overview of handwashing research, 2012-2013

7/21/2019 Overview of Handwashing Research, 2012-2013

1/25

Overview of Handwashing

Research (2012-2013)

Jelena VujcicDept. of Social & Preventive Medicine


2/25

Presentation Content

Global disease prevalenceupdate

Risk factors

Health outcomes

Long term behavior

Behavioral determinants & theory

Alternatives to soap

Measuring behavior

Emergency settings

Implications


3/25

Global disease prevalenceupdate

Liu et al., 2012 Lancet


4/25


Liu et al., 2012 Lancet


5/25


Fischer Walker et al., 2013, Lancet

Diarrhea estimates (children


6/25

Mattioli et al., 2012

Hands and water as important sources of viral and

bacterial pathogens that cause diarrhea (Tanzania)

Mansour et al., 2013

No soap in toilet, no towels in bathroom, sharing toilet asrisk factors for diarrhea among children (case-control

study in Cairo hospital)

Sherkhonov et al., 2013

Handwashing after using the toilet (OR=0.78) and after

handling animals (OR=0.66) protective against intestinal

helminth infection among school-aged children

(Tajikistan)

Risk factors


7/25

Health outcomesDiarrhea

Chase and Do, 2012, WSP Policy research working paper cRCT evaluating at-scale WSP program (Vietnam)

Program: 1.5 million, targeted caregivers

Evaluation: ~3,100 households

Slightly higher availability of HW materials in householdamong exposed

HWWS (observed) low and not different between

groups

No impact on health or productivity


8/25

Health outcomesDiarrhea

Galiani et al., 2012, WSP Policy research working paper

RCT evaluating new approaches to promotion in Peru

Program: 800 districts, targeted caregivers, children


9/25

Health outcomes

Warren-Gash et al., 2013 (Review of evidence for HW and flu/ARI)

Schoolsmoderate to low-quality evidence of reductions with HW

Childcare settingsHigh quality evidence showed small reductions

Squatter settlementsHigh quality evidence showed large

reductions

Nicholson et al., 2013, TMIH

Social marking program targeted at children under 5 in rural India

educate, motivate and reward HWWS after defecation, before 3

meals

established social norms for child and mother, used fear of

contamination and disgust and created peer pressure

free soap

25% fewer diarrhea episodes ,15% fewer episodes of ARI,27% less

school absences due to illness, 47% less eye infections in children


10/25

Health outcomesGrowth

Dangour et al., 2013 (Systematic review WASH on

nutritional status)

No evidence of effect on weight-for-age Z-score, weight-for-

height Z-score and borderline significant effect on height-for-

age Z-score.

Low methodological quality but larger trials are underway

Davis et al., 2013 (Pre/Post evaluation, Mozambique)

Care group model to teach newborn survival and nutrition

skills (incl. HW and building a HW station) via community

volunteer

Undernutrition (WAZ score < two standard deviations below

mean) declined by 8.1 percentage points over five years Cannot be sure effects are attributed to the program only

However, undernutrition decline is 4X the national rate


11/25

Health outcomesDevelopment

Bowen et al., 2012 (RCT in informal settlements inKarachi, Pakistan)

Global development quotients of 0.4 SDs greater in

children from households receiving HW promotion for 30

months than control group

Gains comparable to at risk children enrolled in

publicly funded preschools in the US

Child growth was not different between groups


12/25

Bowen et al., 2013, TMIH

5 year follow-up of the Karachi Soap Health Study (Luby

et. al Lancet 2005)

Intervention households (weekly HW education, soap

provision for 9 months) compared to controls

3.4 times more likely to have soap at the household HW station

knew more key times to wash hands

reported purchasing more soap

Suggests habituation of improved HW practices

but cannot be certain because using proxy indicators

Long-term behavior


13/25

Greenland et al., 2013 (Indonesia)

HWWS infrequent among new mothers, and occurred after eating,cooking, household chores, or cleaning a babys bottom

rarely occurred before preparing food or eating.

Habits of hand washing pre-pregnancy disrupted/lost after childsbirth

New mothers, midwives and grandmothers

critical target

Moyer et al., 2012 (Ghana)

Handwashing during and/or after delivery by family/communitymembers not frequently reported

Grandmothers play a crucial role in delivery practices

Shamba et al, 2013 (Tanzania)

Birth attendants did not discuss handwashing and wearing of glovesas being important for newborn health

Lack of water, lack of gloves and lack of awareness cited as significant

barriers to good hand hygiene practice during delivery

Handwashing at birthqualitative data


14/25

Kenya (WSP, UNICEF, Kenya MoPHS, 2012)

disgust, nurture and comfort were identified as main motivators forhandwashing among caregivers

justification (the need to wash off germs that cause disease), fun andfitting-in emerged as motivators among school children

In Kenyan schools, teachers serving as role models and activeparticipants in promotion, and giving verbal reminders of importance

of handwashing were facilitators of student handwashing

Vietnam (WSP, 2012)

Presence of a convenient handwashing place with soap and water wasreported as an important facilitator of behavior

may serve as a physical reminder

Peru and Senegal (WSP, Learning Note, 2012)

beliefs about soap, and access to soap and water correlated with havingsoap and water at a designated place results were inconsistent when compared to different handwashing behavior

proxy measures

Handwashing determinantsMotivators


15/25

Household level (Affleck et al., 2012 (Bangladesh), WSP, UNICEF,

Kenya MoPHS, 2012 (Kenya)) lack of soap for handwashing (other activities prioritized)

lack of a designated place for handwashing and easy access to soap

long distance between toilet and water

perfumed soap (tainting/affecting the taste of food)

excessive household work load Mother feel soap only needed if childs hands appear very dirty

Lack of autonomy

Lack of support from household

Poverty

School- level (WSP, UNICEF, Kenya MoPHS, 2012)

placement of handwashing facilities (too far from toilet )

impractical facilities for children (ex. sink out of reach)

overcrowding

lack of water drainage

lack of support from teachers

Handwashing determinantsBarriers


16/25

Dreibelbis et al., 2013 (systematic review) 15 WASH frameworks/models aimed at guiding

behavior change interventions

Existing models

under-represent the role that technology on behavior

change

focus on individual behavioral outcomes, ignore

physical and environmental determinants

Behavioral theory


17/25

Behavioral theory

Integrated Behavioral Model for Water, Sanitation andHygiene (IBM-WASH)

Dreibelbis et al., 2013


18/25

Pickering et al., 2013 (primary schools, Nairobi, Kenya)

Hand cleansing after toileting (observed) using sanitizer 82% of thetime compared to 38% of the time using soap and water

Children in schools with sanitizer 23% less likely to contract

rhinorrhea than those at the schools using soap and water

No significant differences in gastrointestinal illness

Correa et al., 2012 (child care centers, Colombia)

Children (1-5 years old) less likely to have acute diarrhea and ARI if

attending childcare centers which received education about alcohol-

based hand rub, dispensers and replenishment of the hand rubs

Pandejpong et al., 2012 (Thailand)

Children from classrooms that received sanitizer had fewer doctor

visits compared control group

Reduced rate of absenteeism due to influenza-like illness among those

applying hourly compared to applying every two hours or only at lunch

Sanitizer


19/25

Toure et al, 2013 (Mali), Islam et al., 2012 (Bangladesh)

Hazard Analysis, Critical Control Point (HACCP) approach

commonly used in industrialized countries for food hygiene

to reduce fecal contamination that can occur during the food

preparation or feeding

Identify critical control points for food contamination thenidentified corrective measures to address those critical

control points, including handwashing with soap

Significant reduction in weaning food contamination after the

intervention and some sustained reductions three months afterthe intervention at both sites

some reactivity to observer presence

Microbial impact


20/25

Halder et al., 2013, BMC Public Health

Comparison of 90 minute vs 5 hour structured observation

Disproportionately lower number of fecal contact events

and eating events in 90 minute observation

Soap more frequently used early in 5-hour observation

Minimal progress on improving handwashing behavior

measurement

Measurement


21/25

Mahmud et al., 2012

refugee camp in Kakuma, Kenya

persons with cholera (cases) were 75% less likely to reporthandwashing with soap than those without cholera (controls)

Biran et al., 2012 long-term refugee camps in Thailand, Ethiopia and Kenya

30% of key handwashing opportunities were accompanied bysoap use, and 20% of times when latrines were used werefollowed by handwashing with soap

variable availability of soapreflected extent of distributionof free soap

prioritization of soap for laundry as barrier to practice

Overall lack of published data

Emergency settings


22/25

Implications of recent research

Diarrhea and pneumonia still large global health problem

Important trade-off between scale and intensity of handwashingpromotion programs Evidence of effectiveness of HW at scale still needed

Moving beyond health messagingtrying more engagingbehavior change approaches

Including structural or environmental factors that influencebehavior

Better measures of handwashing behavior (same as 2 years ago)

Designing interventions to promote handwashing habit/longterm behavior


23/25

Thank you.

[email protected]


24/25

References Affleck, W. and G. Pelto, Caregivers' responses to an intervention to improve young child feeding behaviors in rural Bangladesh: A mixed method study of

the facilitators and barriers to change.Soc Sci Med, 2012. 75(4): p. 651-8.

Ashraf S, Huque MH, Kenah E, Agboatwalla M, and Luby SP. 2013. Effect of recent diarrhoeal episodes on risk of pneumonia in children under the age of 5

years in Karachi, Pakistan. International journal of epidemiology 42(1):194-200.

Bieri FA, Gray DJ, Williams GM, Raso G, Li YS, Yuan L, He Y, Li RS, Guo FY, Li SM et al. . 2013. Health-education package to prevent worm infections inChinese schoolchildren. The New England journal of medicine 368(17):1603-1612.

Biran A, Schmidt WP, Zeleke L, Emukule H, Khay H, Parker J, and Peprah D. 2012. Hygiene and sanitation practices amongst residents of three long-term

refugee camps in Thailand, Ethiopia and Kenya. Trop Med Int Health 17(9):1133-1141.

Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, and Hoekstra RM. 2012. Association between intensive handwashing promotion and child

development in Karachi, Pakistan: a cluster randomized controlled trial. Arch Pediatr Adolesc Med 166(11):1037-1044

Bowen A, Agboatwalla M, Ayers T, Tobery T, Tariq M, and Luby SP. 2013. Sustained improvements in handwashing indicators more than 5 years after a

cluster-randomised, community-based trial of handwashing promotion in Karachi, Pakistan. Tropical medicine & international health : TM & IH 18(3):259-

267.

Chase C, and Do Q. 2012. WSP Policy Research Working Paper: Handwashing Behavior Change at Scale, Evidence from a Randomized Evaluation in

Vietnam. http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207

Correa JC, Pinto D, Salas LA, Camacho JC, Rondon M, and Quintero J. 2012. A cluster-randomized controlled trial of handrubs for prevention of infectious

diseases among children in Colombia. Rev Panam Salud Publica 31(6):476-484.

Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, Cavill S, Allen E, and Uauy R. 2013. Interventions to improve water quality and supply,

sanitation and hygiene practices, and their effects on the nutritional status of children. The Cochrane database of systematic reviews 8:CD009382.

Davis TP, Wetzel C, Hernandez Avilan E, De Mendoza Lopes C, Chase RP, Winch PJ, and Perry HB. 2013. Reducing child global undernutrition at scale in

Sofala Province, Mozambique, using Care Group Volunteers to communicate health messages to mothers. Global Health: Science and Practice 1(1):35-51.

Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, and Luby SP. 2013. The Integrated Behavioural Model for Water, Sanitation, and

Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-

restricted settings. BMC public health 13:1015.

Galiani S, Gertler P, and Orsola-Vidal A. 2012. Water and Sanitation Program (WSP). Policy Research Working Paper: Promoting Handwashing Behavior in

Peru; The effect of larg-scale mass-media and community level interventions. http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257.

Greenland K, Iradati E, Ati A, Maskoen YY, and Aunger R. 2013. The context and practice of handwashing among new mothers in Serang, Indonesia: a

formative research study. BMC public health 13:830.

Halder AK, Molyneaux JW, Luby SP, and Ram PK. 2013. Impact of duration of structured observations on measurement of handwashing behavior at

critical times. BMC public health 13(1):705.

Islam MS, Mahmud ZH, Gope PS, Zaman RU, Hossain Z, Mondal D, Sharker MA, Islam K, Jahan H, Bhuiya A et al. . 2012. Hygiene intervention reduces

contamination of weaning food in Bangladesh. Trop Med Int Health.
http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6257http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6207


25/25

References Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with

time trends since 2000. The Lancet 2012;379(9832):2151-61.

Mahamud, A.S., et al., Epidemic cholera in Kakuma Refugee Camp, Kenya, 2009: the importance of sanitation and soap. J Infect Dev Ctries, 2012. 6(3): p. 234-41.

Mansour AM, Mohammady HE, Shabrawi ME, Shabaan SY, Zekri MA, Nassar M, Salem ME, Mostafa M, Riddle MS, Klena JD et al. . 2013. Modifiable diarrhoea risk

factors in Egyptian children aged

overview of handwashing research, 2012-2013

Documents