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Overview of Handwashing Research (2012-2013)

Jelena Vujcic Dept. of Social & Preventive Medicine

Presentation Content
Global disease prevalence- update Risk factors Health outcomes Long term behavior Behavioral determinants & theory Alternatives to soap Measuring behavior Emergency settings Implications

Global disease prevalence


Liu et al., 2012 Lancet

Global disease prevalence


Liu et al., 2012 Lancet

Global disease prevalence

Fischer Walker et al., 2013, Lancet Diarrhea estimates (children <5) 1.7 billion episodes (2010) decline from 1.9 billion in 1990 (BMC) 700,000 diarrhea episodes lead to death (2011) High proportion occurred in first 2 years of life

Pneumonia estimates (children <5) 120 million episodes (2010) 1.3 million episodes lead to death (2011) High proportion occurred in first 2 years of life Ashraf et al., 2013 6% increased risk of pneumonia for every additional day of diarrhea for children under 5 (Karachi, Pakistan)

Risk factors
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 as risk 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)

Health outcomes
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 household among exposed HWWS (observed) low and not different between groups No impact on health or productivity


Health outcomes
Galiani et al., 2012, WSP Policy research working paper RCT evaluating new approaches to promotion in Peru Program: 800 districts, targeted caregivers, children <12 years Evaluation: approximately 3,500 households Mass medial alone had no effect on exposing communities to HW messages no effect of knowledge or behavior


Community-level interventions (incl. schools) able to reach, improve knowledge and behavior but no impact on health of children < 5

Health outcomes
Warren-Gash et al., 2013 (Review of evidence for HW and flu/ARI) Schools moderate to low-quality evidence of reductions with HW Childcare settings High quality evidence showed small reductions Squatter settlements High 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 <5

Health outcomes
Dangour et al., 2013 (Systematic review WASH on nutritional status) No evidence of effect on weight-for-age Z-score, weight-forheight Z-score and borderline significant effect on height-forage 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

Health outcomes
Bowen et al., 2012 (RCT in informal settlements in Karachi, 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

Long-term behavior
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

Handwashing at birth
qualitative data
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 childs birth New mothers, midwives and grandmothers critical target

Moyer et al., 2012 (Ghana) Handwashing during and/or after delivery by family/community members 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 gloves as 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 determinants
Kenya (WSP, UNICEF, Kenya MoPHS, 2012) disgust, nurture and comfort were identified as main motivators for handwashing among caregivers justification (the need to wash off germs that cause disease), fun and fitting-in emerged as motivators among school children In Kenyan schools, teachers serving as role models and active participants 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 was reported 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 having soap and water at a designated place
results were inconsistent when compared to different handwashing behavior proxy measures

Handwashing determinants
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

Behavioral theory
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
Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH)

Dreibelbis et al., 2013

Pickering et al., 2013 (primary schools, Nairobi, Kenya) Hand cleansing after toileting (observed) using sanitizer 82% of the time 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 alcoholbased 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

Microbial impact
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 then identified 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 after the intervention at both sites some reactivity to observer presence

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

Emergency settings
Mahmud et al., 2012 refugee camp in Kakuma, Kenya persons with cholera (cases) were 75% less likely to report handwashing 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 by soap use, and 20% of times when latrines were used were followed by handwashing with soap variable availability of soap reflected extent of distribution of free soap prioritization of soap for laundry as barrier to practice Overall lack of published data

Implications of recent research

Diarrhea and pneumonia still large global health problem

Important trade-off between scale and intensity of handwashing promotion programs

Evidence of effectiveness of HW at scale still needed

Moving beyond health messaging trying more engaging behavior change approaches Including structural or environmental factors that influence behavior Better measures of handwashing behavior (same as 2 years ago) Designing interventions to promote handwashing habit/long term behavior

Thank you.

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