An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. I. Application of the case-control method for development of an intervention

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

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

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth

OBJECTIVE

To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural Bangladesh.

STUDY DESIGN

Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin.

FINDINGS

Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child's age (P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <-2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (-0.34 [95% CI -0.68, -0.01] and weight-for-height z score (-0.52 [95% CI -0.98, -0.06]).

CONCLUSION

Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations.

Hand washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register (27 May 2015); CENTRAL (published in the Cochrane Library 2015, Issue 5); MEDLINE (1966 to 27 May 2015); EMBASE (1974 to 27 May 2015); LILACS (1982 to 27 May 2015); PsycINFO (1967 to 27 May 2015); Science Citation Index and Social Science Citation Index (1981 to 27 May 2015); ERIC (1966 to 27 May 2015); SPECTR (2000 to 27 May 2015); Bibliomap (1990 to 27 May 2015); RoRe, The Grey Literature (2002 to 27 May 2015); World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), metaRegister of Controlled Trials (mRCT), and reference lists of articles up to 27 May 2015. We also contacted researchers and organizations in the field.

SELECTION CRITERIA

Individually randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risk of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CIs). We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 22 RCTs: 12 trials from child day-care centres or schools in mainly high-income countries (54,006 participants), nine community-based trials in LMICs (15,303 participants), and one hospital-based trial among people with acquired immune deficiency syndrome (AIDS) (148 participants).Hand washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevents around one-third of diarrhoea episodes in high income countries (rate ratio 0.70; 95% CI 0.58 to 0.85; nine trials, 4664 participants, high quality evidence), and may prevent a similar proportion in LMICs but only two trials from urban Egypt and Kenya have evaluated this (rate ratio 0.66, 95% CI 0.43 to 0.99; two trials, 45,380 participants, low quality evidence). Only three trials reported measures of behaviour change and the methods of data collection were susceptible to bias. In one trial from the USA hand washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; three trials, 1845 participants, low quality evidence).Hand washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (rate ratio 0.72, 95% CI 0.62 to 0.83; eight trials, 14,726 participants, moderate quality evidence). However, six of these eight trials were from Asian settings, with only single trials from South America and sub-Saharan Africa. In six trials, soap was provided free alongside hand washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: rate ratio 0.66, 95% CI 0.56 to 0.78; six trials, 11,422 participants; education only: rate ratio: 0.84, 95% CI 0.67 to 1.05; two trials, 3304 participants). There was increased hand washing at major prompts (before eating/cooking, after visiting the toilet or cleaning the baby's bottom), and increased compliance to hand hygiene procedure (behavioural outcome) in the intervention groups than the control in community trials (data not pooled: three trials, 3490 participants, high quality evidence).Hand washing promotion for the one trial conducted in a hospital among high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (Mean difference 1.68, 95% CI 1.93 to 1.43; one trial, 148 participants, moderate quality evidence). There was increase in hand washing frequency, seven times per day in the intervention group versus three times in the control in this hospital trial (one trial, 148 participants, moderate quality evidence).We found no trials evaluating or reporting the effects of hand washing promotions on diarrhoea-related deaths, all-cause-under five mortality, or costs.

AUTHORS' CONCLUSIONS

Hand washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. However, less is known about how to help people maintain hand washing habits in the longer term.

Epidemiologists working together with anthropologists: lessons from a study to evaluate the epidemiological impact of a city-wide sanitation program

This paper discusses the role of qualitative approaches in epidemiological studies, beginning with a general discussion of epidemiological and anthropological methods. It focuses on a case study of the health impact of an environmental intervention carried out in Salvador, Bahia State, Brazil. Most of the precedent studies fields, based on primary date, use to devote little attention to the methodological and theorethical questions attached to long-term studies. Four specific aspects of this experience are highlighted: (a) drawing up epidemiological study; (b) construction of an observational instrument to measure hygiene habits; (c) an ethnographic study that was carried out before the epidemiological study; (d) observation of the effects of health intervention on health inequalities. Finally, the report details how the findings of qualitative and quantitative studies might be synthesized. It provides a critical overview of follow-up strategies, illustrated with proper examples whenever possible.

Challenges to changing health behaviours in developing countries: a critical overview

This overview of recent research on health behaviour change in developing countries shows progress as well as pitfalls. In order to provide guidance to health and social scientists seeking to change common practices that contribute to illness and death, there needs to be a common approach to developing interventions and evaluating their outcomes. Strategies forming the basis of interventions and programs to change behaviour need to focus on three sources: theories of behaviour change, evidence for the success and failure of past attempts, and an in-depth understanding of one's audience. Common pitfalls are a lack of attention to the wisdom of theories that address strategies of change at the individual, interpersonal, and community levels. Instead, programs are often developed solely from a logic model, formative qualitative research, or a case-control study of determinants. These are relevant, but limited in scope. Also limited is the focus solely on one's specific behaviour; regardless of whether the practice concerns feeding children or seeking skilled birth attendants or using a latrine, commonalities among behaviours allow generalizability. What we aim for is a set of guidelines for best practices in interventions and programs, as well as a metric to assess whether the program includes these practices. Some fields have approached closer to this goal than others. This special issue of behaviour change interventions in developing countries adds to our understanding of where we are now and what we need to do to realize more gains in the future.

Hand washing for preventing diarrhoea

BACKGROUND

Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens.

OBJECTIVES

To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.

SEARCH STRATEGY

In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 to May 2007), SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field.

SELECTION CRITERIA

Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote hand washing.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and methodological quality. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based, five were community-based, and one was in a high-risk group (AIDS patients). Interventions promoting hand washing resulted in a 29% reduction in diarrhoea episodes in institutions in high-income countries (IRR 0.71, 95% CI 0.60 to 0.84; 7 trials) and a 31% reduction in such episodes in communities in low- or middle-income countries (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials).

AUTHORS' CONCLUSIONS

Hand washing can reduce diarrhoea episodes by about 30%. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.

Nutrition education for illiterate children in southern Madagascar--addressing their needs, perceptions and capabilities

OBJECTIVE

A Knowledge, Attitudes and Practices (KAP) study was conducted in three villages of Bekily District in southern Madagascar prior to the implementation of a health education programme with children. The participatory learning concept of the Child-to-Child approach was followed to involve the children in the planning and implementation of the programme, which was covered by the German Agency for Technical Cooperation.

DESIGN

To this effect, qualitative research methods such as Participatory Learning and Action techniques (focus group discussions, mapping and matrix ranking, etc.) were applied.

SUBJECTS

The survey was conducted between August and December 1999. It involved a total of 55 school-aged children (6-14 years) along with 21 mothers and 34 fathers, representing different ethnic groups and educational backgrounds.

RESULTS

The results show that children's KAP related to health and nutrition strongly reflect those of adults. They are not aware of a possible link between bad hygiene and the occurrence of diseases. According to them, diarrhoea or malaria is caused by consuming too large amounts of certain foods. Even if they know about certain elementary hygiene behaviours, they do not practise this in their everyday life.

CONCLUSION

A major objective of the health education programme for children should be to tackle the discrepancy between hygiene-related knowledge and behaviour. Through the participatory study approach the children revealed their ability to contribute to the programme development. In using appropriate communication channels, the Child-to-Child health education programme is expected to influence the health behaviours of both adults and children. The health education programme should be combined with a literacy programme to address the children's desire to learn reading and writing.

Diarrhoea and garbage disposal in Salvador, Brazil

The association of infantile diarrhoea with the presence of garbage in the environment was investigated in Canabrava, a peripheral neighbourhood of Salvador, northeast of Brazil. A cross-sectional study was conducted with all the 184 children aged less than two years residing in Canabrava, which is located close to the city garbage dump. Variables selected for study included the method used for the disposal of excrement, type of floor, mother's education, unemployment of the head of the family, regularity of the water supply, presence of toilet, storage of garbage inside the house, age, gender, duration of breastfeeding, and the number of people per room. The estimated prevalence of diarrhoea was 21.2%. Exposure to garbage in the environment was found to be the most important factor associated with diarrhoea (adjusted odds ratio [AOR] = 3.98, 95% CI 1.56-10.13). Other important variables were the mother's education (AOR = 2.79, 95% CI 1.09-7.13), maternal breastfeeding (AOR = 2.30, 95% CI 1.05-5.04), and unemployment of the head of the family (AOR = 2.09, 95% CI 0.93-4.69). These findings indicate the necessity of adopting solutions in the public domain and of intersectorial policies for the reduction of diarrhoea.

Effect of nutrition education of mothers on infant feeding practices

OBJECTIVE

To assess current infant feeding practices (IFP) in a relocated slum, to identity the lacunae, to outline, implement, and evaluate the gain in awareness and IFP followed by mothers.

METHODS

Thirty-five mothers of infants aged 5-19 months were interviewed. Based on lacunae, Nutrition Education (NE) was imparted to mothers over two months. Tools used were individual counseling, participatory learning methods, positive deviance and early adopters approach aided with existing information education communication materials. Monthly weight and length of infants was also taken. Awareness and practices on infant feeding (IF) were reviewed at mid and post NE.

RESULTS

Areas of concern at baseline were (i) discarding colostrum (77.0%), (ii) feeding prelacteals (80.0%), (iii) initiation of breast-feeding (BF) after 3 days (54.3%), (iv) absence of exclusive breast-feeding (86.3%), (v) delayed complementary feeding (CF) and (vi) feeding CF grossly inadequate in quality, quantity, frequency and consistency. Post NE results revealed an improved awareness about IF amongst the mothers. An improvement was seen in variety, quantity and consistency of CF fed. Active feeding behaviours were adopted (6.6% pre-NE vs 66.6% post-NE). Early adopters (24%) served as motivators. Weight for age and weight for length showed improvement.

CONCLUSION

NE programs of shorter duration using a 'communication mix' of channels with repeated reinforcement can bring about improvement not only in awareness but also in IFP.

Prevention of bacterial diarrhea by pasteurization of drinking water in Kenya

Diarrheal disease is one of the major causes of morbidity and mortality in developing countries. Drinking water is a primary transmission route of infectious diarrheagenic bacteria in a rural area of Kenya (Microbiol. Immunol. 41: 773-778, 1997). We tried to prevent diarrhea at villages with approximately 1,500 households in Kenya by pasteurizing drinking water. A durable simple thermoindicator which changes color at 70 C was used as an indicator of pasteurization. The number of households in which drinking water was coliform bacteria-free increased from 10.7% to 43.1% after adoption of a pasteurization practice. Consequently, the incidence of severe diarrhea among people drinking pasteurized water was significantly lower than in people taking raw water (odds ratio=0.55, P=0.0016). The reduction ratio of the incidence after pasteurization was nearly equivalent with that after the adoption of a boiling method. Employment of women leaders as fieldworkers and demonstration of bacterial colony disappearance on agar plates by pasteurization also affected reduction of the diarrheal incidence.

The cultural construction of childhood diarrhoea in rural Nicaragua: relevance for epidemiology and health promotion

As a component of a series of studies of childhood diarrhoea in rural Nicaragua, lay knowledge regarding the condition and its appropriate management has been investigated through semistructured interviews with 70 mothers. These data have been combined with information from focus group discussions and observations from investigators who have been resident in the study area for many years. For any episode of childhood diarrhoea, the lay nosology influences the treatment path followed. Thus for some types of diarrhoea, treatment at a health centre or health post and the use of rehydration fluids is seen to be appropriate, while for other types the use of traditional healers or home-based treatment, often explicitly without the use of rehydration fluids, is applicable. The implications of lay nosological systems for the interpretation of epidemiological studies and for the implementation of health promotion programmes are discussed.

Socioeconomic, environmental, demographic and behavioral factors associated with occurrence of diarrhea in young children in the Republic of Congo

This study is the result of a cross-sectional survey undertaken in five regions of the Republic of Congo. A sample of 612 women having children under 3 years of age was interviewed to determine the socioeconomic, environmental, demographic and behavioral factors associated with the occurrence of diarrhea in young children. Logistic regression analysis was used to determine which variables predict the occurrence of diarrhea in a multivariable context. Most of the statistically significant variables were those suggesting behaviorally mediated modes of transmission. These include: type of weaning food fed to the child, maternal age, sex of the child, maternal sickness and method of refuse disposal. Male children had a more than two-fold odds of experiencing recent diarrhea than did female children among those greater than 1 year of age. Although breastfeeding status was not statistically significantly associated with diarrheal disease, children under 1 year of age who were already weaned had a greater odds of disease than those who were still breasted. Due to the pattern of extended breastfeeding in this population, this relationship was difficult to assess. Urban residence also was highly associated with diarrheal disease occurrence. Urban residence is likely to reflect a host of socioeconomic, environmental and behavioral factors. These findings underscore the potential impact of educational interventions on the occurrence of diarrheal disease among young children.

Theory-driven behavioral intervention research for the control of diarrheal diseases

Essentially all methods to reduce diarrheal morbidity and mortality require behavioral change. Research is required to design, implement and evaluate behavior-modifying interventions. Accumulated experience in the many involved disciplines should serve as a basis for this research. However, each of these disciplines is associated with different research perspectives and analytic assumptions; thus integration of these varied but potentially complementary experiences has been elusive. In the present paper, arguing that such perspectives and assumptions are embodied in discipline-based theory, we have developed a generic framework for the conduct of theory-based behavioral intervention research. We illustrate the application of this framework through two vignettes applying two of the theories and models to the development of hypothetical handwashing interventions.

The use of ethnography and structured observations in the study of risk factors for the transmission of diarrhea in highland Papua New Guinea

Methods that combine anthropological and epidemiological data are needed for the study of behavioral risk factors in communicable diseases, but as yet remain undeveloped. Ethnography is often undervalued as both the preliminary and integrative step in the design and execution of such studies. The analysis of critical methodological issues emerging from a case-control study of the behavioral and environmental risk factors for the transmission of childhood diarrhea in both urban and rural highland Papua New Guinea suggests that focused ethnographic assessments, complemented by structured observations performed by nonprofessionals, may provide a viable research design. In highland Papua New Guinea, significant risk factors include non-usage of latrines and sleeping with pigs; the latter is a factor that could have important implications regarding women's roles in a changing economy.

Association of indicators of hygiene behavior with persistent diarrhea of young children

We examined the association between water and hygiene-related behaviors and persistent diarrhea (duration > or = 14 days) among children under age three years in an indigenous rural Guatemalan community. Behavior indicators were specific aspects of the appearance of the mother, study child, other children and household that could be observed using a spot observation technique. Thirty-four percent of children had one or more episodes of persistent diarrhea during the year of study. Bivariate analyses found that a higher proportion of observations in which the anti-hygienic condition was observed was significantly associated with persistent diarrhea for 11 of 26 behavior indicators; these 11 indicators were also strongly correlated with each other. In individual logistic regression models, which included overall rate of diarrhea and other child characteristics associated with persistent diarrhea, six behavior indicators maintained significant association with persistent diarrhea: presence of toy on the ground, presence of baby bottle on the ground, the hands of the mother being dirty, presence of a fecally soiled diaper on the ground in the household compound, presence of feces in the yard, and the study child wearing a fecally soiled diaper. Three additional indicators closely approached significant association with persistent diarrhea. Excluding the three soiled diaper indicators, which might be the result rather than the cause of diarrhea, we found the six other behavior indicators to demonstrate a significant dose-response effect in increasing risk of persistent diarrhea. These findings suggest that behaviors which promote increased exposure of young children to enteric pathogens increase risk of persistent diarrhea.

Addressing national and regional health needs: a framework for health planning

Completion of the first decade since the Alma-Ata Declaration of 'health for all' (1978) has led to numerous appraisals, in international forums, of progress achieved by the current primary health care strategy. Although this strategy appears to have contributed to improvements in selected health outcomes, changing circumstances in many developing countries may now require a more flexible and country-specific approach to health care programming. This article argues for the development of a pragmatic framework: to articulate problems which should be addressed in the development of national health programs; and, to organize concepts and methodologies to address these problems. Such a framework should enable an assessment of currently implicit value judgments, and enable strategies to be considered that assess several input and output variables simultaneously. Moreover, this framework would, we believe, further the goal of improved health delivery at a national level, and serve as a guide for further methodologic and conceptual development.

Risk factors for high diarrhoea frequency: a study in rural Zimbabwe

Diarrhoea morbidity data were collected prospectively over 22 months from a cohort of young children living in a deprived community in rural Zimbabwe. Despite the general high prevalence of diarrhoeal disease, there was considerable individual variability in attack rates. Risk factors associated with high diarrhoea frequency were therefore sought by a questionnaire study on feeding, environmental, educational and socio-economic factors. This was supported by observation of living conditions, and water and sanitation facilities. Surprisingly, no association was found between diarrhoeal morbidity and any of these factors, suggesting that other factors such as individual hygiene behaviour or individual susceptibility to diarrhoea may play a role in determining the observed differences in diarrhoea rates in this community.

Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. II. A hygiene intervention study in rural north-east Thailand

An intervention study was developed from risk-factors associated with faeco-oral transmission, based on the levels of contamination in stored water and fingertip-rinses from households in rural north-east Thailand. This was designed to improve: (a) handwashing, particularly before cooking/eating and after defecation: (b) washing dishes immediately after use. Verbal messages were administered to two intervention groups, one also received a plastic container with a tap to assist these activities. Indicators of compliance were the direct observation of soaking dishes and the presence of faecal streptococci from fingertip-rinses; the main outcome indicator was Escherichia coli contamination of stored water. The intervention group receiving the container was significantly better than the control for indicators of compliance (P less than 0.001 and P less than 0.01) and its stored water was significantly less contaminated (P less than 0.001). There was no significant improvement to the other intervention group, although some features of the intervention had clearly been made available to the control group. Humidity was significantly correlated with fingertip contamination (r = 0.2; P less than 0.001) and with the peak of reported diarrhoea around the beginning of the rainy season.

Community-based intervention trials

The randomized controlled trial has become the standard basis for the evaluation of new therapeutic agents and procedures (and for measuring the protective efficacy of new vaccines or for assessing the value of screening procedures). Patients, who have met the criteria for eligibility and have agreed to participate in the trial, are allocated on a random basis to the alternative therapies under consideration. In order to avoid possible bias in the handling or assessment of these groups, a double blind procedure is preferred; the therapy given is not known to those who administer it, to those who assess the course of the disease thereafter, nor to the patients themselves. There is an extensive literature on clinical trials covering their logic and history, modern developments and the many complex, often controversial, issues that such trials have provoked. Not all issues have been fully resolved but by and large the principle, the practice and the ethical concerns of clinical trials are worked out and firmly established.

Community-based intervention programs for trachoma control

Trachoma continues to be a leading cause of blindness largely confined to developing countries. Trachoma control programs have primarily been oriented to drug therapy, an approach which may be successful if it is community-based. However, the costs to ensure long-term success are substantial. Community-based health education approaches to reduce risk factors currently provide the most promising approach for long-term trachoma control.