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

Impact of the COVID-19 pandemic on handwashing practices among community members in the middle belt of Ghana: evidence from a cross-sectional study

Handwashing is an effective public health intervention for preventing the spread of coronavirus (COVID-19). Maintenance of clean hands is particularly important during the pandemic, to break the cycle of human-to-human transmission of the virus. This study explored the potential impact of the COVID-19 pandemic on the handwashing behaviours of residents before and during the pandemic. A mixed-method cross-sectional design using standardised questionnaire was used to examine hand handwashing behaviours among residents before and during the COVID-19 pandemic in the middle belt of Ghana. However, this paper reports on the quantitative data on handwashing behaviour only. A total of 517 participants between 18 to 60 years were randomly selected from the Kintampo Health and Demographic Surveillance System (HDSS) database. Descriptive statistics were performed and McNamar test was used to estimate the difference in the handwashing behaviour of residents. Majority of the respondents were females (54.6%). The majority of them 77.0% (398) usually wash their hands with soap and water. Those who washed hands 4 to 6 times a day before the pandemic increased from 39.9% (159) to 43.7% (174). About 34.8% (180) had received training on hand washing and television 53.3% (96) emerged as the main source of training. Ownership of handwashing facilities increased from 11.4% (59) to 22.8% (118) during the pandemic. The odds of handwashing after handshaking were lower 0.64 (95% C1: 0.44-0.92,) during the pandemic. Television (53.3%) was the main source of training for respondents who had received training on handwashing (34.8%). The odds of owning a handwashing facility during the pandemic were 3 times higher than before (OR = 2.97, 95% CI: 1.94 - 4.65). The odds of handwashing after sneezing were 1.8 (95% CI: 1.19-2.92) times higher during the pandemic. Handwashing behaviours during the pandemic improved among residents than before. However, there is a need to intensify health education and media engagement on proper handwashing practices to protect the population against infectious diseases.

Promoting COVID-19 prevention strategies in student dormitory setting: A qualitative study

OBJECTIVE

To explore the risk perceptions and COVID-19 prevention practices of dormitory residents in Indonesia. Participants: Nineteen dormitory residents, 3 staff and 1 dormitory manager were recruited from the Saint Theresa Avila student dormitory. Methods: This qualitative study used individual interviews and framework analysis. Results: Generally, the study confirms that there is a gap between risk perception and COVID-19 prevention practices among dormitory residents. There are barriers in accessing hand washing facilities and in complying with COVID-19 prevention protocols including not wearing masks, not following quarantine procedures and visiting friends' rooms. Conclusion: Dormitory managers and staff should repeatedly remind residents to wear masks and maintain safe distance through sending short messages on dormitory social media groups. In addition to psychological assistance and basic supplies during self-quarantine, providing sanitizer and installing posters detailing the hand-washing steps are essential at each hand-washing facility in the dormitory.

Effect of a novel hygiene intervention on older children's handwashing in a humanitarian setting in Kahda district, Somalia: A cluster-randomised controlled equivalence trial

INTRODUCTION

Improving handwashing with soap (HWWS) among children in humanitarian emergencies has the potential to reduce the transmission of several important infectious diseases. However, there is limited evidence on which approaches are effective in increasing HWWS among children in humanitarian settings. One recent innovation - the "Surprise Soap" intervention - was shown to be successful in a small-scale efficacy trial in a humanitarian setting in Iraq. This intervention includes soap with embedded toys delivered through a short household session comprising a glitter game, instruction of how and when to wash hands, and HWWS practice. Whilst promising, this approach has not been evaluated at programmatic scale in a complex humanitarian setting.

METHODS

We conducted a cluster-randomised controlled equivalence trial of the Surprise Soap intervention in IDP camps in Kahda district, Somalia. Proportionate stratified random sampling was employed to recruit 200 households, with at least one child aged 5-12, across the camps. Eligible households were randomly allocated to receive the Surprise Soap intervention (n = 100) or an active comparator handwashing intervention in which plain soap was delivered in a short household session comprising standard health-based messaging and instruction of how and when to wash hands (n = 100). The primary outcome was the proportion of pre-specified occasions when HWWS was practiced by children aged 5-12 years, measured at baseline, 4-weeks, 12 weeks, and 16 weeks post invention delivery.

RESULTS

HWWS increased in both groups (by 48 percentage points in the intervention group and 51 percentage points in the control group, at the 4-week follow up), however, there was no evidence of a difference in HWWS between the groups at the 4-week (adjusted RR (aRR) = 1.0, 95% CI 0.9-1.1), 12-week (aRR = 1.1, 95% CI 0.9-1.3), or 16-week (aRR = 1.0, 95% CI 0.9-1.2) follow-up.

CONCLUSIONS

In this complex humanitarian setting, where soap availability and past exposure to handwashing promotion was low, it appears that well-designed, household-level targeted handwashing interventions that include soap provision can increase child HWWS and potentially reduce disease risk, but the Surprise Soap intervention offers no marginal benefit over a standard intervention that would justify the additional costs.

Water and Handwashing in a Drought-Prone Region of Southern Niger: How Environment, Household Infrastructure, and Exposure to Social and Behavior Change Messages Interact

This study aims to inform multisectoral development programs by exploring the extent to which social and behavior change (SBC) messages, environment, and household infrastructure are associated with knowledge and practice of handwashing behaviors. A cross-sectional survey of 2,708 households in the Maradi and Zinder districts of Niger was collected in April 2021. Household data were integrated with two local environmental measures: 1) water level at the nearest waterhole point, and 2) anomalous rainfall for the previous rainy season derived from climate hazards infrared precipitation with station rainfall (CHIRPS) data. Logistic regression models were constructed to explore how environment, household infrastructure, and exposure to SBC messages were associated with two hygiene-related outcomes: 1) observed water and soap available at household handwashing stations, a behavior, and 2) knowledge of critical moments for handwashing, a behavioral determinant. We find that in households near a water point with higher water depth, households were statistically significantly more likely (odds ratio [OR] = 1.25); (confidence interval [CI] = 1.12-1.49) to have water and soap observed at the handwashing station. Women in households near a water point with increased water depth (more water) were more likely to know three or more critical handwashing moments (OR = 1.07; CI = 1.03-1.11). Exposure to messages about the importance of handwashing was significantly associated with knowledge of critical handwashing moments and having water and soap observed at a handwashing station. Multisectoral programming should consider layering efforts so that development projects that increase access to water sources are complemented with SBC approaches focused on hygiene.

Nongovernmental Organization Practitioners' Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study

BACKGROUND

Increasing handwashing with soap (HWWS) among older children (aged 5-14 years) can achieve a substantial public health impact. However, HWWS interventions targeting older children have had mixed success. Recent research has attempted to quantitatively identify effective intervention techniques; however, success is likely also influenced by the wider context of implementation. We explore nongovernmental organization (NGO) practitioners' perspectives on the challenges and solutions to HWWS interventions targeting older children to enhance understanding of what is required, beyond intervention content, for them to be effective.

METHODS

We conducted in-depth, semistructured interviews in April-November 2020 with 25 practitioners employed across 11 NGOs and involved in HWWS interventions targeting older children in development and humanitarian settings. We used purposive and snowball sampling to recruit participants in roles at the global, national/regional, and local levels. Interviews were audio-recorded, transcribed, and thematically analyzed to identify challenges and solutions to HWWS interventions targeting older children. Results were organized according to program development cycle stages.

RESULTS

Twelve themes relating to perceived challenges emerged: (1) lack of prioritization, (2) funding inconsistency, (3) insufficient formative research, (4) demand on resources, (5) unengaging intervention content, (6) non-enabling physical environments, (7) availability of skilled implementers, (8) reaching out-of-school children, (9) community mistrust, (10) lack of coordination, (11) lack of evaluation rigor, and (12) failure to assign older children's HWWS as a primary outcome in evaluations of hygiene interventions. Recommended solutions were at the intervention, organization, and sector levels.

CONCLUSION

Intervention design and delivery are important for the success of HWWS interventions for older children, but contextual factors, such as the availability of human and material resources and the level of coordination within and beyond the NGO sector, should also be considered. NGOs need to prioritize HWWS promotion among older children and support programs accordingly.

What influences individuals to invest in improved sanitation services and hygiene behaviours in a small town? A formative research study in Babati, Tanzania

Sub-Sahara African countries face immense challenges in ensuring adequate sanitation and hygiene behaviours to the rapidly growing populations. Attempts to address these challenges require empirical evidence to inform policy and planning. We contribute toward that goal by unveiling findings of formative research conducted in Babati, a rapidly growing town in Tanzania. We conducted a cross-sectional study involving 486 households, to unwind motives and barriers for individuals to invest in improved sanitation services and hygiene behaviour change. We used several methods including household survey, focus group discussions, behaviour observations and spot checks. The findings revealed that households derive their motivation to invest in improved sanitation and hygiene practices from comfort, raising social status, and the need for personal safety and privacy. Other motives include fear of penalties and fines and fear of disease outbreaks, whilst the barriers include, limited water availability and accessibility, environmental factors, property rights, cultural issues, financial constraints, and a person’s attitude. Quantitative data were subjected to multivariate analysis to identify determinants of households to invest in sanitation and hygiene practices. The logistic regression analyses revealed that sources of water, property rights, and education level were the main determinants of households to invest in sanitation and hygiene facilities, while household income was the main determinant for households to invest in both construction of handwashing facility and water treatment. We argue that the initiative to promote sanitation and hygiene behaviour change in small towns should focus on promoting motivation factors and abating the determinant factors identified in this study.

Necessary conditions for sustainable water and sanitation service delivery in schools: A systematic review

Access to water, sanitation, and hygiene (WASH) services confers significant health and economic benefits, especially for children, but only if those services can be delivered on a consistent basis. The challenge of sustainable, school-based WASH service delivery has been widely documented, particularly in resource-constrained contexts. We conducted a systematic review of published research that identifies drivers of, or tests solutions to, this challenge within low- and middle-income countries (PROSPERO 2020 CRD42020199163). Authors in the first group employ cross-sectional research designs and interrogate previously implemented school WASH interventions. Most conclude that dysfunctional accountability and information sharing mechanisms drive school WASH service delivery failures. By contrast, most of the interventions developed and tested experimentally by authors in the second group focus on increasing the financial and material resources available to schools for WASH service delivery. Overall, these authors find negligible impact of such infusions of cash, infrastructure, and supplies across a variety of sustainability outcome metrics. Taken together, the evidence suggests that sustainable service delivery depends on three simultaneously necessary components: resources, information, and accountability. Drawing upon theory and evidence from social psychology, public management, and political science, we identify priority knowledge gaps that can meaningfully improve the design of effective interventions. We also highlight the importance of both interdisciplinary collaboration and local expertise in designing WASH programming that aligns with sociocultural and institutional norms, and is thus more likely to generate sustainable impact.

What is the risk of acquiring SARS-CoV-2 from the use of public toilets?

Public toilets and bathrooms may act as a contact hub point where community transmission of SARS-CoV-2 occurs between users. The mechanism of spread would arise through three mechanisms: inhalation of faecal and/or urinary aerosol from an individual shedding SARS-CoV-2; airborne transmission of respiratory aerosols between users face-to-face or during short periods after use; or from fomite transmission via frequent touch sites such as door handles, sink taps, lota or toilet roll dispenser. In this respect toilets could present a risk comparable with other high throughput enclosed spaces such as public transport and food retail outlets. They are often compact, inadequately ventilated, heavily used and subject to maintenance and cleaning issues. Factors such as these would compound the risks generated by toilet users incubating or symptomatic with SARS-CoV-2. Furthermore, toilets are important public infrastructure since they are vital for the maintenance of accessible, sustainable and comfortable urban spaces. Given the lack of studies on transmission through use of public toilets, comprehensive risk assessment relies upon the compilation of evidence gathered from parallel studies, including work performed in hospitals and prior work on related viruses. This narrative review examines the evidence suggestive of transmission risk through use of public toilets and concludes that such a risk cannot be lightly disregarded. A range of mitigating actions are suggested for both users of public toilets and those that are responsible for their design, maintenance and management.

Cohort profile: The UK COVID-19 Public Experiences (COPE) prospective longitudinal mixed-methods study of health and well-being during the SARSCoV2 coronavirus pandemic

Public perceptions of pandemic viral threats and government policies can influence adherence to containment, delay, and mitigation policies such as physical distancing, hygienic practices, use of physical barriers, uptake of testing, contact tracing, and vaccination programs. The UK COVID-19 Public Experiences (COPE) study aims to identify determinants of health behaviour using the Capability, Opportunity, Motivation (COM-B) model using a longitudinal mixed-methods approach. Here, we provide a detailed description of the demographic and self-reported health characteristics of the COPE cohort at baseline assessment, an overview of data collected, and plans for follow-up of the cohort. The COPE baseline survey was completed by 11,113 UK adult residents (18+ years of age). Baseline data collection started on the 13th of March 2020 (10-days before the introduction of the first national COVID-19 lockdown in the UK) and finished on the 13th of April 2020. Participants were recruited via the HealthWise Wales (HWW) research registry and through social media snowballing and advertising (Facebook®, Twitter®, Instagram®). Participants were predominantly female (69%), over 50 years of age (68%), identified as white (98%), and were living with their partner (68%). A large proportion (67%) had a college/university level education, and half reported a pre-existing health condition (50%). Initial follow-up plans for the cohort included in-depth surveys at 3-months and 12-months after the first UK national lockdown to assess short and medium-term effects of the pandemic on health behaviour and subjective health and well-being. Additional consent will be sought from participants at follow-up for data linkage and surveys at 18 and 24-months after the initial UK national lockdown. A large non-random sample was recruited to the COPE cohort during the early stages of the COVID-19 pandemic, which will enable longitudinal analysis of the determinants of health behaviour and changes in subjective health and well-being over the course of the pandemic.

Hand hygiene intervention to optimise soil-transmitted helminth infection control among primary school children: the Mikono Safi cluster randomised controlled trial in northwestern Tanzania

BACKGROUND

Soil-transmitted helminth (STH) infections are highly prevalent in resource-limited countries. We assessed the effect of a combination intervention aiming to enhance handwashing with soap on STH reinfection following mass drug administration among primary school children in Kagera region, Northwestern Tanzania.

METHODS

We conducted a cluster randomised trial in sixteen primary schools with known high STH prevalence. Schools were randomly assigned in a 1:1 ratio to either receive the intervention or continue with routine health education. The intervention included teacher-led classroom teaching, parental engagement sessions, environmental modifications and improved handwashing stations. The evaluation involved two cross-sectional surveys in a representative sample of students, with the end-line survey conducted 12 months after the baseline survey. The primary outcome was the combined prevalence of Ascaris lumbricoides and Trichuris trichiura infections at the end-line survey. Secondary outcomes included reported handwashing behaviour, the prevalence and intensity of individual STHs, and hand contamination with STH ova and coliform bacteria. End-line STH prevalence and intensity were adjusted for baseline differences of potential confounders.

RESULTS

At the end-line survey, 3081 school children (1566 from intervention schools and 1515 from control schools) provided interview data and stool specimens. More school children in the intervention group reported the use of water and soap during handwashing compared to school children in the control group (58% vs. 35%; aOR=1.76, 95%CI 1.28-2.43, p=0.001). The combined prevalence of A. lumbricoides and T. trichiura infections was 39% in both trial arms (aOR = 1.19; 95%CI 0.74-1.91). The prevalence of A. lumbricoides was 15% in the intervention and 17% in the control arm (aOR =1.24, 95%CI 0.59-2.59) and that of T. trichiura was 31% in both arms (aOR=1.17, 95%CI 0.73-1.88). No significant differences were found for STH infection intensity in both the main study and the hand contamination sub-study.

CONCLUSIONS

The intervention was effective in increasing reported handwashing behaviour at school, but failed to show a similar effect in the home. The intervention had no effect on STH infection, possibly due to infection in the home environment, other transmission routes such as contaminated water or food or limited changes in school children's handwashing behaviour.

TRIAL REGISTRATION

The trial was registered on June 21, 2017, by the International Standard Randomised Controlled Trial Number ( ISRCTN45013173) .

Can Social Motivators Improve Handwashing Behavior among Children? Evidence from a Cluster Randomized Trial of a School Hygiene Intervention in the Philippines

This study reports the impact of the HiFive program, a 6-week handwashing campaign that targets social and emotional motivators to improve student handwashing in primary schools in the Philippines. We designed a clustered randomized trial to evaluate the impact of HiFive on student handwashing behavior, motivation, and access. Of the sample of 196 primary schools located in two districts, half were randomly assigned to receive the program in the 2017–2018 school year. Survey and observation data were collected 3 months after the conclusion of the campaign. In control schools, only 2.5% of students were observed washing their hands with soap and water, our primary outcome and 14.8% were observed washing their hands with at least water. HiFive led to a 3.7 percentage point (p.p.) increase (P < 0.01) in the rate of handwashing with soap and water and a 5.6 p.p. increase (P = 0.03) in handwashing with at least water after toilet use. HiFive also led to a 10.8 p.p. (P < 0.01) increase in the number of handwashing facilities stocked with soap. The program had limited impact on the motivators targeted by the program, suggesting that the small improvements in handwashing may have been driven by increases in the availability of soap. More research is needed to understand how interventions can effectively trigger social motivators to improve handwashing behavior among schoolchildren, and whether the effectiveness of these programs can be augmented with “nudge”-based interventions from the behavioral sciences.