Use, adoption, and effectiveness of tippy-tap handwashing station in promoting hand hygiene practices in resource-limited settings: a systematic review

The effect of education given to secondary school students on hand hygiene behaviors: a Quasi experimental study

AIMS

This study aimed to examine the effect of the hand hygiene education on middle school students' behavioral scores related to hand hygiene practices.

DESIGN

The research adheres to a quasi-experimental design suitable for the pre-test Posttest model with a control group.

METHODS

The population of the study consists of a total of 1159 students, comprising 5th, 6th, 7th, and 8th graders. During the first semester of the 2021-2022 academic year, face-to-face education was conducted at a middle school located in Ankara. Two face-to-face training sessions were conducted to increase awareness of hand hygiene.

RESULTS

The groups indicate homogeneity in terms of demographic characteristics. The mean hand hygiene behavior score was 56.45 ± 8.03 before the education in the intervention group, which increased to 59.79 ± 7.62 after the education. In the control group, the mean score was 55.98 ± 7.89 before the education and 57.15 ± 7.63 after the education. It was found that after the educational program, there was a statistically significant increase in hand hygiene behavior scores of the groups.

CONCLUSION

The research findings indicate a beneficial impact of hand hygiene education on students' average behavioral scores.

IMPACT

To foster lasting behavioral changes from a young age, it is advisable to implement hygiene education in schools periodically, including targeted interventions for middle school students.

Effect of the lack of access to handwashing facilities on the global burden of lower respiratory infections, 1990-2019: A systematic analysis from the global burden of disease study 2019

A lack of access to handwashing facilities is a significant risk factor for lower respiratory infections(LRIs). However, no studies have reported epidemiologic changes in the burden of LRIs attributed to the lack of access to handwashing facilities. We conducted an integrated assessment of the burden of LRIs attributable to the lack of handwashing facilities from 1990 to 2019 using data from the Global Burden of Disease Study 2019. In 2019, 270,000 deaths were attributed to LRIs due to a lack of access to handwashing facilities, with DALYs reaching 14.02 million. The age-standardized mortality rate (ASMR) of LRIs caused by a lack of access to handwashing facilities was approximately 3.74, while the age-standardized DALY rate (ASDR) was reported to be 203.55 in 2019. Over the past 30 years, the burden of LRIs attributed to the lack of access to handwashing facilities has shown a global decline. In 2019, this burden was most pronounced in infants under 1 year of age and in those older than 95 years, reflecting the highest DALY (5591.83) and mortality rates (79.43), respectively. The burden of LRIs caused by the lack of access to handwashing facilities was found to be more severe in males and significantly more pronounced in regions with a low sociodemographic index (SDI), such as the Sahara African region. The development of targeted strategies to address the inadequate and unequal distribution of handwashing facilities holds important value in improving the disease burden of LRIs.

Evaluation of the RISE II integrated social and behavior change approach in Niger: A contribution analysis

OBJECTIVE

Niger faces a myriad of health challenges and development efforts are complicated by persistent poverty, high population growth rates, and climate change. Integrated social and behavior change (SBC) addresses health outcomes through collective action and approaches at the limited points of entry individuals have with the health system.

METHODS

We conducted a mixed-methods study to evaluate the effectiveness of an integrated SBC program in the Maradi, and Zinder regions of Niger. We applied contribution analysis, a theory-based plausibility analysis, to assess contributions of the intervention.

RESULTS

We found the program contributed to improved behavioral determinants. Male engagement and income generating activities provided further support for women to practice health behaviors. However, increases in male partner out-migration was negatively associated with health outcomes. While the program did not generate statistically significant improvements in health outcomes in the intervention area, exposure to health messages and participation in women's groups were positively associated with health outcomes suggesting sustained implementation of the integrated SBC approach at scale may achieve improved health outcomes.

CONCLUSION

Programs should continue to invest in health promotion efforts that include gender sensitive interventions. Further research is needed to understand how women's agency and autonomy evolves as household composition changes through male out-migration.

Synthesising the evidence for effective hand hygiene in community settings: an integrated protocol for multiple related systematic reviews

INTRODUCTION

Despite evidence for the efficacy and effectiveness of hand hygiene in reducing the transmission of infectious diseases, there are gaps in global normative guidance around hand hygiene in community settings. The goal of this review is to systematically retrieve and synthesise available evidence on hand hygiene in community settings across four areas: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures.

METHODS AND ANALYSIS

This protocol entails a two-phased approach to identify relevant studies for multiple related systematic reviews. Phase 1 involves a broad search to capture all studies on hand hygiene in community settings. Databases, trial registries, expert consultations and hand searches of reference lists will be used to ensure an exhaustive search. A comprehensive, electronic search strategy will be used to identify studies indexed in PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary published in English from January 1980 to March 2023. The outcome of phase 1 will be a reduced sample of studies from which further screening, specific to research questions across the four key areas can be performed. Two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer. Quantitative and qualitative data will be extracted following best practices. We will assess all studies using the Mixed Method Appraisal Tool. All effect measures pertaining to review outcomes will be reported and a narrative synthesis of all studies will be presented including 'data-driven' descriptive themes and 'theory-driven' analytical themes as applicable.

ETHICS AND DISSEMINATION

This systematic review is exempt from ethics approval because the work is carried out on published documents. The findings of the reviews will be disseminated in related peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023429145.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

Knowledge about Hand Hygiene and Related Infectious Disease Awareness among Primary School Children in Germany

Hand hygiene is a cornerstone of infection prevention. However, few data are available for school children on their knowledge of infectious diseases and their prevention. The aim of the study was to develop and apply a standardized questionnaire for children when visiting primary schools to survey their knowledge about infectious diseases, pathogen transmission and prevention measures. Enrolling thirteen German primary schools, 493 questionnaires for grade three primary school children were included for further analyses, comprising 257 (52.1%) girls and 236 (47.9%) boys with an age range of 8–11 years. Out of 489 children, 91.2% participants indicated that they knew about human-to-human transmissible diseases. Of these, 445 children responded in detail, most frequently mentioning respiratory and gastrointestinal diseases, followed by childhood diseases. Addressing putative hygiene awareness-influencing factors, it was worrisome that more than 40.0% of the children avoided visiting the sanitary facilities at school. Most of the children (82.9%) noted that they did not like to use the sanitary facilities at school because of their uncleanliness and the poor hygienic behavior of their classmates. In conclusion, basic infection awareness exists already in primary school age children. Ideas about the origin and prevention of infections are retrievable, however, this knowledge is not always accurate and adequately contextualized. Since the condition of sanitary facilities has a strong influence on usage behavior, the child’s perspective should be given more consideration in the design and maintenance of sanitary facilities.

Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water

Waterborne diseases account for 1.5 million deaths a year globally, particularly affecting children in low-income households in subtropical areas. It is one of the most enduring and economically devastating biological hazards in our society today. The World Health Organization Health Emergency and Disaster Risk Management (health-EDRM) Framework highlights the importance of primary prevention against biological hazards across all levels of society. The framework encourages multi-sectoral coordination and lessons sharing for community risk resilience. A narrative review, conducted in March 2021, identified 88 English-language articles published between January 2000 and March 2021 examining water, sanitation, and hygiene primary prevention interventions against waterborne diseases in resource-poor settings. The literature identified eight main interventions implemented at personal, household and community levels. The strength of evidence, the enabling factors, barriers, co-benefits, and alternative measures were reviewed for each intervention. There is an array of evidence available across each intervention, with strong evidence supporting the effectiveness of water treatment and safe household water storage. Studies show that at personal and household levels, interventions are effective when applied together. Furthermore, water and waste management will have a compounding impact on vector-borne diseases. Mitigation against waterborne diseases require coordinated, multi-sectoral governance, such as building sanitation infrastructure and streamlined waste management. The review showed research gaps relating to evidence-based alternative interventions for resource-poor settings and showed discrepancies in definitions of various interventions amongst research institutions, creating challenges in the direct comparison of results across studies.

Innovation for improved hand hygiene: Field testing the Autarky handwashing station in collaboration with informal settlement residents in Durban, South Africa

Safe and accessible water services for hand hygiene are critical to human health and well-being. However, access to handwashing facilities is limited in cities in the Global South, where rapid urbanisation, service backlogs, lack of infrastructure and capacity, and water scarcity impact on the ability of local governments to provide them. Community participation and the co-production of knowledge in the development of innovative technologies, which are aligned with Water, Sanitation and Hygiene (WASH) principles, can lead to more sustainable and socially-acceptable hand hygiene systems. This paper presents the outcomes of the testing of the Autarky handwashing station, a technology that provides onsite treatment and recycling of handwashing water, in an informal settlement in Durban, South Africa. The transdisciplinary research approach adopted enabled the participation of multiple stakeholders with different knowledge systems in the framing, testing and evaluation of the system. The process of co-producing knowledge, as well as the outcomes of the testing, namely high levels of functionality and social acceptability of the technology, supported the WASH principles. The evaluation revealed that the Autarky handwashing station is a niche intervention that improved access to safe and appealing handwashing facilities in an informal settlement. Its novel design, socially desirable features, reliability and ability to save water increased its acceptance in the community. The testing of the system in a real-world context revealed the value of including communities in knowledge production processes for technology innovation. Further work is required to ensure that real-time monitoring of system function is feasible before such systems can be implemented at larger scale.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment

Background

Nudging, a strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion.

Methods

A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations.

Results

This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience.

Conclusion

Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of ‘what works’ and ‘how it works’. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.

Behavior is at the core of neglected tropical disease (NTD) prevention and control, certainly within low-, and middle- income countries (LMIC) where resources are often limited. Therefore, strategies to promote behavior change should be included and investigated in future efforts. Nudging, a low-cost strategy that subtly directs people towards positive behavioral choices, has recently gained attention in global health promotion. Nudge strategies have been applied to a wide range of health-promoting behaviors such as handwashing. To understand which strategies were used, where and how these were applied, and whether these were ethically informed and implemented, we undertook a comprehensive review of the available sources. This resulted in 33 included studies, with a total of 67 nudge strategies for behavior-based prevention and control of NTDs in LMIC. Only two studies targeted NTDs in particular, the other 31 included studies were focused on more general health promoting behaviors, with the majority targeting handwashing with soap. The most common nudge strategies were those targeting decision assistance, such as fostering commitment and reminder actions. In general, the ethical assessment presented favorable results. We identified the need for robust study designs to better understand how nudges can be implemented in the future.

Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial

Background

Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA).

Methods

The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants’ interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs’ HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders’ insight workshop.

The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children’s wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention.

Discussion

The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs’ HH practice.

Trial registration

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06082-3.

Explaining Handwashing Behavior in a Sample of College Students during COVID-19 Pandemic Using the Multi-Theory Model (MTM) of Health Behavior Change: A Single Institutional Cross-Sectional Survey

Amidst the COVID-19 pandemic, handwashing offers a simple and effective hygienic measure for disease prevention. Reportedly, a significant proportion of college students did not follow handwashing recommendations provided by the Centers for Disease Control and Prevention (CDC) in the pre-COVID era. The purpose of this cross-sectional study was to explore and explain the handwashing behavior among college students during the COVID-19 pandemic using a contemporary fourth-generation multi-theory model (MTM) of health behavior change. Data were collected from 713 college students at a large public university in the Southern U.S. in October 2020 using a validated 36-item survey. Statistical analyses included independent samples t-tests, Pearson correlation, and hierarchical regression modeling. Among students not following handwashing recommendations, the constructs of participatory dialogue (β = 0.152; p < 0.05) and behavioral confidence (β = 0.474; p < 0.0001) were statistically significant and accounted for 27.2% of the variance in the likelihood of initiation of the behavior. Additionally, the constructs of emotional transformation (β = 0.330; p < 0.0001), practice for change (β = 0.296; p < 0.0001), and changes in the social environment (β = 0.180; p < 0.05) were statistically significant and accounted for 45.1% of the variance in the likelihood of sustaining handwashing behavior. This study highlights the applicability and usability of the MTM in designing and testing behavior change interventions and media messaging in campaigns targeting college students.