For all survey years except 2007, BMIZ increased through age 36 mo, then declined; for the 2005-7 sample, BMIZ did not vary by age. The prevalence of BMIZ >1.00 was 21.1% in 1968 and 19.6% in 2005-7 (P > 0.05); for BMI <-1.00, the respective prevalences were 7.9% and 5.2% (P > 0.05). There have been long-term improvements in child growth, as measured by HAZ, without concurrent increases in BMI over successive generations of children.