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Crocker J, Ogutu EA, Snyder J, Freeman MC. The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation, and hygiene interventions: A scoping review. Int J Hyg Environ Health 2024; 259:114363. [PMID: 38604106 DOI: 10.1016/j.ijheh.2024.114363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/05/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION To accurately assess evidence from environmental and public health field trials, context and implementation details of the intervention must be weighed with trial results; yet these details are under and inconsistently reported for water, sanitation, and hygiene (WASH), limiting the external validity of the evidence. METHODS To quantify the level of reporting of context and implementation in WASH evaluations, we conducted a scoping review of the 40 most cited evaluations of WASH interventions published in the last 10 years (2012-2022). We applied criteria derived from a review of existing reporting guidance from other sectors including healthcare and implementation science. We subsequently reviewed main articles, supplements, protocols, and other associated resources to assess thoroughness of context and implementation reporting. RESULTS Of the final 25 reporting items we searched for, four-intervention name, approach, location, and temporality-were reported by all studies. Five items-theory, implementer qualifications, dose intensity, targeting, and measured fidelity-were not reported in over a third of reviewed articles. Only two studies (5%) reported all items in our checklist. Only 74% of items were found in the main article, while the rest were found in separate papers (7%) or not at all (19%). DISCUSSION Inconsistent reporting of WASH implementation illustrates a major challenge in the sector. It is difficult to know what interventions are actually being evaluated and how to compare evaluation results. This inconsistent and incomplete implementation reporting limits the ability of programmers and policy makers to apply the available evidence to their contexts. Standardized reporting guidelines would improve the application of the evidence for WASH field evaluations.
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Affiliation(s)
- Jonny Crocker
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA.
| | - Emily A Ogutu
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Jedidiah Snyder
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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Ogutu EA, Ellis AS, Hester KA, Rodriguez K, Sakas Z, Jaishwal C, Yang C, Dixit S, Bose AS, Sarr M, Kilembe W, Bednarczyk R, Freeman MC. Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia. BMJ Open 2024; 14:e079358. [PMID: 38569679 DOI: 10.1136/bmjopen-2023-079358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVES Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts. DESIGN We employed a multiple case study design using qualitative research methods. SETTING We conducted research in Nepal, Senegal and Zambia. PARTICIPANTS We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts. RESULTS Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work. CONCLUSION Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.
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Affiliation(s)
- Emily A Ogutu
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Anna S Ellis
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Kyra A Hester
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Katie Rodriguez
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Zoe Sakas
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Chandni Jaishwal
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Chenmua Yang
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Moussa Sarr
- Institut de Recherche en Santé, de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | | | - Robert Bednarczyk
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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Caruso BA, Snyder JS, Cumming O, Esteves Mills J, Gordon B, Rogers H, Freeman MC, Wolfe M. Synthesising the evidence for effective hand hygiene in community settings: an integrated protocol for multiple related systematic reviews. BMJ Open 2023; 13:e077677. [PMID: 37967997 PMCID: PMC10660659 DOI: 10.1136/bmjopen-2023-077677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/19/2023] [Indexed: 11/17/2023] Open
Abstract
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.
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Affiliation(s)
- Bethany A Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jedidiah S Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
- Water, Sanitation, Hygiene and Health Unit, World Health Organization, Geneva, Switzerland
| | - Joanna Esteves Mills
- Water, Sanitation, Hygiene and Health Unit, World Health Organization, Geneva, Switzerland
| | - Bruce Gordon
- Water, Sanitation, Hygiene and Health Unit, World Health Organization, Geneva, Switzerland
| | - Hannah Rogers
- Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Marlene Wolfe
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Shioda K, Brouwer AF, Lamar F, Mucache HN, Levy K, Freeman MC. Opportunities to Interrupt Transmission of Enteropathogens of Poultry Origin in Maputo, Mozambique: A Transmission Model Analysis. Environ Health Perspect 2023; 131:117004. [PMID: 37910131 PMCID: PMC10619637 DOI: 10.1289/ehp12314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 09/09/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The burden of diarrheal diseases remains high among children in low-income countries. Enteropathogens are challenging to control because they are transmitted via multiple pathways. Chickens are an important animal protein source, but live chickens and their products are often highly contaminated with enteropathogens. OBJECTIVES We conducted this study to a) understand the contribution of multiple transmission pathways to the force of infection of Campylobacter spp. and nontyphoidal Salmonella spp., b) quantify the potential impact of reducing each pathway on human infection, and c) quantify hypothesized pathway reduction from the context of Maputo, Mozambique. METHODS We developed transmission models for Campylobacter and Salmonella that captured person-to-person, water-to-person, food-to-person, soil-to-person, animal-to-person, and all-other-sources-to-person in an urban, low-income setting in Mozambique. We calibrated these models using prevalence data from Maputo, Mozambique and estimates of attributable fraction of transmission pathways for the region. We simulated the prevalence of human infection after reducing transmission through each pathway. RESULTS Simulation results indicated that if foodborne transmission were reduced by 90%, the prevalence of Campylobacter and Salmonella infection would decline by [52.2%; 95% credible interval (CrI): 39.7, 63.8] and (46.9%; 95% CrI: 39, 55.4), respectively. Interruption of any other pathway did not have a substantial impact. Combined with survey and microbiology data, if contamination of broiler chicken meat at informal markets in Maputo could be reduced by 90%, the total infection of Campylobacter and Salmonella could be reduced by 21% (16-26%) and 12% (10-13%), respectively. DISCUSSION Our transmission models showed that the foodborne transmission has to be reduced to control enteropathogen infections in our study site, and likely in other similar contexts, but mitigation of this transmission pathway has not received sufficient attention. Our model can serve as a tool to identify effective mitigation opportunities to control zoonotic enteropathogens. https://doi.org/10.1289/EHP12314.
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Affiliation(s)
- Kayoko Shioda
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Department of Global Health, Boston University, Boston, MA
- Boston University Center for Emerging Infectious Diseases Policy and Research, Boston, MA
| | - Andrew F Brouwer
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Frederica Lamar
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Karen Levy
- Department of Environmental & Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Lamar F, Mucache HN, Mondlane-Milisse A, Jesser KJ, Victor C, Fafetine JM, Saíde JÂO, Fèvre EM, Caruso BA, Freeman MC, Levy K. Quantifying Enteropathogen Contamination along Chicken Value Chains in Maputo, Mozambique: A Multidisciplinary and Mixed-Methods Approach to Identifying High Exposure Settings. Environ Health Perspect 2023; 131:117007. [PMID: 37962439 PMCID: PMC10644898 DOI: 10.1289/ehp11761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Small-scale poultry production is widespread and increasing in low- and middle-income countries (LMICs). Exposure to enteropathogens in poultry feces increases the hazard of human infection and related sequela, and the burden of disease due to enteric infection in children < 5 y in particular is substantial. Yet, the containment and management of poultry-associated fecal waste in informal settings in LMICs is largely unregulated. OBJECTIVES To improve the understanding of potential exposures to enteropathogens carried by chickens, we used mixed methods to map and quantify microbial hazards along production value chains among broiler, layer, and indigenous chickens in Maputo, Mozambique. METHODS To map and describe the value chains, we conducted 77 interviews with key informants working in locations where chickens and related products are sold, raised, and butchered. To quantify microbial hazards, we collected chicken carcasses (n = 75 ) and fecal samples (n = 136 ) from chickens along the value chain and assayed them by qPCR for the chicken-associated bacterial enteropathogens C. jejuni/coli and Salmonella spp. RESULTS We identified critical hazard points along the chicken value chains and identified management and food hygiene practices that contribute to potential exposures to chicken-sourced enteropathogens. We detected C. jejuni/coli in 84 (76%) of fecal samples and 52 (84%) of carcass rinses and Salmonella spp. in 13 (11%) of fecal samples and 16 (21%) of carcass rinses. Prevalence and level of contamination increased as chickens progressed along the value chain, from no contamination of broiler chicken feces at the start of the value chain to 100% contamination of carcasses with C. jejuni/coli at informal markets. Few hazard mitigation strategies were found in the informal sector. DISCUSSION High prevalence and concentration of C. jejuni/coli and Salmonella spp. contamination along chicken value chains suggests a high potential for exposure to these enteropathogens associated with chicken production and marketing processes in the informal sector in our study setting. We identified critical control points, such as the carcass rinse step and storage of raw chicken meat, that could be intervened in to mitigate risk, but regulation and enforcement pose challenges. This mixed-methods approach can also provide a model to understand animal value chains, sanitary risks, and associated exposures in other settings. https://doi.org/10.1289/EHP11761.
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Affiliation(s)
- Frederica Lamar
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | | | - Kelsey J. Jesser
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Courtney Victor
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - José M. Fafetine
- Veterinary Faculty, Universidade Eduardo Mondlane, Maputo, Mozambique
- Biotechnology Centre, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Eric M. Fèvre
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Neston, UK
- International Livestock Research Institute, Nairobi, Kenya
| | - Bethany A. Caruso
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
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Sakas Z, Hester KA, Ellis A, Ogutu EA, Rodriguez K, Bednarczyk R, Dixit S, Kilembe W, Sarr M, Freeman MC. Critical success factors for high routine immunisation performance: a qualitative analysis of interviews and focus groups from Nepal, Senegal, and Zambia. BMJ Open 2023; 13:e070541. [PMID: 37793916 PMCID: PMC10551940 DOI: 10.1136/bmjopen-2022-070541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/16/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Vaccination averts an estimated 2-3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained below global targets, several countries have outperformed their peers with significant increases in coverage. The objective of this study was to examine these countries' vaccination programmes and to identify and describe critical success factors that may have supported these improvements. DESIGN Multiple case study design using qualitative research methods. SETTING Three countries with high routine immunisation rates: Nepal, Senegal, and Zambia. PARTICIPANTS We conducted 207 key informant interviews and 71 focus group discussions with a total of 678 participants. Participants were recruited from all levels, including government officials, health facility staff, frontline workers, community health workers, and parents. Participants were recruited from both urban and rural districts in Nepal, Senegal, and Zambia. RESULTS Our data revealed that the critical success factors for vaccination programmes relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunisation coverage was driven by (1) strong governance structures and healthy policy environments; (2) adjacent successes in health system strengthening; (3) government-led community engagement initiatives, and (4) adaptation considering contextual factors at all levels of the health system. CONCLUSIONS Throughout this project, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may help identify transferable lessons and support actionable recommendations to improve national immunisation coverage in other settings.
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Affiliation(s)
- Zoe Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kyra A Hester
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Anna Ellis
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Emily A Ogutu
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Katie Rodriguez
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Robert Bednarczyk
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Sameer Dixit
- Center for Molecular Dynamics Nepal, Kathmandu, Nepal
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Smalley HK, Castillo-Zunino F, Keskinocak P, Nazzal D, Sakas ZM, Sarr M, Freeman MC. Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis. BMJ Open 2023; 13:e074388. [PMID: 37793917 PMCID: PMC10551957 DOI: 10.1136/bmjopen-2023-074388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere. DESIGN Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports for years 2005-2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates. SETTING The 14 administrative regions of Senegal were chosen for analysis. PARTICIPANTS DHS women's survey respondents with living children aged 12-23 months for survey years 2005-2019. OUTCOME MEASURES Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme. RESULTS Factors associated with childhood vaccination coverage include urban residence (β=0.61, p=0.0157), female literacy (β=1.11, p=0.0007), skilled prenatal care (β=1.80, p<0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (β=-0.70, p=0.0009) and concerns over travelling alone (β=-1.08, p<0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas. CONCLUSIONS Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.
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Affiliation(s)
- Hannah K Smalley
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Francisco Castillo-Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
- Center for Health and Humanitarian Systems, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Zoë M Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation, Dakar, Senegal
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Das R, Palit P, Haque MA, Levine MM, Kotloff KL, Nasrin D, Hossain MJ, Sur D, Ahmed T, Breiman RF, Freeman MC, Faruque ASG. Symptomatic and asymptomatic enteric protozoan parasitic infection and their association with subsequent growth parameters in under five children in South Asia and sub-Saharan Africa. PLoS Negl Trop Dis 2023; 17:e0011687. [PMID: 37816031 PMCID: PMC10588856 DOI: 10.1371/journal.pntd.0011687] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/20/2023] [Accepted: 09/27/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Entamoeba histolytica, Giardia, and Cryptosporidium are common intestinal protozoan parasites that contribute to a high burden of childhood morbidity and mortality. Our study quantified the association between intestinal protozoan parasites and child anthropometric outcomes among children under-5. METHODS We analyzed data from 7,800 children enrolled in the Global Enteric Multicenter Study (GEMS) across seven study sites that were positive for intestinal protozoan parasites between December 2007 and March 2011. Parasites were assessed using stool immunoassays (ELISA). We applied multiple linear regression to test the association between any or concurrent parasite and child anthropometric outcomes: length/height-for-age (HAZ), weight-for-age (WAZ), and weight-for-length/height (WHZ) z-score after 60 days of enrollment. Models were stratified by diarrheal symptoms, driven by the study design, and adjusted for potential covariates. FINDINGS During the follow-up at day 60 after enrollment, child anthropometric outcomes, among the asymptomatic children showed, negative associations between Giardia with HAZ [β: -0.13; 95% CI: -0.17, -0.09; p<0.001] and WAZ [β -0.07; 95% CI: -0.11, -0.04; p<0.001], but not WHZ [β: -0.02; 95% CI:-0.06, 0.02; p = 0.36]; Cryptosporidium with WAZ [β: -0.15; 95% CI: -0.22, -0.09; p<0.001] and WHZ [β: -0.18; 95%CI: -0.25, -0.12; p<0.001], but not with HAZ [β: -0.03; 95% CI: -0.09, 0.04; p = 0.40]. For symptomatic children, no associations were found between Giardia and anthropometry; negative associations were found between Cryptosporidium with HAZ [β: -0.17; 95% CI: -0.23, -0.11; p<0.001], WAZ [β: -0.25; 95% CI: -0.31, -0.19; p<0.001] and WHZ [β: -0.23; 95% CI: -0.30, -0.17; p<0.001]. Among the asymptomatic 24-59 months children, Giardia had a negative association with HAZ [β: -0.09; 95% CI: -0.15, -0.04; p = 0.001]. No significant associations were found between E. histolytica with child growth. CONCLUSIONS While some studies have found that Giardia is not associated with (or protective against) acute diarrhea, our findings suggest that it is associated with growth shortfall. This observation underscores the need for preventive strategies targeting enteric protozoan parasites among young children, to reduce the burden of childhood malnutrition.
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Affiliation(s)
- Rina Das
- Nutrition Research Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Parag Palit
- Nutrition Research Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Md. Ahshanul Haque
- Nutrition Research Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Myron M. Levine
- University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Karen L. Kotloff
- University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Dilruba Nasrin
- University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - M. Jahangir Hossain
- Medical Research Council Unit, London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Robert F. Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - A. S. G. Faruque
- Nutrition Research Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Escoffery C, Ogutu EA, Sakas Z, Hester KA, Ellis A, Rodriguez K, Jaishwal C, Yang C, Dixit S, Bose A, Sarr M, Kilembe W, Bednarczyk RA, Freeman MC. Drivers of early childhood vaccination success in Nepal, Senegal, and Zambia: a multiple case study analysis using the Consolidated Framework for Implementation Research. Implement Sci Commun 2023; 4:109. [PMID: 37667374 PMCID: PMC10478385 DOI: 10.1186/s43058-023-00489-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION The fundamental components of a vaccine delivery system are well-documented, but robust evidence is needed on how the related processes and implementation strategies - including the facilitators and barriers - contribute to improvements in childhood vaccination coverage. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success. METHODS We conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia to identify intervention activities and the facilitators and barriers to implementation. We used thematic analysis grounded in the Consolidated Framework for Implementation Research (CFIR) constructs of inner and outer settings to identify immunization program key facilitators and barriers. RESULTS We found that the common facilitators to program implementation across the countries were the CFIR inner setting constructs of (1) networks and communications, (2) goals and feedback, (3) relative priority, and (4) readiness for implementation and outer setting constructs of (5) cosmopolitanism and (6) external policies and mandates. The common barriers were incentives and rewards, available resources, access to knowledge and information, and patients' needs and resources. Critical to the success of these national immunization programs were prioritization and codification of health as a human right, clear chain of command and shared ownership of immunization, communication of program goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the program, key partnerships and guidance on implementation and adoption of vaccination policies. CONCLUSION Adequate organizational commitment, resources, communication, training, and partnerships were the most critical facilitators for these countries to improve childhood vaccination.
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Affiliation(s)
- Cam Escoffery
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kyra A Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Katie Rodriguez
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chenmua Yang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sameer Dixit
- Center for Molecular Dynamics Nepal, Kathmandu, Nepal
| | - Anindya Bose
- WHO Nepal Immunization Preventable Disease Division, Kathmandu, Nepal
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidemiologique Et de Formation (IRESSEF), Dakar, Senegal
| | - William Kilembe
- Center for Family, Health Research in Zambia, Lusaka, Zambia
| | | | - Matthew C Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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10
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Hester KA, Sakas Z, Ogutu EA, Dixit S, Ellis AS, Yang C, Chanda C, Freeman MC, Orenstein WA, Sarr M, Bednarczyk RA. Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination. Vaccine X 2023; 14:100341. [PMID: 37519776 PMCID: PMC10372309 DOI: 10.1016/j.jvacx.2023.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Childhood vaccination is an effective intervention for lowering the burden of infectious disease. Vaccine coverage has increased globally, but vaccine hesitancy and refusal threatens these gains. The 5C psychological antecedents of vaccination ("5C") provides a validated measure of "vaccine hesitancy or confidence" to assess individual thoughts and behaviors behind vaccination. We investigated population-level factors that contributed to high and sustained vaccination coverage in Zambia, Nepal, and Senegal, and alignment with the 5Cs. Methods Data was collected in the larger Exemplars in Vaccine Delivery study, from focus group discussions (FDGs) and key informant interviews (KIIs) at the national, regional, district, health facility, and community levels of health systems in Zambia, Nepal, and Senegal. We assessed the demand environment, as relayed by participants, and identified interventions reported as successful for demand generation, then retroactively aligned the interventions with the 5C constructs. Results Demand was positively correlated with high confidence and collective responsibility. Psychological constraints sometimes impacted demand. Physical constraints created barriers in some communities, particularly difficult to access (i.e., mountainous). Occasionally, physical constraints did not affect vaccination behavior - parents believed the benefits of vaccination worth pursuing. Factors negatively correlated with demand and intent, complacency and calculation, had limited impact. Critical interventions were: targeted and tailored health education activities (media partnerships, school outreach); community engagement; community ownership; and community involvement (community health workers, leaders, religious figures). Conclusion We found similar interventions used to generate demand, with strategies aligned with the 5C constructs. Categorizing interventions by drivers of demand may help strategic planning and the division of resources; decision makers may choose to implement our suggested interventions. Assessing the 5Cs allows decision-makers to operationalize demand generation into concrete interventions and policies, and determine the individual impact of these constructs on the population and focus efforts on interventions tailored to a specific need.
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Affiliation(s)
- Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Sameer Dixit
- Center for Molecular Dynamics Nepal, Katmandu, Nepal
| | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chenmua Yang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chama Chanda
- Center for Family Health Research in Zambia, Lusaka, Zambia
| | | | | | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation (IRESSEF), Dakar, Senegal
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11
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Wolf J, Johnston RB, Ambelu A, Arnold BF, Bain R, Brauer M, Brown J, Caruso BA, Clasen T, Colford JM, Mills JE, Evans B, Freeman MC, Gordon B, Kang G, Lanata CF, Medlicott KO, Prüss-Ustün A, Troeger C, Boisson S, Cumming O. Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes. Lancet 2023; 401:2060-2071. [PMID: 37290458 PMCID: PMC10290941 DOI: 10.1016/s0140-6736(23)00458-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/25/2023] [Accepted: 02/28/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels. METHODS We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure-response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH. FINDINGS We estimate that 1·4 (95% CI 1·3-1·5) million deaths and 74 (68-80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65-0·72), 0·14 (0·13-0·17) for acute respiratory infections, and 0·10 (0·09-0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH. INTERPRETATION WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns. FUNDING WHO and Foreign, Commonwealth & Development Office.
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Affiliation(s)
- Jennyfer Wolf
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
| | - Richard B Johnston
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Argaw Ambelu
- Division of Water and Health, Ethiopian Institution of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia
| | - Benjamin F Arnold
- FI Proctor Foundation, University of California, San Francisco, CA, USA
| | - Robert Bain
- UNICEF Middle East and North Africa, Amman, Jordan
| | - Michael Brauer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bethany A Caruso
- The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Gangarose Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Joanna Esteves Mills
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Barbara Evans
- School of Civil Engineering, University of Leeds, Leeds, UK
| | - Matthew C Freeman
- Gangarose Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bruce Gordon
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Gagandeep Kang
- Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tami Nadu, India
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru; School of Medicine, Vanderbilt University, Nashville, TN, USA; Department of Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kate O Medlicott
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Annette Prüss-Ustün
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Christopher Troeger
- Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Sophie Boisson
- Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
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Kann RS, Snyder JS, Woreta M, Zewudie K, Freeman MC, Delea MG. Quantifying Factors Associated with Personal Hygiene as Measured by the qPHAT Methodology: Andilaye Trial, Ethiopia. Am J Trop Med Hyg 2023; 108:1277-1286. [PMID: 37127265 PMCID: PMC10540125 DOI: 10.4269/ajtmh.22-0603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/10/2023] [Indexed: 05/03/2023] Open
Abstract
Many water, sanitation, and hygiene (WASH) interventions target improvements in personal hygiene behaviors. Yet measuring personal hygiene behaviors is a challenge due to a lack of reliable, valid, objective, and simple-to-use approaches. The purpose of this study was to examine differences between two types of hygiene outcome measures and their ability to detect relationships between WASH-related behavioral factors and behaviors. We compared hygiene outcomes generated by the Quantitative Personal Hygiene Assessment Tool (qPHAT), which yields objective measures of cleanliness on an 11-point scale, and those generated by conventional, dichotomous indicators of cleanliness. We used cross-sectional data on hygiene outcomes related to facial and hand cleanliness collected during the Andilaye Trial, an impact evaluation of a community-based WASH intervention implemented in Amhara, Ethiopia. We fit multivariable models to examine associations between measures of children's facial and hand cleanliness, via both qPHAT and dichotomous indicators, and 1) household WASH conditions, 2) psychosocial factors, and 3) reported personal hygiene practices. The qPHAT-generated outcomes were able to detect relationships between intermediate behavioral factors and hygiene outcomes that dichotomous indicators were not, including associations with water insecurity and various psychosocial factors. qPHAT-generated outcomes were negatively associated with reported face washing practices, suggesting a bias in reported behaviors. Our study highlights the limitations of reported practices and dichotomous hygiene indicators and indicates that using more quantitative hygiene outcome measures, such as those generated by qPHAT, may reveal important intermediate factors that influence hygiene behavior and support improved monitoring and evaluation of interventions.
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Affiliation(s)
- Rebecca S. Kann
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jedidiah S. Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maryann G. Delea
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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13
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Ross I, Bick S, Ayieko P, Dreibelbis R, Wolf J, Freeman MC, Allen E, Brauer M, Cumming O. Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 2023; 401:1681-1690. [PMID: 37121242 DOI: 10.1016/s0140-6736(23)00021-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/07/2022] [Accepted: 01/03/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs. METHODS In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414. FINDINGS 26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence. INTERPRETATION Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease. FUNDING Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.
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Affiliation(s)
- Ian Ross
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Sarah Bick
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Ayieko
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert Dreibelbis
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jennyfer Wolf
- Department of Environmental, Climate Change and Health, World Health Organization, Geneva, Switzerland
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Elizabeth Allen
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Brauer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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14
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Ballard AM, Laramee N, Haardörfer R, Freeman MC, Levy K, Caruso BA. Measurement in the study of human exposure to animal feces: A systematic review and audit. Int J Hyg Environ Health 2023; 249:114146. [PMID: 36868140 PMCID: PMC10044406 DOI: 10.1016/j.ijheh.2023.114146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/31/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Human exposure to animal feces is increasingly recognized as an important transmission route of enteric pathogens. Yet, there are no consistent or standardized approaches to measurement of this exposure, limiting assessment of the human health effects and scope of the issue. OBJECTIVE To inform and improve approaches to the measurement of human exposure to animal feces, we audited existing measurement in low- and middle-income countries. METHODS We systematically searched peer-reviewed and gray literature databases for studies with quantitative measures of human exposure to animal feces and we classified measures in two ways. First, using a novel conceptual model, we categorized measures into three 'Exposure Components' identified a priori (i.e., Animal, Environmental, Human Behavioral); one additional Component (Evidence of Exposure) inductively emerged. Second, using the exposure science conceptual framework, we determined where measures fell along the source-to-outcome continuum. RESULTS We identified 1,428 measures across 184 included studies. Although studies overwhelmingly included more than one single-item measure, the majority only captured one Exposure Component. For example, many studies used several single-item measures to capture the same attribute for different animals, all of which were classified as the same Component. Most measures captured information about the source (e.g. animal presence) and contaminant (e.g. animal-sourced pathogens), which are most distal from exposure on the source-to-outcome continuum. DISCUSSION We found that measurement of human exposure to animal feces is diverse and largely distal from exposure. To facilitate better assessment of the human health effects of exposure and scope of the issue, rigorous and consistent measures are needed. We recommend a list of key factors from the Animal, Environmental, and Human Behavioral Exposure Components to measure. We also propose using the exposure science conceptual framework to identify proximal measurement approaches.
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Affiliation(s)
- April M Ballard
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA.
| | - Nicholas Laramee
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Regine Haardörfer
- Department of Behavioral, Social and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, WA, USA
| | - Bethany A Caruso
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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15
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Sakas Z, Hester KA, Rodriguez K, Amos Diatta S, Ellis AS, Malick Gueye D, Matapano D, Souleymane Mboup P, Awino Ogutu E, Yang C, Bednarczyk RA, Freeman MC, Sarr M, Castillo Zunino F, Darwar R, Dounebaine B, Dudgeon MR, Escoffery C, Isett KR, Jaishwal C, James H, Keskinocak P, Pablo Montagnes B, Nazzali D, Orenstein W, Rueda Robayo M, Rosenblum S, Smalley HK. Critical success factors for high routine immunization performance: A case study of Senegal. Vaccine X 2023; 14:100296. [PMID: 37113739 PMCID: PMC10126928 DOI: 10.1016/j.jvacx.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background The essential components of a vaccine delivery system are well-documented, but robust evidence is lacking on how policies and implementation strategies are operationalized to drive catalytic improvements in coverage. To address this gap, we identified success factors that supported improvements in routine immunization coverage in Senegal, especially from 2000 to 2019. Methods We identified Senegal as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health facility, and community-level, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Strong political will and prioritization of resources for immunization programming supported urgent allocation of funding and supplies; 2) Collaboration between the Ministry of Health and Social Action and external partners fostered innovation, capacity building, and efficiency; 3) Improved surveillance, monitoring, and evaluation allowed for timely and evidence-based decision making; 4) Community ownership of vaccine service delivery supported tailored programming and response to local needs; and 5) Community health workers spearheaded vaccine promotion and demand generation for vaccines. Conclusion The vaccination program in Senegal was supported by evidence-based decision making at the national-level, alignment of priorities between governmental entities and external partners, and strong community engagement initiatives that fostered local ownership of vaccine delivery and uptake. High routine immunization coverage was likely driven by prioritization of immunization programming, improved surveillance systems, a mature and reliable community health worker program, and tailored strategies for addressing geographical, social, and cultural barriers.
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Levy K, Garn JV, Cumbe ZA, Muneme B, Fagnant-Sperati CS, Hubbard S, Júnior A, Manuel JL, Mangamela M, McGunegill S, Miller-Petrie MK, Snyder JS, Victor C, Waller LA, Konstantinidis KT, Clasen TF, Brown J, Nalá R, Freeman MC. Study design and rationale for the PAASIM project: a matched cohort study on urban water supply improvements and infant enteric pathogen infection, gut microbiome development and health in Mozambique. BMJ Open 2023; 13:e067341. [PMID: 36863743 PMCID: PMC9990653 DOI: 10.1136/bmjopen-2022-067341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
INTRODUCTION Despite clear linkages between provision of clean water and improvements in child health, limited information exists about the health impacts of large water infrastructure improvements in low-income settings. Billions of dollars are spent annually to improve urban water supply, and rigorous evaluation of these improvements, especially targeting informal settlements, is critical to guide policy and investment strategies. Objective measures of infection and exposure to pathogens, and measures of gut function, are needed to understand the effectiveness and impact of water supply improvements. METHODS AND ANALYSIS In the PAASIM study, we examine the impact of water system improvements on acute and chronic health outcomes in children in a low-income urban area of Beira, Mozambique, comprising 62 sub-neighbourhoods and ~26 300 households. This prospective matched cohort study follows 548 mother-child dyads from late pregnancy through 12 months of age. Primary outcomes include measures of enteric pathogen infections, gut microbiome composition and source drinking water microbiological quality, measured at the child's 12-month visit. Additional outcomes include diarrhoea prevalence, child growth, previous enteric pathogen exposure, child mortality and various measures of water access and quality. Our analyses will compare (1) subjects living in sub-neighbourhoods with the improved water to those living in sub-neighbourhoods without these improvements; and (2) subjects with household water connections on their premises to those without such a connection. This study will provide critical information to understand how to optimise investments for improving child health, filling the information gap about the impact of piped water provision to low-income urban households, using novel gastrointestinal disease outcomes. ETHICS AND DISSEMINATION This study was approved by the Emory University Institutional Review Board and the National Bio-Ethics Committee for Health in Mozambique. The pre-analysis plan is published on the Open Science Framework platform (https://osf.io/4rkn6/). Results will be shared with relevant stakeholders locally, and through publications.
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Affiliation(s)
- Karen Levy
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Joshua V Garn
- Division of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada Reno, Reno, Nevada, USA
| | | | | | - Christine S Fagnant-Sperati
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Sydney Hubbard
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - João Luís Manuel
- Beira Operations Research Center, National Health Institute (INS), Ministry of Health of Mozambique, Beira, Mozambique
| | | | - Sandy McGunegill
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Molly K Miller-Petrie
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Jedidiah S Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Courtney Victor
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Joe Brown
- Environmental Science and Engineering, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Rassul Nalá
- Ministry of Health, Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Sullivan KM, Harding-Esch EM, Keil AP, Freeman MC, Batcho WE, Bio Issifou AA, Bucumi V, Bella AL, Epee E, Bobo Barkesa S, Seife Gebretsadik F, Sanha S, Kalua KM, Masika MP, Minnih AO, Abdala M, Massangaie ME, Amza A, Kadri B, Nassirou B, Mpyet CD, Olobio N, Badiane MD, Elshafie BE, Baayenda G, Kabona GE, Kaitaba O, Simon A, Al-Khateeb TQ, Mwale C, Bakhtiari A, Westreich D, Solomon AW, Gower EW. Exploring water, sanitation, and hygiene coverage targets for reaching and sustaining trachoma elimination: G-computation analysis. PLoS Negl Trop Dis 2023; 17:e0011103. [PMID: 36780437 PMCID: PMC9925017 DOI: 10.1371/journal.pntd.0011103] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/14/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Trachoma is the leading infectious cause of blindness. To reduce transmission, water, sanitation, and hygiene (WaSH) improvements are promoted through a comprehensive public health strategy. Evidence supporting the role of WaSH in trachoma elimination is mixed and it remains unknown what WaSH coverages are needed to effectively reduce transmission. METHODS/FINDINGS We used g-computation to estimate the impact on the prevalence of trachomatous inflammation-follicular among children aged 1-9 years (TF1-9) when hypothetical WaSH interventions raised the minimum coverages from 5% to 100% for "nearby" face-washing water (<30 minutes roundtrip collection time) and adult latrine use in an evaluation unit (EU). For each scenario, we estimated the generalized prevalence difference as the TF1-9 prevalence under the intervention scenarios minus the observed prevalence. Data from 574 cross-sectional surveys conducted in 16 African and Eastern Mediterranean countries were included. Surveys were conducted from 2015-2019 with support from the Global Trachoma Mapping Project and Tropical Data. When modeling interventions among EUs that had not yet met the TF1-9 elimination target, increasing nearby face-washing water and latrine use coverages above 30% was generally associated with consistent decreases in TF1-9. For nearby face-washing water, we estimated a ≥25% decrease in TF1-9 at 65% coverage, with a plateau upon reaching 85% coverage. For latrine use, the estimated decrease in TF1-9 accelerated from 80% coverage upward, with a ≥25% decrease in TF1-9 by 85% coverage. Among EUs that had previously met the elimination target, results were inconclusive. CONCLUSIONS Our results support Sustainable Development Goal 6 and provide insight into potential WaSH-related coverage targets for trachoma elimination. Targets can be tested in future trials to improve evidence-based WaSH guidance for trachoma.
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Affiliation(s)
- Kristin M. Sullivan
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America,* E-mail:
| | - Emma M. Harding-Esch
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alexander P. Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, United States of America
| | - Wilfrid E. Batcho
- Programme National De Lutte Contre Les Maladies Transmissibles, Ministère De La Santé, Cotonou, Benin
| | | | - Victor Bucumi
- Département En Charge des Maladies Tropicales, Négligées Ministère De La Santé Publique Et De La Lutte Contre Le Sida, Bujumbura, Burundi
| | - Assumpta L. Bella
- Programme National De Lutte Contre La Cécité, Ministère De La Santé Publique, Yaounde, Cameroon
| | - Emilienne Epee
- Department Of Ophthalmology, University of Yaoundé 1 Yaounde Centre, Yaoundé, Cameroun
| | - Segni Bobo Barkesa
- Neglected Tropical Disease Prevention and Control Program, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Fikre Seife Gebretsadik
- Neglected Tropical Disease Prevention and Control Program, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Salimato Sanha
- Programa Nacional De Saúde De Visão, Minsap, Bissau, Guinea-Bissau
| | | | - Michael P. Masika
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Abdallahi O. Minnih
- Département Des Maladies Transmissibles, Ministère De La Santé Nouakchott, Nouakchott, Mauritania
| | - Mariamo Abdala
- Direcção Nacional De Saúde Pública Ministerio Da Saude, Maputo, Mozambique
| | | | - Abdou Amza
- Programme National De Santé Oculaire Ministère De La Santé Publique, Niamey, Niger
| | - Boubacar Kadri
- Programme National De Santé Oculaire Ministère De La Santé Publique, Niamey, Niger
| | - Beido Nassirou
- Programme National De Santé Oculaire Ministère De La Santé Publique, Niamey, Niger
| | - Caleb D. Mpyet
- Department of Ophthalmology, University of Jos, Jos, Plateau, Nigeria
| | - Nicholas Olobio
- Neglected Tropical Diseases Division, Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
| | - Mouctar D. Badiane
- Programme National de Promotion de La Santé Oculaire, Ministère de la Santé et de L’Action sociale, Dakar, Senegal
| | - Balgesa E. Elshafie
- National Program for Prevention of Blindness, Federal Ministry of Health, Khartoum, Sudan
| | | | - George E. Kabona
- Neglected Tropical Disease Control Program, Ministry of Health, Dodoma, United Republic of Tanzania
| | - Oscar Kaitaba
- Neglected Tropical Disease Control Program, Ministry of Health, Dodoma, United Republic of Tanzania
| | - Alistidia Simon
- Neglected Tropical Disease Control Program, Ministry of Health, Dodoma, United Republic of Tanzania
| | | | - Consity Mwale
- Provincial Health Office, Ministry of Health, Lusaka, Zambia
| | - Ana Bakhtiari
- International Trachoma Initiative, Task Force for Global Health, Decatur, Georgia, United States of America
| | - Daniel Westreich
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Anthony W. Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Emily W. Gower
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Sakas Z, Uwah EA, Bhattrai RK, Garn JV, Gc KH, Mutta A, Ndlovu K, Nyaboro F, Singh RP, Rinzin U, Snyder JS, Wangdi K, Freeman MC. Assessing Sustainability Factors for Rural Household Sanitation Coverage in Bhutan, Kenya, Nepal, and Zambia: A Qualitative Analysis. Glob Health Sci Pract 2022; 10:GHSP-D-21-00724. [PMID: 36951284 PMCID: PMC9771455 DOI: 10.9745/ghsp-d-21-00724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/25/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Few countries are likely to achieve universal sanitation within the next decade as sustaining household sanitation coverage remains a critical challenge. This study aimed to investigate factors that may have supported or hindered sustainability of sanitation coverage 1-2 years after the completion of an integrated, area-wide sanitation program in 4 countries. METHODS We conducted qualitative analyses to identify factors related to the sustainability of sanitation coverage in Bhutan, Kenya, Nepal, and Zambia, 2 years after completion of the Sustainable Sanitation and Hygiene for All program. From November 2019 to March 2020, we conducted focus group discussions and key informant interviews with community members, project implementers, and decision makers. We triangulated the qualitative findings with data from household surveys to characterize subnational sanitation coverage throughout implementation and 1-2 years after. RESULTS Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to construction materials, local government commitment postimplementation, functioning monitoring systems, private sector uptake of supply chain improvements, and capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits. CONCLUSION The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work and where adaptations may be required. By comparing sustainability factors with subnational slippage rates, we were able to illustrate how local service delivery systems may respond to barriers and enablers. Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context.
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Affiliation(s)
- Zoe Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eberechukwu A Uwah
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Joshua V Garn
- Division of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, Reno, NV, USA
| | | | - Anna Mutta
- SNV Netherlands Development Organisation, The Hague, The Netherlands
| | | | | | | | | | - Jedidiah S Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Brouwer AF, Eisenberg MC, Bakker KM, Boerger SN, Zahid MH, Freeman MC, Eisenberg JNS. Leveraging infectious disease models to interpret randomized controlled trials: Controlling enteric pathogen transmission through water, sanitation, and hygiene interventions. PLoS Comput Biol 2022; 18:e1010748. [DOI: 10.1371/journal.pcbi.1010748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 12/15/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Randomized controlled trials (RCTs) evaluate hypotheses in specific contexts and are often considered the gold standard of evidence for infectious disease interventions, but their results cannot immediately generalize to other contexts (e.g., different populations, interventions, or disease burdens). Mechanistic models are one approach to generalizing findings between contexts, but infectious disease transmission models (IDTMs) are not immediately suited for analyzing RCTs, since they often rely on time-series surveillance data. We developed an IDTM framework to explain relative risk outcomes of an infectious disease RCT and applied it to a water, sanitation, and hygiene (WASH) RCT. This model can generalize the RCT results to other contexts and conditions. We developed this compartmental IDTM framework to account for key WASH RCT factors: i) transmission across multiple environmental pathways, ii) multiple interventions applied individually and in combination, iii) adherence to interventions or preexisting conditions, and iv) the impact of individuals not enrolled in the study. We employed a hybrid sampling and estimation framework to obtain posterior estimates of mechanistic parameter sets consistent with empirical outcomes. We illustrated our model using WASH Benefits Bangladesh RCT data (n = 17,187). Our model reproduced reported diarrheal prevalence in this RCT. The baseline estimate of the basic reproduction number R 0 for the control arm (1.10, 95% CrI: 1.07, 1.16) corresponded to an endemic prevalence of 9.5% (95% CrI: 7.4, 13.7%) in the absence of interventions or preexisting WASH conditions. No single pathway was likely able to sustain transmission: pathway-specific R 0 s for water, fomites, and all other pathways were 0.42 (95% CrI: 0.03, 0.97), 0.20 (95% CrI: 0.02, 0.59), and 0.48 (95% CrI: 0.02, 0.94), respectively. An IDTM approach to evaluating RCTs can complement RCT analysis by providing a rigorous framework for generating data-driven hypotheses that explain trial findings, particularly unexpected null results, opening up existing data to deeper epidemiological understanding.
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Hester KA, Sakas Z, Ellis AS, Bose AS, Darwar R, Gautam J, Jaishwal C, James H, Keskinocak P, Nazzal D, Awino Ogutu E, Rodriguez K, Castillo Zunino F, Dixit S, Bednarczyk RA, Freeman MC. Critical success factors for high routine immunization performance: A case study of Nepal. Vaccine X 2022; 12:100214. [PMID: 36148265 PMCID: PMC9486040 DOI: 10.1016/j.jvacx.2022.100214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/14/2022] [Accepted: 08/31/2022] [Indexed: 12/04/2022] Open
Abstract
Nepal reported high and sustained immunization coverage compared to peers. National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building. Pro-vaccine messaging through various mediums, including Female Community Health Volunteers, which was tailored to local needs, generated public awareness. Cultural values fostered collective responsibility and community ownership of vaccine coverage.
Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.
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Affiliation(s)
- Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anindya S. Bose
- World Health Organization, Nepal-Immunization Prevention Division, Nepal
| | - Roopa Darwar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jhalak Gautam
- Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal
| | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hanleigh James
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Katie Rodriguez
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Francisco Castillo Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Matthew C. Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Corresponding author at: 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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21
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Ogutu EA, Ellis A, Rodriguez KC, Caruso BA, McClintic EE, Ventura SG, Arriola KRJ, Kowalski AJ, Linabarger M, Wodnik BK, Webb-Girard A, Muga R, Freeman MC. Determinants of food preparation and hygiene practices among caregivers of children under two in Western Kenya: a formative research study. BMC Public Health 2022; 22:1865. [PMID: 36203140 PMCID: PMC9535979 DOI: 10.1186/s12889-022-14259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 09/19/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diarrhea is a leading cause of child morbidity and mortality worldwide and is linked to early childhood stunting. Food contamination from improper preparation and hygiene practices is an important transmission pathway for exposure to enteric pathogens. Understanding the barriers and facilitators to hygienic food preparation can inform interventions to improve food hygiene. We explored food preparation and hygiene determinants including food-related handwashing habits, meal preparation, cooking practices, and food storage among caregivers of children under age two in Western Kenya. METHODS We used the Capabilities, Opportunities, and Motivations model for Behavior Change (COM-B) framework in tool development and analysis. We conducted 24 focus group discussions with mothers (N = 12), fathers (N = 6), and grandmothers (N = 6); 29 key informant interviews with community stakeholders including implementing partners and religious and community leaders; and 24 household observations. We mapped the qualitative and observational data onto the COM-B framework to understand caregivers' facilitators and barriers to food preparation and hygiene practices. RESULTS Facilitators and barriers to food hygiene and preparation practices were found across the COM-B domains. Caregivers had the capability to wash their hands at critical times; wash, cook, and cover food; and clean and dry utensils. Barriers to food hygiene and preparation practices included lack of psychological capability, for instance, caregivers' lack of knowledge of critical times for handwashing, lack of perceived importance of washing some foods before eating, and not knowing the risks of storing food for more than four hours without refrigerating and reheating. Other barriers were opportunity-related, including lack of resources (soap, water, firewood) and an enabling environment (monetary decision-making power, social support). Competing priorities, socio-cultural norms, religion, and time constraints due to work hindered the practice of optimal food hygiene and preparation behaviors. CONCLUSION Food hygiene is an underexplored, but potentially critical, behavior to mitigate fecal pathogen exposure for young children. Our study revealed several knowledge and opportunity barriers that could be integrated into interventions to enhance food hygiene.
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Affiliation(s)
- Emily A. Ogutu
- grid.189967.80000 0001 0941 6502Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322 USA
| | - Anna Ellis
- grid.189967.80000 0001 0941 6502Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322 USA
| | - Katie C. Rodriguez
- grid.189967.80000 0001 0941 6502Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322 USA
| | - Bethany A. Caruso
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Emilie E. McClintic
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Sandra Gómez Ventura
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Kimberly R. J. Arriola
- grid.189967.80000 0001 0941 6502Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502James T. Laney School of Graduate Studies, Emory University, Atlanta, GA USA
| | - Alysse J. Kowalski
- grid.189967.80000 0001 0941 6502James T. Laney School of Graduate Studies, Emory University, Atlanta, GA USA
| | - Molly Linabarger
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Breanna K. Wodnik
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Amy Webb-Girard
- grid.189967.80000 0001 0941 6502Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502James T. Laney School of Graduate Studies, Emory University, Atlanta, GA USA
| | - Richard Muga
- grid.472446.7Uzima University College, Kisumu, Kenya
| | - Matthew C. Freeman
- grid.189967.80000 0001 0941 6502Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322 USA
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Apanga PA, Freeman MC, Sakas Z, Garn JV. Assessing the Sustainability of an Integrated Rural Sanitation and Hygiene Approach: A Repeated Cross-Sectional Evaluation in 10 Countries. Glob Health Sci Pract 2022; 10:GHSP-D-21-00564. [PMID: 36041842 PMCID: PMC9426995 DOI: 10.9745/ghsp-d-21-00564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 06/03/2022] [Indexed: 11/29/2022]
Abstract
An evaluation of area-wide sanitation interventions in 10 countries found that 6 of the 12 program areas had sustained similar levels of basic sanitation 1–2 years post-implementation, with varying levels of slippage in the other program areas. Introduction: While many studies have implemented programs to increase sanitation coverage throughout the world, there are limited rigorous studies on the sustainability of these sanitation programs. Methods: Between 2014 and 2018, the rural Sustainable Sanitation and Hygiene for All (SSH4A) approach was implemented by SNV in sub-Saharan Africa and Asia. Repeated cross-sectional household surveys were administered annually throughout program implementation and 1 to 2 years following completion of program activities. We characterize to what extent sanitation coverage was sustained 1 to 2 years after implementation of this SSH4A intervention. Results: Surveys were conducted in 12 program areas in 10 countries, with 22,666 households receiving a post-implementation survey. Six of 12 program areas (Bhutan, Ghana, Kenya, both Nepal sites, Tanzania) had similar coverage levels of basic sanitation 1–2 years post-implementation, whereas there were varying levels of slippage in the other program areas (both Ethiopia sites, Indonesia, Mozambique, Uganda, Zambia), ranging from a drop of 63 percentage points in coverage in Ethiopia to a drop of only 4 percentage points in Indonesia. In countries that experienced losses in the coverage of household sanitation, sanitation sharing among neighbors generally did not increase, whereas open defecation did increase. In each of the areas where slippage occurred, the sanitation coverage levels at the final time point were all still higher than the initial time point before SNV started working in these areas. We found several factors to be associated with the sustainability of sanitation coverage, including household socioeconomic status, having household members with disabilities, baseline sanitation coverage levels of the program areas, and rate of change of coverage during program activities. Conclusions: Data revealed sustained gains in sanitation coverage in some program areas, yet slippage in other areas. This work may serve to benchmark the sustainability of sanitation interventions in sub-Saharan Africa and Asia.
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Micek K, Hester KA, Chanda C, Darwar R, Dounebaine B, Ellis AS, Keskinocak P, Leslie A, Manyando M, Sililo Manyando M, Nazzal D, Awino Ogutu E, Sakas Z, Castillo-Zunino F, Kilembe W, Bednarczyk RA, Freeman MC. Critical success factors for routine immunization performance: A case study of Zambia 2000 to 2018. Vaccine X 2022; 11:100166. [PMID: 35707220 PMCID: PMC9189203 DOI: 10.1016/j.jvacx.2022.100166] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022] Open
Abstract
This paper describes how policies and programs contributed to improved vaccine coverage in Zambia. Communication, coordination, and collaboration between implementing levels were imperative. Adjacent successes in health systems strengthening and governance were leveraged. Policies in Zambia include flexibility in implementation for tailored approaches in each district.
Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018. Methods We identified Zambia as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national and subnational levels, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities. Conclusion Broader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.
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Affiliation(s)
- Katie Micek
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chama Chanda
- Center for Family Health Research in Zambia, Lusaka, Zambia
| | - Roopa Darwar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinar Keskinocak
- College of Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | | | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Francisco Castillo-Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Matthew C. Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Corresponding author at: 404-712-8767; 1518 Clifton Road NE, Atlanta, GA, 30322
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Wolf J, Hubbard S, Brauer M, Ambelu A, Arnold BF, Bain R, Bauza V, Brown J, Caruso BA, Clasen T, Colford JM, Freeman MC, Gordon B, Johnston RB, Mertens A, Prüss-Ustün A, Ross I, Stanaway J, Zhao JT, Cumming O, Boisson S. Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis. Lancet 2022; 400:48-59. [PMID: 35780792 PMCID: PMC9251635 DOI: 10.1016/s0140-6736(22)00937-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Estimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs). METHODS In this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164. FINDINGS 19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41-0·60]), solar treatment (n=13; 0·63 [0·50-0·80]), and chlorination (n=25; 0·66 [0·56-0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26-0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61-0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30-0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64-0·76]). INTERPRETATION WASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG. FUNDING WHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.
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Affiliation(s)
- Jennyfer Wolf
- Department of Environmental, Climate Change and Health, WHO, Geneva, Switzerland.
| | - Sydney Hubbard
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael Brauer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Argaw Ambelu
- Department of Environmental Health Sciences and Technology, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Benjamin F Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Robert Bain
- UNICEF Middle East and North Africa, Amman, Jordan
| | - Valerie Bauza
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joe Brown
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Bethany A Caruso
- The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bruce Gordon
- Department of Environmental, Climate Change and Health, WHO, Geneva, Switzerland
| | - Richard B Johnston
- Department of Environmental, Climate Change and Health, WHO, Geneva, Switzerland
| | - Andrew Mertens
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Annette Prüss-Ustün
- Department of Environmental, Climate Change and Health, WHO, Geneva, Switzerland
| | - Ian Ross
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeffrey Stanaway
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jeff T Zhao
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Sophie Boisson
- Department of Environmental, Climate Change and Health, WHO, Geneva, Switzerland
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McClintic EE, Ellis A, Ogutu EA, Caruso BA, Ventura SG, Arriola KRJ, Kowalski AJ, Linabarger M, Wodnik BK, Muga R, Freeman MC, Girard AW. Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya. Curr Dev Nutr 2022; 6:nzac104. [PMID: 35898312 PMCID: PMC9314706 DOI: 10.1093/cdn/nzac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 02/04/2023] Open
Abstract
Background Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections. Objectives To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya. Methods Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development. Results Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices. Conclusions Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.
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Affiliation(s)
- Emilie Ewart McClintic
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna Ellis
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Emily A Ogutu
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sandra Gomez Ventura
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kimberly R Jacob Arriola
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Alysse J Kowalski
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA USA
| | - Molly Linabarger
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Breanna K Wodnik
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amy Webb Girard
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA USA
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Garn JV, Wilkers JL, Meehan AA, Pfadenhauer LM, Burns J, Imtiaz R, Freeman MC. Interventions to improve water, sanitation, and hygiene for preventing soil-transmitted helminth infection. Cochrane Database Syst Rev 2022; 6:CD012199. [PMID: 35726112 PMCID: PMC9208960 DOI: 10.1002/14651858.cd012199.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is estimated that 1.5 billion people are infected with soil-transmitted helminths (STHs) worldwide. Re-infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours. OBJECTIVES To assess the effectiveness of WASH interventions to prevent STH infection. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 19 October 2021. SELECTION CRITERIA We included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non-random method (non-RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed titles and abstracts and full-text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non-RCTs. We used a random-effects meta-analysis to pool study estimates. We used Moran's I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 32 studies (16 RCTs and 16 non-RCTs) involving a total of 52,944 participants in the review. Twenty-two studies (14 RCTs (16 estimates) and eight non-RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty-one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non-RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non-RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non-RCTs); and one on the prevalence of S stercoralis (1 non-RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non-RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non-RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non-RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis. The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate-certainty evidence) and an OR of 0.71 amongst non-RCTs (95% CI 0.54 to 0.94; low-certainty evidence). All six of the meta-analyses assessing individual worm infection amongst both RCTs and non-RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome. We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA). AUTHORS' CONCLUSIONS Whilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.
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Affiliation(s)
- Joshua V Garn
- Division of Biostatistics, Epidemiology and Environmental Health, School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Jennifer L Wilkers
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ashley A Meehan
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lisa M Pfadenhauer
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Rubina Imtiaz
- Children without Worms, The Task Force for Global Health, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Bednarczyk RA, Hester KA, Dixit SM, Ellis AS, Escoffery C, Kilembe W, Micek K, Sakas ZM, Sarr M, Freeman MC. Exemplars in vaccine delivery protocol: a case-study-based identification and evaluation of critical factors in achieving high and sustained childhood immunisation coverage in selected low-income and lower-middle-income countries. BMJ Open 2022; 12:e058321. [PMID: 35487707 PMCID: PMC9058776 DOI: 10.1136/bmjopen-2021-058321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Increases in global childhood vaccine delivery have led to decreases in morbidity from vaccine-preventable diseases. However, these improvements in vaccination have been heterogeneous, with some countries demonstrating greater levels of change and sustainability. Understanding what these high-performing countries have done differently and how their decision-making processes will support targeted improvements in childhood vaccine delivery. METHODS AND ANALYSIS We studied three countries-Nepal, Senegal, Zambia-with exemplary improvements in coverage between 2000 and 2018 as part of the Exemplars in Global Health Programme. We apply established implementation science frameworks to understand the 'how' and 'why' underlying improvements in vaccine delivery and coverage. Through mixed-methods research, we will identify drivers of catalytic change in vaccine coverage and the decision-making process supporting these interventions and activities. Methods include quantitative analysis of available datasets and in-depth interviews and focus groups with key stakeholders in the global, national and subnational government and non-governmental organisation space, as well as community members and local health delivery system personnel. ETHICS AND DISSEMINATION Working as a multinational and multidisciplinary team, and under oversight from all partner and national-level (where applicable) institutional review boards, we collect data from participants who provided informed consent. Findings are disseminated through a variety of forms, including peer-reviewed manuscripts related to country-specific case studies and vaccine system domain-specific analyses, presentations to key stakeholders in the global vaccine delivery space and narrative dissemination on the Exemplars.Health website.
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Affiliation(s)
- Robert A Bednarczyk
- Hubert Department of Global Health, Rollins School of Public Health, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
| | - Kyra A Hester
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Anna S Ellis
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Katie Micek
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Zoë M Sakas
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Moussa Sarr
- Institut de Recherche et Santé de Épidémiologique et de Formations, Dakar, Senegal
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Anderson DM, Gupta AK, Birken SA, Sakas Z, Freeman MC. Adaptation in rural water, sanitation, and hygiene programs: A qualitative study in Nepal. Int J Hyg Environ Health 2022; 240:113919. [PMID: 35033992 PMCID: PMC8821331 DOI: 10.1016/j.ijheh.2022.113919] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
Adaptations are modifications made to programming to improve effectiveness or contextual fit, and are important for program improvement. However, adaptations can be detrimental if they do not preserve an intervention's underlying theory of change. We present a case study of 45 adaptations made to rural WaSH programming in Nepal, identified through qualitative interviews with implementers conducted in June through August 2019. For each adaptation, we characterized its target outcomes and implementers' motivations for making the adaptation, and we assessed the adaptation's intended and unintended effects on program quality. Participants described adaptations to both interventions (e.g., changes to hygiene promotion messages) and implementation strategies (e.g., sanctions to enforce toilet construction, such as denying work permits to households without a toilet). Adoption was the most common target outcome, specifically increasing toilet construction. Other target outcomes included feasibility of program delivery, acceptability of messages or WaSH products, reach of program activities in the community, and sustainability. Implementers were commonly motivated by intense pressure to meet national open defecation free targets. Most adaptations achieved their target outcomes. However, sanctions adaptations had substantial unintended negative effects. Implementers reported that sanctions were unpopular with communities and had poor sustainability. In contrast, non-sanctions adaptations that targeted outcomes of feasibility, acceptability, and sustainability had few unintended negative consequences. Our findings suggest that adaptations to promote rapid adoption of toilet construction do not consistently achieve sustained behavior change. Furthermore, adaptations to improve feasibility of program delivery or cost and acceptability of WaSH products can indirectly improve adoption even when it is not an explicit target outcome.
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Affiliation(s)
- Darcy M Anderson
- The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, USA.
| | - Ankush Kumar Gupta
- Nepal Health Research Council, Ramshah Path, Kathmandu, P.O.Box 7626, Nepal
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 475 Vine Street, Winston-Salem, NC, 27101, USA; Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Zoe Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA, 30322, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA, 30322, USA
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Freeman MC, Delea MG, Snyder JS, Garn JV, Belew M, Caruso BA, Clasen TF, Sclar GD, Tesfaye Y, Woreta M, Zewudie K, Gobezayehu AG. The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial. PLOS Glob Public Health 2022; 2:e0000056. [PMID: 36962125 PMCID: PMC10021625 DOI: 10.1371/journal.pgph.0000056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/07/2021] [Indexed: 04/19/2023]
Abstract
Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.
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Affiliation(s)
- Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Maryann G. Delea
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jedidiah S. Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Joshua V. Garn
- School of Community Health Sciences, University of Nevada, Reno, Nevada, United States of America
| | | | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Gloria D. Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Yihenew Tesfaye
- Department of Social Anthropology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mulat Woreta
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
| | | | - Abebe Gebremariam Gobezayehu
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
- School of Nursing, Emory University, Atlanta, Georgia, United States of America
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Anderson DM, Birken SA, Bartram JK, Freeman MC. Adaptation of Water, Sanitation, and Hygiene Interventions: A Model and Scoping Review of Key Concepts and Tools. Front Health Serv 2022; 2:896234. [PMID: 36925880 PMCID: PMC10012759 DOI: 10.3389/frhs.2022.896234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022]
Abstract
Background Safe water, sanitation, and hygiene (WaSH) is important for health, livelihoods, and economic development, but WaSH programs have often underdelivered on expected health benefits. Underperformance has been attributed partly to poor ability to retain effectiveness following adaptation to facilitate WaSH programs' implementation in diverse contexts. Adaptation of WaSH interventions is common but often not done systematically, leading to poor outcomes. Models and frameworks from the adaptation literature have potential to improve WaSH adaptation to facilitate implementation and retain effectiveness. However, these models and frameworks were designed in a healthcare context, and WaSH interventions are typically implemented outside traditional health system channels. The purpose of our work was to develop an adaptation model tailored specifically to the context of WaSH interventions. Methods We conducted a scoping review to identify key adaptation steps and identify tools to support systematic adaptation. To identify relevant literature, we conducted a citation search based on three recently published reviews on adaptation. We also conducted a systematic database search for examples of WaSH adaptation. We developed a preliminary model based on steps commonly identified across models in adaptation literature, and then tailored the model to the WaSH context using studies yielded by our systematic search. We compiled a list of tools to support systematic data collection and decision-making throughout adaptation from all included studies. Results and Conclusions Our model presents adaptation steps in five phases: intervention selection, assessment, preparation, implementation, and sustainment. Phases for assessment through sustainment are depicted as iterative, reflecting that once an intervention is selected, adaptation is a continual process. Our model reflects the specific context of WaSH by including steps to engage non-health and lay implementers and to build consensus among diverse stakeholders with potentially competing priorities. We build on prior adaptation literature by compiling tools to support systematic data collection and decision-making, and we describe how they can be used throughout adaptation steps. Our model is intended to improve program outcomes by systematizing adaptation processes and provides an example of how systematic adaptation can occur for interventions with health goals but that are implemented outside conventional health system channels.
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Affiliation(s)
- Darcy M Anderson
- Public Health and Environment, The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, NC, United States
| | - Jamie K Bartram
- Public Health and Environment, The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,School of Civil Engineering, University of Leeds, Leeds, United Kingdom
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Aragie S, Tadesse W, Dagnew A, Hailu D, Dubie M, Wittberg DM, Melo JS, Haile M, Zeru T, Freeman MC, Nash SD, Callahan EK, Tadesse Z, Arnold BF, Porco TC, Lietman TM, Keenan JD. Changing hygiene behaviours: a cluster-randomized trial, Ethiopia. Bull World Health Organ 2021; 99:762-772A. [PMID: 34737469 PMCID: PMC8542271 DOI: 10.2471/blt.21.285915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether a water, sanitation and hygiene intervention could change hygiene behaviours thought to be important for trachoma control. METHODS We conducted a cluster-randomized trial in rural Ethiopia from 9 November 2015 to 5 March 2019. We randomized 20 clusters to an intervention consisting of water and sanitation infrastructure and hygiene promotion and 20 clusters to no intervention. All intervention clusters received a primary-school hygiene curriculum, community water point, household wash station, household soap and home visits from hygiene promotion workers. We assessed intervention fidelity through annual household surveys. FINDINGS Over the 3 years, more wash stations, soap and latrines were seen at households in the intervention clusters than the control clusters: risk difference 47 percentage points (95% confidence interval, CI: 41-53) for wash stations, 18 percentage points (95% CI: 12-24) for soap and 12 percentage points (95% CI: 5-19) for latrines. A greater proportion of people in intervention clusters reported washing their faces with soap (e.g. risk difference 21 percentage points; 95% CI: 15-27 for 0-5 year-old children) and using a latrine (e.g. risk difference 9 percentage points; 95% CI: 2-15 for 6-9 year-old children). Differences between the intervention and control arms were not statistically significant for many indicators until the programme had been implemented for at least a year; they did not decline during later study visits. CONCLUSION The community- and school-based intervention was associated with improved hygiene access and behaviours, although changes in behaviour were slow and required several years of the intervention.
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Affiliation(s)
| | | | - Adane Dagnew
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | | | - Melese Dubie
- The Carter Center Ethiopia, Addis Ababa, Ethiopia
| | - Dionna M Wittberg
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jason S Melo
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | | | - Taye Zeru
- Amhara Public Health Institute, Bahir Dar, Ethiopia
| | | | | | | | | | - Benjamin F Arnold
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Travis C Porco
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California San Francisco, 490 Illinois Street, Floor 2, Box 0944, San Francisco, CA 94158, United States of America (USA)
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Haque SS, Freeman MC. Erratum: "The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice". Environ Health Perspect 2021; 129:89001. [PMID: 34449249 PMCID: PMC8396654 DOI: 10.1289/ehp10060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/16/2021] [Indexed: 06/13/2023]
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Dixit SM, Sarr M, Gueye DM, Muther K, Yarnko TR, Bednarczyk RA, Clarke AT, Diakhite F, Diallo A, Dounebaine B, Duwadi SB, Ellis AS, Fullman N, Gerthe N, Gautam JS, Hester KA, Ikilezi G, Mbengue RS, Mboup S, Ndiaye BP, Rajbhandari RM, Phillips DE, Freeman MC. Addressing disruptions in childhood routine immunisation services during the COVID-19 pandemic: perspectives from Nepal, Senegal and Liberia. BMJ Glob Health 2021; 6:e005031. [PMID: 34230065 PMCID: PMC8264163 DOI: 10.1136/bmjgh-2021-005031] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Daouda M Gueye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | | | | | | | - Adolphus T Clarke
- Expanded Programme on Immunisation, Republic of Liberia Ministry of Health, Monrovia, Liberia
| | - Fatoumata Diakhite
- Focal Point for EPI and Surveillance Activities, Health Center of Rufisque, Dakar, Senegal
| | - Aliou Diallo
- Expanded Programme on Immunisation Unit, WHO Country Office Senegal, Dakar, Senegal
| | | | | | - Anna S Ellis
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Jhalak S Gautam
- Child Health and Immunization Section, Family Welfare Division, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
| | - Kyra A Hester
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Rokhaya S Mbengue
- Focal Point for EPI and Surveillance Activities, Health Center, Philip Maguilene Senghor of Yoff, Dakar, Senegal
| | - Souleymane Mboup
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Birahim P Ndiaye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | | | | | - Matthew C Freeman
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Freeman MC, Ellis AS, Ogutu EA, Caruso BA, Linabarger M, Micek K, Muga R, Girard AW, Wodnik BK, Jacob Arriola K. Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-002806. [PMID: 33234528 PMCID: PMC7689101 DOI: 10.1136/bmjgh-2020-002806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/06/2020] [Accepted: 08/21/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health. METHODS We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods. RESULTS Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6-24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline. CONCLUSION Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.
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Affiliation(s)
- Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA .,Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Anna S Ellis
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Emily Awino Ogutu
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Molly Linabarger
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Katie Micek
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Richard Muga
- Faculty of Health Sciences, Uzima University, Kisumu, Kenya
| | - Amy Webb Girard
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Breanna K Wodnik
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Kimberly Jacob Arriola
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
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Haque SS, Freeman MC. The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice. Environ Health Perspect 2021; 129:65002. [PMID: 34132602 PMCID: PMC8207965 DOI: 10.1289/ehp7762] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Delivery of high quality, at-scale, and sustained services is a major challenge in the water, sanitation, and hygiene (WASH) sector, made more challenging by a dearth of evidence-based models for adaption across contexts in low- and middle-income countries. OBJECTIVE We aim to describe the value of implementation science (IS) for the WASH sector and provide recommendations for its application. METHODS We review concepts from the growing field of IS-defined as the "scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services"-and we translate their relevance to WASH research, learning, and delivery. DISCUSSION IS provides a suite of methods and theories to systematically develop, evaluate, and scale evidence-based interventions. Though IS thinking has been applied most notably in health services delivery in high-income countries, there have been applications in low-income settings in fields such as HIV/AIDS and nutrition. Expanding the application of IS to environmental health, specifically WASH interventions, would respond to the complexity of sustainable service delivery. WASH researchers may want to consider applying IS guidelines to their work, including adapting pragmatic research models, using established IS frameworks, and cocreating knowledge with local stakeholders. https://doi.org/10.1289/EHP7762.
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Affiliation(s)
- Sabrina S. Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Carter A, Akseer N, Ho K, Rothschild O, Bose N, Binagwaho A, Hirschhorn LR, Price M, Muther K, Panjabi R, Freeman MC, Bednarczyk RA, Bhutta ZA. A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems. BMJ Glob Health 2021; 5:bmjgh-2020-002938. [PMID: 33272938 PMCID: PMC7716663 DOI: 10.1136/bmjgh-2020-002938] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022] Open
Abstract
This paper introduces a framework for conducting and disseminating mixed methods research on positive outlier countries that successfully improved their health outcomes and systems. We provide guidance on identifying exemplar countries, assembling multidisciplinary teams, collecting and synthesising pre-existing evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for various target audiences. Through a range of ongoing research studies, we illustrate application of each step of the framework while highlighting key considerations and lessons learnt. We hope uptake of this comprehensive framework by diverse stakeholders will increase the availability and utilisation of rigorous and comparable insights from global health success stories.
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Affiliation(s)
- Austin Carter
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin Ho
- Gates Ventures, Kirkland, Washington, USA
| | | | | | | | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Kyle Muther
- Last Mile Health, Boston, Massachusetts, USA
| | - Raj Panjabi
- Last Mile Health, Boston, Massachusetts, USA
| | - Matthew C Freeman
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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Stoler J, Miller JD, Brewis A, Freeman MC, Harris LM, Jepson W, Pearson AL, Rosinger AY, Shah SH, Staddon C, Workman C, Wutich A, Young SL. Household water insecurity will complicate the ongoing COVID-19 response: Evidence from 29 sites in 23 low- and middle-income countries. Int J Hyg Environ Health 2021; 234:113715. [PMID: 33735823 PMCID: PMC7894133 DOI: 10.1016/j.ijheh.2021.113715] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/25/2021] [Accepted: 02/11/2021] [Indexed: 12/17/2022]
Abstract
In March 2020, the World Health Organization (WHO) issued a set of public guidelines for Coronavirus Disease 2019 (COVID-19) prevention measures that highlighted handwashing, physical distancing, and household cleaning. These health behaviors are severely compromised in parts of the world that lack secure water supplies, particularly in low- and middle-income countries (LMICs). We used empirical data gathered in 2017-2018 from 8,297 households in 29 sites across 23 LMICs to address the potential implications of water insecurity for COVID-19 prevention and response. These data demonstrate how household water insecurity presents many pathways for limiting personal and environmental hygiene, impeding physical distancing and exacerbating existing social and health vulnerabilities that can lead to more severe COVID-19 outcomes. In the four weeks prior to survey implementation, 45.9% of households in our sample either were unable to wash their hands or reported borrowing water from others, which may undermine hygiene and physical distancing. Further, 70.9% of households experienced one or more water-related problems that potentially undermine COVID-19 control strategies or disease treatment, including insufficient water for bathing, laundering, or taking medication; drinking unsafe water; going to sleep thirsty; or having little-to-no drinking water. These findings help identify where water provision is most relevant to managing COVID-19 spread and outcomes.
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Affiliation(s)
| | - Joshua D Miller
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | | | | | | | | | | | - Sameer H Shah
- University of British Columbia, Vancouver, BC, Canada.
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Castillo-Zunino F, Keskinocak P, Nazzal D, Freeman MC. Health spending and vaccination coverage in low-income countries. BMJ Glob Health 2021; 6:e004823. [PMID: 33958392 PMCID: PMC8103936 DOI: 10.1136/bmjgh-2020-004823] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/23/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Routine immunisation is a cost-effective way to save lives and protect people from disease. Some low-income countries (LIC) achieved remarkable success in childhood immunisation. Yet, previous studies comparing the relationship between economic growth and health spending with vaccination coverage have been limited. We investigated these relationships among LIC to understand what financial changes lead to childhood immunisation changes. METHODS We identified which financial indicators were significant predictors of vaccination coverage in LIC by fitting regression models for several vaccines, controlling for population density, land area and female years of education. We then identified LIC with high vaccination coverage (LIC+) and compared their economic and health spending trends with other LIC (LIC-) and lower-middle income countries. We used cross-country multi-year regressions with mixed-effects to test financial indicators' rate of change. We conducted statistical tests to verify if financial trends of LIC+ were significantly different from LIC-. RESULTS During 2014-2018, gross domestic product per capita (p=0.67-0.95, range given by tests with different vaccines), total/private health spending per capita (p=0.57-0.97, p=0.32-0.57) and aggregated development assistance for health (DAH) per capita (p=0.38-0.86) were not significant predictors of vaccination coverage in LIC. Government health spending per capita (p=0.022-0.073) and total/government spending per birth on routine immunisation vaccines (p=0.0007-0.029, p=0.016-0.052) were significant positive predictors of vaccination coverage. From 2000 to 2016, LIC+ increased government health spending per capita by US$0.30 per year, while LIC- decreased by US$0.16 (significant difference, p<0.0001). From 2006 to 2017, LIC+ increased government spending per birth on routine immunisation vaccines by US$0.22 per year, while LIC- increased by US$0.10 (p<0.0093). CONCLUSION Vaccination coverage success of some LIC was not explained by economic development, total health spending nor aggregated DAH. Vaccination coverage success of LIC+ was associated with increasing government health spending particularly in routine immunisation vaccines.
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Affiliation(s)
- Francisco Castillo-Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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Wittberg DM, Aragie S, Tadesse W, Melo JS, Aiemjoy K, Chanyalew M, Emerson PM, Freeman MC, Nash SD, Callahan EK, Tadesse Z, Zerihun M, Porco TC, Lietman TM, Keenan JD. WASH Upgrades for Health in Amhara (WUHA): study protocol for a cluster-randomised trial in Ethiopia. BMJ Open 2021; 11:e039529. [PMID: 33619183 PMCID: PMC7903120 DOI: 10.1136/bmjopen-2020-039529] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Facial hygiene promotion and environmental improvements are central components of the global trachoma elimination strategy despite a lack of experimental evidence supporting the effectiveness of water, sanitation and hygiene (WASH) measures for reducing trachoma transmission. The objective of the WUHA (WASH Upgrades for Health in Amhara) trial is to evaluate if a comprehensive water improvement and hygiene education programme reduces the prevalence of ocular chlamydia infection in rural Africa. METHODS AND ANALYSIS Forty study clusters, each of which had received at least annual mass azithromycin distributions for the 7 years prior to the start of the study, are randomised in a 1:1 ratio to the WASH intervention arm or a delayed WASH arm. The WASH package includes a community water point, community-based hygiene promotion workers, household wash stations, household WASH education books, household soap distribution and a primary school hygiene curriculum. Educational activities emphasise face-washing and latrine use. Mass antibiotic distributions are not provided during the first 3 years but are provided annually over the final 4 years of the trial. Annual monitoring visits are conducted in each community. The primary outcome is PCR evidence of ocular chlamydia infection among children aged 0-5 years, measured in a separate random sample of children annually over 7 years. A secondary outcome is improvement of the clinical signs of trachoma between the baseline and final study visits as assessed by conjunctival photography. Laboratory workers and photo-graders are masked to treatment allocation. ETHICS AND DISSEMINATION Study protocols have been approved by human subjects review boards at the University of California, San Francisco, Emory University, the Ethiopian Food and Drug Authority, and the Ethiopian Ministry of Innovation and Technology. A data safety and monitoring committee oversees the trial. Results will be disseminated through peer-reviewed publications and presentations. TRIAL REGISTRATION NUMBER (http://www.clinicaltrials.gov): NCT02754583; Pre-results.
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Affiliation(s)
- Dionna M Wittberg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | | | | | - Jason S Melo
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kristen Aiemjoy
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Paul M Emerson
- International Trachoma Initiative, Decatur, Georgia, USA
- The Task Force for Global Health, Decatur, Georgia, USA
| | | | | | | | | | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Institute for Global Health, University of California, San Francisco, California, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
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Goddard FB, Ban R, Barr DB, Brown J, Cannon J, Colford JM, Eisenberg JNS, Ercumen A, Petach H, Freeman MC, Levy K, Luby SP, Moe C, Pickering AJ, Sarnat JA, Stewart J, Thomas E, Taniuchi M, Clasen T. Measuring Environmental Exposure to Enteric Pathogens in Low-Income Settings: Review and Recommendations of an Interdisciplinary Working Group. Environ Sci Technol 2020; 54:11673-11691. [PMID: 32813503 PMCID: PMC7547864 DOI: 10.1021/acs.est.0c02421] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 05/06/2023]
Abstract
Infections with enteric pathogens impose a heavy disease burden, especially among young children in low-income countries. Recent findings from randomized controlled trials of water, sanitation, and hygiene interventions have raised questions about current methods for assessing environmental exposure to enteric pathogens. Approaches for estimating sources and doses of exposure suffer from a number of shortcomings, including reliance on imperfect indicators of fecal contamination instead of actual pathogens and estimating exposure indirectly from imprecise measurements of pathogens in the environment and human interaction therewith. These shortcomings limit the potential for effective surveillance of exposures, identification of important sources and modes of transmission, and evaluation of the effectiveness of interventions. In this review, we summarize current and emerging approaches used to characterize enteric pathogen hazards in different environmental media as well as human interaction with those media (external measures of exposure), and review methods that measure human infection with enteric pathogens as a proxy for past exposure (internal measures of exposure). We draw from lessons learned in other areas of environmental health to highlight how external and internal measures of exposure can be used to more comprehensively assess exposure. We conclude by recommending strategies for advancing enteric pathogen exposure assessments.
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Affiliation(s)
- Frederick
G. B. Goddard
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Radu Ban
- Bill and
Melinda Gates Foundation, Seattle, Washington 98109, United States
| | - Dana Boyd Barr
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Joe Brown
- School of
Civil and Environmental Engineering, Georgia
Institute of Technology, Atlanta, Georgia 30332, United States
| | - Jennifer Cannon
- Centers
for Disease Control and Prevention Foundation, Atlanta, Georgia 30308, United States
| | - John M. Colford
- Division
of Epidemiology and Biostatistics, School of Public Health, University of California−Berkeley, Berkeley, California 94720, United States
| | - Joseph N. S. Eisenberg
- Department
of Epidemiology, University of Michigan
School of Public Health, Ann Arbor, Michigan 48109, United States
| | - Ayse Ercumen
- Department
of Forestry and Environmental Resources, North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Helen Petach
- U.S. Agency
for International Development, Washington, DC 20004, United States
| | - Matthew C. Freeman
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Karen Levy
- Department
of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington 98105, United States
| | - Stephen P. Luby
- Division
of Infectious Diseases and Geographic Medicine, Stanford University, California 94305, United States
| | - Christine Moe
- Center
for
Global Safe Water, Sanitation and Hygiene, Rollins School of Public
Health, Emory University, Atlanta, Georgia 30322, United States
| | - Amy J. Pickering
- Department
of Civil and Environmental Engineering, School of Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Jeremy A. Sarnat
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
| | - Jill Stewart
- Department
of Environmental Sciences and Engineering, Gillings School of Global
Public Health, University of North Carolina, Chapel Hill, North Carolina 27599, United States
| | - Evan Thomas
- Mortenson
Center in Global Engineering, University
of Colorado Boulder, Boulder, Colorado 80303, United States
| | - Mami Taniuchi
- Division
of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia 22903, United States
| | - Thomas Clasen
- Gangarosa
Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, United States
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Freeman MC, Caruso BA. Comment on "Global Access to Handwashing: Implications for COVID-19 Control in Low-Income Countries". Environ Health Perspect 2020; 128:98001. [PMID: 32902304 PMCID: PMC7480169 DOI: 10.1289/ehp7852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Snyder JS, Prentice-Mott G, Boera C, Mwaki A, Alexander KT, Freeman MC. The Sustainability and Scalability of Private Sector Sanitation Delivery in Urban Informal Settlement Schools: A Mixed Methods Follow Up of a Randomized Trial in Nairobi, Kenya. Int J Environ Res Public Health 2020; 17:ijerph17155298. [PMID: 32717846 PMCID: PMC7432725 DOI: 10.3390/ijerph17155298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 11/16/2022]
Abstract
There are considerable challenges to achieving the Sustainable Development Goals’ target of universal access to basic sanitation in schools. Schools require safe, clean, and sex-segregated facilities for a large number of students. Robust and affordable solutions are needed to address the economic, spatial, social, institutional, and political factors which contribute to poor sanitary conditions in informal settlements. In 2015, we undertook a randomized controlled trial to assess the feasibility of private sector sanitation delivery (PSSD) in 20 primary schools, in informal settlements of Nairobi, Kenya. Our preliminary evaluation after one year of service delivery suggested that PSSD of urine-diverting dry latrines with routine waste collection and maintenance provided a feasible, lower-cost alternative to the government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. We conducted a mixed-methods follow-up study to assess sanitation delivery over 3–4 years and investigate prevailing drivers and barriers that may influence the scalability of PSSD. The conditions of newly constructed and rehabilitated GSD facilities diminished quickly, reverting to the conditions of existing facilities, indicating lower sustainability compared to sanitation delivered from the private sector. Barriers in financial aspects related to the ongoing implementation of PSSD emerged, particularly among public schools, and few were able to pay for continued service. Our study demonstrates that the engagement of the private sector may lead to improvements in affordable, safely managed sanitation for schools and their students. Yet, to reach a sustained scale, additional guidance is needed on how to develop these partnerships, streamline procurement and contracting processes, and incorporate appropriate financing mechanisms.
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Affiliation(s)
- Jedidiah S. Snyder
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA 30322, USA; (J.S.S.); (G.P.-M.)
| | - Graeme Prentice-Mott
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA 30322, USA; (J.S.S.); (G.P.-M.)
| | | | - Alex Mwaki
- Safe Water & AIDS Project, Kisumu 40100, Kenya;
| | | | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA 30322, USA; (J.S.S.); (G.P.-M.)
- Correspondence:
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Reese H, Routray P, Torondel B, Sinharoy SS, Mishra S, Freeman MC, Chang HH, Clasen T. Assessing longer-term effectiveness of a combined household-level piped water and sanitation intervention on child diarrhoea, acute respiratory infection, soil-transmitted helminth infection and nutritional status: a matched cohort study in rural Odisha, India. Int J Epidemiol 2020; 48:1757-1767. [PMID: 31363748 PMCID: PMC6929523 DOI: 10.1093/ije/dyz157] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Open defecation is widespread in rural India, and few households have piped water connections. While government and other efforts have increased toilet coverage in India, and evaluations found limited immediate impacts on health, longer-term effects have not been rigorously assessed. METHODS We conducted a matched cohort study to assess the longer-term effectiveness of a combined household-level piped water and sanitation intervention implemented by Gram Vikas (an Indian NGO) in rural Odisha, India. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least 5 years before, and matched to 45 control villages. We conducted surveys and collected stool samples between June 2015 and October 2016 in households with a child <5 years of age (n = 2398). Health surveillance included diarrhoea (primary outcome), acute respiratory infection (ARI), soil-transmitted helminth infection, and anthropometry. RESULTS Intervention villages had higher improved toilet coverage (85% vs 18%), and increased toilet use by adults (74% vs 13%) and child faeces disposal (35% vs 6%) compared with control villages. There was no intervention association with diarrhoea [adjusted OR (aOR): 0.94, 95% confidence interval (CI): 0.74-1.20] or ARI. Compared with controls, children in intervention villages had lower helminth infection (aOR: 0.44, 95% CI: 0.18, 1.00) and improved height-for-age z scores (HAZ) (+0.17, 95% CI: 0.03-0.31). CONCLUSIONS This combined intervention, where household water connections were contingent on community-wide household toilet construction, was associated with improved HAZ, and reduced soil-transmitted helminth (STH) infection, though not reduced diarrhoea or ARI. Further research should explore the mechanism through which these heterogenous effects on health may occur.
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Affiliation(s)
- Heather Reese
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Parimita Routray
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Belen Torondel
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sheela S Sinharoy
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samir Mishra
- Kalinga Institute of Industrial Technology, Bhubaneswar, India
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
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Phillips DE, Bhutta ZA, Binagwaho A, Boerma T, Freeman MC, Hirschhorn LR, Panjabi R. Learning from Exemplars in Global Health: a road map for mitigating indirect effects of COVID-19 on maternal and child health. BMJ Glob Health 2020; 5:e003430. [PMID: 32737028 PMCID: PMC7397977 DOI: 10.1136/bmjgh-2020-003430] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 01/20/2023] Open
Affiliation(s)
- David E Phillips
- Health and Life Sciences, Gates Ventures, Seattle, Washington, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Agnes Binagwaho
- Office of the Vice Chancellor, University of Global Health Equity, Kigali, Rwanda
| | - Ties Boerma
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Matthew C Freeman
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raj Panjabi
- Last Mile Health, Boston, Massachusetts, United States
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Ellis A, McClintic EE, Awino EO, Caruso BA, Arriola KRJ, Ventura SG, Kowalski AJ, Linabarger M, Wodnik BK, Webb-Girard A, Muga R, Freeman MC. Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya. Am J Trop Med Hyg 2020; 102:1094-1103. [PMID: 32124727 PMCID: PMC7204574 DOI: 10.4269/ajtmh.19-0389] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.
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Affiliation(s)
- Anna Ellis
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emilie E McClintic
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emily O Awino
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Bethany A Caruso
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kimberly R J Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sandra Gomez Ventura
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alysse J Kowalski
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Molly Linabarger
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Breanna K Wodnik
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Amy Webb-Girard
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Affiliation(s)
- Bethany A Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
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Wolf J, Johnston R, Freeman MC, Ram PK, Slaymaker T, Laurenz E, Prüss-Ustün A. Handwashing with soap after potential faecal contact: global, regional and country estimates. Int J Epidemiol 2020; 48:1204-1218. [PMID: 30535198 PMCID: PMC6693803 DOI: 10.1093/ije/dyy253] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2018] [Indexed: 02/01/2023] Open
Abstract
Background Limited data have been available on the global practice of handwashing with soap (HWWS). To better appreciate global HWWS frequency, which plays a role in disease transmission, our objectives were to: (i) quantify the presence of designated handwashing facilities; (ii) assess the association between handwashing facility presence and observed HWWS; and (iii) derive country, regional and global HWWS estimates after potential faecal contact. Methods First, using data from national surveys, we applied multilevel linear modelling to estimate national handwashing facility presence. Second, using multilevel Poisson modelling on datasets including both handwashing facility presence and observed HWWS after potential faecal contact, we estimated HWWS prevalence conditional on handwashing facility presence by region. For high-income countries, we used meta-analysis to pool handwashing prevalence of studies identified through a systematic review. Third, from the modelled handwashing facility presence and estimated HWWS prevalence conditional on the presence of a handwashing facility, we estimated handwashing practice at country, regional and global levels. Results First, approximately one in four persons did not have a designated handwashing facility in 2015, based on 115 data points for 77 countries. Second the prevalence ratio between HWWS when a designated facility was present compared with when it was absent was 1.99 (1.66, 2.39) P <0.001 for low- and middle-income countries, based on nine datasets. Third, we estimate that in 2015, 26.2% (23.1%, 29.6%) of potential faecal contacts were followed by HWWS. Conclusions Many people lack a designated handwashing facility, but even among those with access, HWWS is poorly practised. People with access to designated handwashing facilities are about twice as likely to wash their hands with soap after potential faecal contact as people who lack a facility. Estimates are based on limited data.
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Affiliation(s)
- Jennyfer Wolf
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
| | - Richard Johnston
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pavani K Ram
- School of Public Health and Health Professions, University of Buffalo, Buffalo, NY, USA
| | - Tom Slaymaker
- Division of Data, Research and Policy, UNICEF, New York City, NY, USA
| | - Eric Laurenz
- Fraunhofer ISE, Fraunhofer Institute for Solar Energy Systems, Freiburg, Germany
| | - Annette Prüss-Ustün
- Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland
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Delea MG, Snyder JS, Woreta M, Zewudie K, Solomon AW, Freeman MC. Development and reliability of a quantitative personal hygiene assessment tool. Int J Hyg Environ Health 2020; 227:113521. [PMID: 32278303 PMCID: PMC7116344 DOI: 10.1016/j.ijheh.2020.113521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/12/2020] [Accepted: 03/29/2020] [Indexed: 01/19/2023]
Abstract
Personal hygiene practices, including facewashing and handwashing, reduce transmission of pathogens, but are difficult to measure. Using color theory principles, we developed and tested a novel metric that generates quantitative measures of facial and hand cleanliness, proxy indicators of personal hygiene practices. In this cross-sectional study, conventional qualitative cleanliness metrics (e.g., presence or absence of nasal and ocular discharge, dirt under nails or on finger pads and palms) were also recorded. We generated Gwet’s agreement coefficients to determine the inter-rater reliability of novel and conventional metrics between various rating groups, where appropriate, including two non-blinded raters, non-blinded vs. blinded raters, three blinded raters, and blinded vs. computer raters. Inter-rater reliability of the novel metric was high across all rating groups, ranging from 0.98 (95% CI: 0.97, 0.99) to 0.90 (95% CI: 0.90, 0.91) for facial cleanliness, and 0.97 (95% CI: 0.96, 0.98) to 0.92 (95% CI: 0.91, 0.93) for hand cleanliness. Our novel metric generates more nuanced data than conventional qualitative metrics, and allows for quantifiable assessments of facial and hand cleanliness.
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Affiliation(s)
- Maryann G Delea
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA.
| | - Jedidiah S Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | | | | | - Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, USA
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Chard AN, Levy K, Baker KK, Tsai K, Chang HH, Thongpaseuth V, Sistrunk JR, Freeman MC. Environmental and spatial determinants of enteric pathogen infection in rural Lao People's Democratic Republic: A cross-sectional study. PLoS Negl Trop Dis 2020; 14:e0008180. [PMID: 32267881 PMCID: PMC7170279 DOI: 10.1371/journal.pntd.0008180] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 04/20/2020] [Accepted: 02/28/2020] [Indexed: 01/10/2023] Open
Abstract
TRIAL REGISTRATION clinicaltrials.gov (NCT02342860).
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Affiliation(s)
- Anna N. Chard
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Karen Levy
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Kelly K. Baker
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, Iowa, United States of America
| | - Kevin Tsai
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, Iowa, United States of America
| | - Howard H. Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Vonethalom Thongpaseuth
- Laboratory and Treatment Unit, Center for Malariology, Parasitology, and Entomology, Ministry of Health, Vientiane, Lao PDR
| | - Jeticia R. Sistrunk
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Jacob Arriola KR, Ellis A, Webb-Girard A, Ogutu EA, McClintic E, Caruso B, Freeman MC. Designing integrated interventions to improve nutrition and WASH behaviors in Kenya. Pilot Feasibility Stud 2020; 6:10. [PMID: 32042436 PMCID: PMC6998333 DOI: 10.1186/s40814-020-0555-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 01/23/2020] [Indexed: 01/05/2023] Open
Abstract
Background Child stunting, an indicator of chronic malnutrition, is a global public health problem. Malnutrition during pregnancy and the first 2 years of life undermines the survival, growth, and development of children. Exposure to fecal pathogens vis-à-vis inadequate water, sanitation, and hygiene (WASH) has been implicated in the etiology of child stunting, highlighting the need to integrate WASH with nutrition-sensitive interventions to comprehensively address this complex problem. The aim of this study was to describe a systematic, theoretically informed approach (that drew from the Starr and Fornoff approach to the Theory of Change development and the Behavior Change Wheel approach) to design a multi-component and integrated social and behavior change intervention to improve WASH and nutrition-related behaviors in western Kenya. Methods This intervention was developed to be integrated into an existing project that utilized the care group model and aimed to create a culture of care and support for HIV/AIDS-affected children under two and their caregivers and was executed by local partners. We tested the newly created intervention packages in user-testing trials using an adapted Trials of Improved Practices approach to pilot acceptability and feasibility. Results Using authentic stakeholder engagement and relevant theories, we conducted an 8-step process: (1) conduct mixed methods formative research, (2) prioritize target behaviors, (3) use causal analysis to create problem trees, (4) develop solution trees and articulate assumptions and rationales for change, (5) link solution trees to intervention functions, (6) develop the intervention plan, (7) create the intervention packages, and (8) test and refine the intervention packages. Conclusions This study highlights the need to take a multi-sectorial, integrated approach that integrates contextually relevant behavior change theories with the experiential knowledge gleaned from stakeholders into the design of interventions that seek to reduce child stunting. This process resulted in the creation of intervention packages that grouped behaviors thematically to be most relevant and responsive to the population context. This work has the potential to make important contributions towards achievement of the United Nations’ sustainable development goals.
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Affiliation(s)
- Kimberly R Jacob Arriola
- 1Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Anna Ellis
- 2Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Amy Webb-Girard
- 3Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Emily Awino Ogutu
- 2Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Emilie McClintic
- 2Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Bethany Caruso
- 2Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Matthew C Freeman
- 2Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA USA
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