Exploring customers' perceptions of food adulteration at bazaars and supermarkets in Dhaka, Bangladesh; a qualitative exploration.

BACKGROUND: Food adulteration is an increasingly recognized global public health problem. In low- and middle-income countries like Bangladesh, adulteration is difficult to detect and respond to. We explored customers' perceptions on food adulteration, perception of risk and connections between information, participant characteristics and patterns of adulterated food concerns that impact risk perception in urban Bangladesh. METHODS: A formative study was conducted in Dhaka, between June and August 2015 at a supermarket and a wet market. We explored community awareness and response to chemical contaminants (adulterants) among participants from a range of socio-economic backgrounds. The team conducted 38 in-depth interviews with 12 customers and 4 staff from a supermarket, and 12 customers and 10 vendors from a wet market. Participants were selected purposively. Audio recorded data were coded based on thematic content and analyzed manually. RESULTS: We asked participants how common foods were likely adulterated, and most gave figures of 70% or more. They reported that foods were adulterated with chemicals or artificial colors, especially fish, milk, and vegetables. The supermarket more commonly sold packaged foods with nutritional and expiry information on the label; and offered convenience in terms of building size, layout, and cleanliness. All customers from the wet market thought that foods were cheaper and fresher than from supermarkets. Supermarket customers expressed greater concern about adulterated foods than wet market customers. Most participants from both markets reported that food adulteration is invisible, adulterated foods cannot be avoided, and have long-term negative health impacts including cancer, diabetes, paralysis, heart attack, and others. Nearly half of customers from both markets were concerned about the poor nutritional value of adulterated food. Participants from both settings expressed the need for access to credible information about adulteration to help choose safe foods. The majority expressed the need for government action against those who are responsible for adulteration. CONCLUSIONS: Food adulteration was considered a major health threat. The government could act on food adulteration prevention if provided credible population-based data on disease burden, a model food sampling and testing protocol, a model for inspections, organizational strengthening and training, example social and behavioral change communications with estimated costs.

Gender and urban-rural influences on antibiotic purchasing and prescription use in retail drug shops: a one health study.

INTRODUCTION: Few studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh. METHODS: We conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2). RESULTS: Of 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases). CONCLUSION: This study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans.

Evaluation of an on-site sanitation intervention against childhood diarrhea and acute respiratory infection 1 to 3.5 years after implementation: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh.

BACKGROUND: Diarrhea and acute respiratory infection (ARI) are leading causes of death in children. The WASH Benefits Bangladesh trial implemented a multicomponent sanitation intervention that led to a 39% reduction in the prevalence of diarrhea among children and a 25% reduction for ARI, measured 1 to 2 years after intervention implementation. We measured longer-term intervention effects on these outcomes between 1 to 3.5 years after intervention implementation, including periods with differing intensity of behavioral promotion. METHODS AND FINDINGS: WASH Benefits Bangladesh was a cluster-randomized controlled trial of water, sanitation, hygiene, and nutrition interventions (NCT01590095). The sanitation intervention included provision of or upgrades to improved latrines, sani-scoops for feces removal, children's potties, and in-person behavioral promotion. Promotion was intensive up to 2 years after intervention initiation, decreased in intensity between years 2 to 3, and stopped after 3 years. Access to and reported use of latrines was high in both arms, and latrine quality was significantly improved by the intervention, while use of child feces management tools was low. We enrolled a random subset of households from the sanitation and control arms into a longitudinal substudy, which measured child health with quarterly visits between 1 to 3.5 years after intervention implementation. The study period therefore included approximately 1 year of high-intensity promotion, 1 year of low-intensity promotion, and 6 months with no promotion. We assessed intervention effects on diarrhea and ARI prevalence among children <5 years through intention-to-treat analysis using generalized linear models with robust standard errors. Masking was not possible during data collection, but data analysis was masked. We enrolled 720 households (360 per arm) from the parent trial and made 9,800 child observations between June 2014 and December 2016. Over the entire study period, diarrheal prevalence was lower among children in the sanitation arm (11.9%) compared to the control arm (14.5%) (prevalence ratio [PR] = 0.81, 95% CI 0.66, 1.00, p = 0.05; prevalence difference [PD] = -0.027, 95% CI -0.053, 0, p = 0.05). ARI prevalence did not differ between sanitation (21.3%) and control (22.7%) arms (PR = 0.93, 95% CI 0.82, 1.05, p = 0.23; PD = -0.016, 95% CI -0.043, 0.010, p = 0.23). There were no significant differences in intervention effects between periods with high-intensity versus low-intensity/no promotion. Study limitations include use of caregiver-reported symptoms to define health outcomes and limited data collected after promotion ceased. CONCLUSIONS: The observed effect of the WASH Benefits Bangladesh sanitation intervention on diarrhea in children appeared to be sustained for at least 3.5 years after implementation, including 1.5 years after heavy promotion ceased. Existing latrine access was high in the study setting, suggesting that improving on-site latrine quality can deliver health benefits when latrine use practices are in place. Further work is needed to understand how latrine adoption can be achieved and sustained in settings with low existing access and how sanitation programs can adopt transformative approaches of excreta management, including safe disposal of child and animal feces, to generate a hygienic home environment. TRIAL REGISTRATION: ClinicalTrials.gov; NCT01590095; https://clinicaltrials.gov/ct2/show/NCT01590095.

The effect of a large-scale water, sanitation and hygiene intervention in Bangladesh on knowledge, behaviour and health: Findings from an endline programme evaluation.

OBJECTIVES: The Sanitation, Hygiene Education and Water Supply in Bangladesh Programme (SHEWA-B) was a 5-year intervention aiming to improve water, sanitation and hygiene (WASH) practices among 20 million rural residents through community hygiene promoters. This analysis evaluates the impact of SHEWA-B on knowledge, behaviour and childhood diarrhoea outcomes. METHODS: The evaluation included repeated cross-sectional surveys and health surveillance in matched cohorts in intervention and control clusters. Cross-sectional surveys and structured observations at baseline, midline, and endline assessed the availability of WASH technology, caregiver knowledge and behaviour. Fieldworkers collected monthly health data in a subset of control and intervention households to determine the prevalence of diarrhoea. RESULTS: Of 5091 households surveyed, participants residing in intervention clusters showed minimal improvements in knowledge, reported behaviour, or use of WASH technology compared to the control clusters. During structured observations, intervention households increased more than control households at handwashing before preparing food and after cleaning a baby's anus when comparing endline to baseline, but these changes were not seen when comparing endline to the midline. The prevalence of childhood diarrhoea remained similar in both groups before (10.2% in intervention, 10.0% in control) and after (8.8% in intervention, 11.7% in control) midline changes were made to improve the intervention. Intervention clusters showed no improvement in diarrhoea over time compared to control clusters. CONCLUSIONS: SHEWA-B's community-based WASH promotion did not yield the intended impact on knowledge, behaviour or health. Greater priority should be given to approaches that have demonstrated effectiveness. Including rigorous evaluations would broaden the evidence base to support and improve large-scale programmes.

Evaluation of a menstrual hygiene intervention in urban and rural schools in Bangladesh: a pilot study.

Girls' menstrual experiences impact their social and educational participation, physical and psychological health. We conducted a pilot study to assess the acceptability and feasibility of a multi-component intervention intended to support menstruating girls; improve menstrual care knowledge, practices, and comfort; and increase school attendance.We conducted a pre/post evaluation of a 6-month pilot intervention in four schools (2 urban, 2 rural) in Dhaka, Bangladesh. We selected 527 schoolgirls (grades 5 to 10; aged 10 to 17 years) for a baseline survey and 528 girls at endline. The intervention included: 1) Menstrual Hygiene Management (MHM) packs- reusable cloth pads, underwear, carry bags and menstrual cycle tracking calendars, 2) education curriculum- pictorial flipcharts, puberty related-booklets, and teachers' training to deliver puberty and MHM sessions, 3) maintenance- improvements to school sanitation, provision of disposable pads in the school office, provision of chute disposal systems for disposable pads, and gender committees to promote a gender-friendly school environment and maintenance of intervention facilities. We estimated intervention uptake and intervention effect by calculating prevalence differences and 95% confidence intervals using fixed-effects logistic regression.The intervention uptake was more than 85% for most indicators; 100% reported receiving puberty education, 85% received MHM packs, and 92% received booklets. Reusable cloth pads uptake was 34% by endline compared with 0% at baseline. Knowledge about menstrual physiology and knowledge of recommended menstrual management practices significantly improved from baseline to endline. Reported improvements included more frequent changing of menstrual materials (4.2 times/day at endline vs. 3.4 times/day at baseline), increased use of recommended disposal methods (prevalence difference (PD): 8%; 95% Confidence Interval: 1, 14), and fewer staining incidents (PD: - 12%; 95% CI: - 22, - 1). More girls reported being satisfied with their menstrual materials (59% at endline vs. 46% at baseline, p < 0.005) and thought school facilities were adequate for menstrual management at endline compared to baseline (54% vs. 8%, p < 0.001). At endline, 64% girls disagreed/strongly disagreed that they felt anxious at school due to menstruation, compared to 33% at baseline (p < 0.001). Sixty-five percent girls disagreed/strongly disagreed about feeling distracted or trouble concentrating in class at endline, compared to 41% at baseline (p < 0.001). Self-reported absences decreased slightly (PD: - 8%; 95% CI: - 14, - 2).Uptake of cloth pads, improved maintenance and disposal of menstrual materials, and reduced anxiety at school suggest acceptability and feasibility of the intervention aiming to create a supportive school environment.

Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh.

Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1-3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh.

BACKGROUND: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels. METHODS: The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline. RESULTS: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (- 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, - 25% (- 35, - 15) Q2: - 34% (- 44, - 23%)] than the wealthiest household [Q5 DID: - 1% (- 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). CONCLUSION: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. TRIAL REGISTRATION: WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.

Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel.

BACKGROUND: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics. METHODS: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings. RESULTS: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course. CONCLUSIONS: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Effect of water, sanitation, handwashing and nutrition interventions on enteropathogens in children 14 months old: a cluster-randomized controlled trial in rural Bangladesh.

BACKGROUND: We evaluated the impact of low-cost water, sanitation, handwashing (WSH) and child nutrition interventions on enteropathogen carriage in the WASH Benefits cluster-randomized controlled trial in rural Bangladesh. METHODS: We analyzed 1411 routine fecal samples from children 14±2 months old in the WSH (n = 369), nutrition counseling plus lipid-based nutrient supplement (n = 353), nutrition plus WSH (n = 360), and control (n = 329) arms for 34 enteropathogens using quantitative PCR. Outcomes included the number of co-occurring pathogens; cumulative quantity of four stunting-associated pathogens; and prevalence and quantity of individual pathogens. Masked analysis was by intention-to-treat. RESULTS: 326 (99.1%) control children had one or more enteropathogens detected (mean 3.8±1.8). Children receiving WSH interventions had lower prevalence and quantity of individual viruses than controls (prevalence difference for norovirus: -11% [95% confidence interval [CI], -5 to -17%]; sapovirus: -9% [95%CI, -3 to -15%]; and adenovirus 40/41: -9% [95%CI, -2 to - 15%]). There was no difference in bacteria, parasites, or cumulative quantity of stunting-associated pathogens between controls and any intervention arm. CONCLUSIONS: WSH interventions were associated with fewer enteric viruses in children aged 14 months. Different strategies are needed to reduce enteric bacteria and parasites at this critical young age.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh.

BACKGROUND: We hypothesized that drinking water, sanitation, handwashing (WSH), and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting. METHODS: Within a subsample of a cluster-randomized, controlled trial in rural Bangladesh, we enrolled pregnant women in 4 arms: control, WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1ß) at median ages 3, 14, and 28 months. Analysis was intention-to-treat. RESULTS: We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L; 95% confidence interval [CI], -.37, -.05) and N+WSH (-0.20 log nmol/L; 95% CI, -.34, -.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH and nutrition arms (0.23-0.27 log ng/mL) and lactulose was higher in the WSH arm (0.30 log mmol/L; 95% CI, .07, .53). CONCLUSIONS: Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months, the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of developing a better understanding of EED pathophysiology and targeting interventions early in childhood, when they are likely to have the largest benefit to intestinal health. CLINICAL TRIALS REGISTRATION: NCT01590095.

Ingestion of Fecal Bacteria along Multiple Pathways by Young Children in Rural Bangladesh Participating in a Cluster-Randomized Trial of Water, Sanitation, and Hygiene Interventions (WASH Benefits).

Quantifying the contribution of individual exposure pathways to a child's total ingestion of fecal matter could help prioritize interventions to reduce environmental enteropathy and diarrhea. This study used data on fecal contamination of drinking water, food, soil, hands, and objects and second-by-second data on children's contacts with these environmental reservoirs in rural Bangladesh to assess the relative contribution of different pathways to children's ingestion of fecal indicator bacteria and if ingestion decreased with the water, sanitation, and hygiene interventions implemented in the WASH Benefits Trial. Our model estimated that rural Bangladeshi children <36 months old consume 3.6-4.9 log10 most probable number E. coli/day. Among children <6 months, placing objects in the mouth accounted for 60% of E. coli ingested. For children 6-35 months old, mouthing their own hands, direct soil ingestion, and ingestion of contaminated food were the primary pathways of E. coli ingestion. The amount of E. coli ingested by children and the predominant pathways of E. coli ingestion were unchanged by the water, sanitation, and hygiene interventions. These results highlight contaminated soil, children's hands, food, and objects as primary pathways of E. coli ingestion and emphasize the value of intervening along these pathways.

Piloting an acceptable and feasible menstrual hygiene products disposal system in urban and rural schools in Bangladesh.

BACKGROUND: Access to washroom facilities and a place to dispose of menstrual waste are prerequisites for optimal menstrual hygiene management in schools. Like other low- and middle-income countries, Bangladeshi schools lack facilities for girls to change and dispose of their menstrual absorbents. We explored existing systems for disposing of menstrual absorbent wastes in urban and rural schools of Bangladesh and assessed the feasibility and acceptability of alternative disposal options. METHODS: We explored how girls dispose of their menstrual products, identified girls' preferences and choices for a disposal system and piloted four disposal options in four different schools. We then implemented one preferred option in four additional schools. We explored girls', teachers', and janitors' perspectives and evaluated the acceptability, feasibility, and potential for sustainability of the piloted disposal system. RESULTS: Barriers to optimal menstrual hygiene management included lack of functional toilets and private locations for changing menstrual products, and limited options for disposal. Girls, teachers, and janitors preferred and ranked the chute disposal system as their first choice, because it has large capacity (765 L), is relatively durable, requires less maintenance, and will take longer time to fill. During implementation of the chute disposal system in four schools, girls, teachers, and janitors reported positive changes in toilet cleanliness and menstrual products disposal resulting from the intervention. CONCLUSIONS: The chute disposal system for menstrual products is a durable option that does not require frequent emptying or regular maintenance, and is accepted by schoolgirls and janitors alike, and can improve conditions for menstrual hygiene management in schools. However, regular supervision, motivation of girls to correctly dispose of their products, and a long-term maintenance and management plan for the system are necessary.

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study.

BACKGROUND: Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh. METHODS: We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method. RESULTS: Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals. CONCLUSIONS: Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs.

Snack food consumption among Bangladeshi children, supplementary data from a large RCT.

Childhood obesity has been associated with consumption of energy-dense foods such as caloric beverages and fast foods. Many low- and middle-income countries like Bangladesh are now experiencing a rising problem of noncommunicable diseases along with the long-standing problem of stunting and undernutrition. WASH Benefits Bangladesh was a large community-based cluster randomized controlled trial conducted in rural Bangladesh. Study clusters were randomized into seven arms: single nutrition (N); water (W); sanitation (S); hygiene (H); combined water, sanitation, and hygiene (WSH); WSH and nutrition (N + WSH); and a double sized control (C). Nutrition intervention messages included four promotional components: maternal nutrition, breastfeeding, complementary feeding, and lipid-based nutrient supplements. The World Health Organization infant food frequency questionnaire (24-hr recall and 7-day recall) was administered at Year 1 and Year 2 of intervention. The likelihood of any snack food consumption was significantly lower (odds ratio 0.37: 95% confidence interval [0.28, 0.49]) in the nutrition intervention arms compared to the control arm in Year 2 follow-up. In addition, in the water intervention arm, fewer children (about 50% less) consumed soft drinks, but not the other sugar-sweetened beverages, compared with control in Year 2. There were no other differences between groups. Simple messages about balanced diet and feeding family foods were effective in lowering commercially produced snack food consumption of the young children in low-income rural communities of Bangladesh. Provision of safe water apparently encouraged mothers to reduce offering unhealthy beverages to the young children.

Effectiveness of a large-scale handwashing promotion intervention on handwashing behaviour in Dhaka, Bangladesh.

OBJECTIVE: The behavioural effect of large-scale handwashing promotion programmes has been infrequently evaluated, and variation in the effect over time has not been described. We assess the effect of a large-scale handwashing promotion programme on handwashing outcomes in a community setting in Dhaka, Bangladesh. METHODS: We analysed data from a cluster-randomised trial that included three arms: vaccine-and-behaviour-change intervention (VBC), vaccine-only (V) and no intervention (Control). Data collectors randomly selected different subsets of households each month during the study period and assessed: (i) temporal variation in availability of soap and water at handwashing place; (ii) the use of water and soap by participants when asked to demonstrate handwashing, and; (iii) handwashing behaviour according to structured observation. We used log-binomial regression analyses to calculate prevalence ratios (PRs) and 95% confidence intervals and compare outcomes by study arms. RESULTS: Data collectors surveyed 9325 households over 28 months. In VBC, there was a significant positive trend on availability of water and soap from baseline to 9 months after the start of the intervention (P-for-trends <0.001), and no significant trend during months 10-28 (P-for-trend = 0.297). In the entire study period, availability of water and soap was higher in VBC (43%) than in V (23%) (PR = 1.92; CI = 1.72, 2.15) and Control (28%) (PR = 1.53; CI = 1.38, 1.69) households. There were no differences between study arms with regard to use of soap during handwashing demonstrations. Observed handwashing with soap after toilet use was higher in VBC (17%) than in V (8%) (PR = 1.47, CI = 0.58, 3.75) and Control (2%) (PR = 3.47, CI = 0.48, 23.33) groups. At other possible pathogen transmission events, the prevalence of handwashing with soap was ≤3%. CONCLUSION: VBC households maintained soap and water for handwashing, but the prevalence of observed handwashing was low in all study arms. The results underscore the need to strengthen scalable behaviour change approaches.

OBJECTIF: L'effet sur le comportement des programmes de promotion du lavage des mains à grande échelle a été rarement évalué et aucune variation de cet effet dans le temps n'a été décrite. Nous évaluons les effets d'un programme de promotion du lavage des mains à grande échelle sur les résultats dans un cadre communautaire à Dhaka, au Bangladesh. MÉTHODES: Nous avons analysé les données d'un essai randomisé par grappes comprenant 3 groupes: intervention vaccin-changement de comportement (VBC), vaccin uniquement (V) et aucune intervention (contrôle). Les collecteurs de données ont sélectionné au hasard différents sous-ensembles de ménages chaque mois au cours de la période d'étude et ont évalué: 1) la variation temporelle de la disponibilité de savon et d'eau sur le lieu de lavage des mains, 2) l'utilisation d'eau et de savon par les participants lorsqu'on leur a demandé de faire la démonstration du lavage des mains, 3) le comportement du lavage des mains selon une observation structurée. Nous avons utilisé des analyses de régression log-binomiales pour calculer les ratios de prévalence (PR) et les intervalles de confiance à 95%, ainsi que pour comparer les résultats par groupe d'étude. RÉSULTATS: Les collecteurs de données ont interrogé 9325 ménages au cours de 28 mois. Dans le groupe VBC, il y avait une tendance positive significative sur la disponibilité d'eau et de savon de la ligne de base à 9 mois après le début de l'intervention (p-pour-tendances <0,001) et aucune tendance significative au cours des mois 10 à 28 (p-pour- tendance = 0,297). Sur l'ensemble de la période d'étude, la disponibilité en eau et en savon était plus élevée dans le groupe VBC (43%) que dans le groupe V (23%) (PR = 1,92; IC: 1,72 - 2,15) et dans le groupe contrôle (28%) (PR = 1,53; IC: 1,38 - 1,69). Il n'y avait pas de différence entre les groupes d'étude en ce qui concerne l'utilisation de savon lors de démonstrations de lavage des mains. Le lavage des mains observé avec du savon après l'utilisation des toilettes était plus élevé dans le groupe VBC (17%) que dans le groupe V (8%) (PR = 1,47; IC: 0,58 - 3,75) et dans le groupe témoin (2%) (PR = 3,47, IC: 0,48 - 23,33). Lors d'autres événements possibles de transmission d'agents pathogènes, la fréquence du lavage des mains au savon était ≤ 3%. CONCLUSION: Les ménages du groupe VBC ont maintenu du savon et de l'eau pour se laver les mains, mais la prévalence du lavage des mains observé était faible dans tous les groupes de l'étude. Les résultats soulignent la nécessité de renforcer les approches évolutives de changement de comportement.

Sand Barriers around Latrine Pits Reduce Fecal Bacterial Leaching into Shallow Groundwater: A Randomized Controlled Trial in Coastal Bangladesh.

We evaluated the effectiveness of a sand barrier around latrine pits in reducing fecal indicator bacteria (FIB) leaching into shallow groundwater. We constructed 68 new offset single pit pour flush latrines in the Galachipa subdistrict of coastal Bangladesh. We randomly assigned 34 latrines to include a 50 cm thick sand barrier under and around the pit and 34 received no sand barrier. Four monitoring wells were constructed around each pit to collect water samples at baseline and subsequent nine follow-up visits over 24 months. Samples were tested using the IDEXX Colilert method to enumerate E. coli and thermotolerant coliforms most probable number (MPN). We determined the difference in mean log10MPN FIB counts/100 mL in monitoring well samples between latrines with and without a sand barrier using multilevel linear models and reported cluster robust standard error. The sand barrier latrine monitoring well samples had 0.38 mean log10MPN fewer E. coli (95% CI: 0.16, 0.59; p = 0.001) and 0.38 mean log10MPN fewer thermotolerant coliforms (95% CI: 0.14, 0.62; p = 0.002), compared to latrines without sand barriers, a reduction of 27% E. coli and 24% thermotolerant coliforms mean counts. A sand barrier can modestly reduce the risk presented by pit leaching.

Predictors of Enteric Pathogens in the Domestic Environment from Human and Animal Sources in Rural Bangladesh.

Fecal indicator organisms are measured to indicate the presence of fecal pollution, yet the association between indicators and pathogens varies by context. The goal of this study was to empirically evaluate the relationships between indicator Escherichia coli, microbial source tracking markers, select enteric pathogen genes, and potential sources of enteric pathogens in 600 rural Bangladeshi households. We measured indicators and pathogen genes in stored drinking water, soil, and on mother and child hands. Additionally, survey and observational data on sanitation and domestic hygiene practices were collected. Log10 concentrations of indicator E. coli were positively associated with the prevalence of pathogenic E. coli genes in all sample types. Given the current need to rely on indicators to assess fecal contamination in the field, it is significant that in this study context indicator E. coli concentrations, measured by IDEXX Colilert-18, provided quantitative information on the presence of pathogenic E. coli in different sample types. There were no significant associations between the human fecal marker (HumM2) and human-specific pathogens in any environmental sample type. There was an increase in the prevalence of Giardia lamblia genes, any E. coli virulence gene, and the specific E. coli virulence genes stx1/2 with every log10 increase in the concentration of the animal fecal marker (BacCow) on mothers' hands. Thus, domestic animals were important contributors to enteric pathogens in these households.

Complementary feeding practices among rural Bangladeshi mothers: Results from WASH Benefits study.

Inappropriate complementary feeding contributes to linear growth faltering in early childhood. Behaviour change interventions have been effective at improving practice, but few studies have investigated the effects of multicomponent integrated interventions. We conducted a cluster-randomized controlled trial in rural Bangladesh in which geographic clusters were randomized into seven arms: water treatment (W), sanitation (S), handwashing (H), water, sanitation, and handwashing (WSH), improved nutrition with infant and young child feeding messages and lipid-based nutrient supplementation for 6- to 24-month olds (N), N+WSH, and control. The objective of this paper was to examine the independent and combined effects of interventions on indicators of complementary feeding. Approximately 1 and 2 years after initiation of the intervention, research assistants surveyed mothers about infant feeding practices. Complementary feeding was examined using the World Health Organization indicators of infant and young child feeding practices. We used Poisson regression models to estimate prevalence ratios and linear regression models for prevalence differences with clustered sandwich estimators to adjust for clustering. A total of 4,718 households from 720 clusters were surveyed at year 1 and 4,667 at year 2. The children in the nutrition arms had a higher prevalence of meeting the minimum dietary diversity score compared with controls (year 1: N: 66.4%; N+WSH: 65.0% vs. C:32.4%; year 2: N: 91.5%; N+WSH: 91.6% vs. C:77.7%). Children in the nutrition arms received diverse food earlier than the children in control arm. In addition, the average consumption of lipid-based nutrient supplementation was >90% in each follow-up. Nutrition-specific interventions could be integrated with nutrition-sensitive interventions such as WSH without compromising the uptake of the nutrition intervention.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Child Enteric Protozoan Infections in Rural Bangladesh: A Cluster-Randomized Controlled Trial.

Background: We evaluated effects of individual and combined water, sanitation, handwashing (WSH), and nutritional interventions on protozoan infections in children. Methods: We randomized geographical clusters of pregnant women in rural Bangladesh into chlorinated drinking water, hygienic sanitation, handwashing, nutrition, combined WSH, nutrition plus WSH (N+WSH), or control arms. Participants were not masked. After approximately 2.5 years of intervention, we measured Giardia, Cryptosporidium, and Entamoeba histolytica prevalence and infection intensity by multiplex real-time polymerase chain reaction of child stool. Analysis was intention-to-treat. Results: Between May 2012 and July 2013, we randomized 5551 pregnant women. At follow-up, among 4102 available women, we enrolled 6694 children into the protozoan assessment. We analyzed stool from 5933 children (aged ~31 months) for protozoan infections. Compared with 35.5% prevalence among controls, Giardia infection prevalence was lower in the sanitation (26.5%; prevalence ratio [PR], 0.75 [95% confidence interval {CI}, .64-.88]), handwashing (28.2%; PR, 0.80 [95% CI, .66-.96]), WSH (29.7%; PR, 0.83 [95% CI, .72-.96]), and N+WSH (26.7%; PR, 0.75 [95% CI, .64-.88]) arms. Water and nutrition interventions had no effect. Low prevalence of E. histolytica and Cryptosporidium (<2%) resulted in imprecise effect estimates. Conclusions: Individual handwashing and hygienic sanitation interventions significantly reduced childhood Giardia infections, and there were no effects of chlorinated drinking water and nutrition improvements in this context. Combined WSH interventions provided no additional benefit. To reduce Giardia infection, individual WSH interventions may be more feasible and cost-effective than combined interventions in similar rural, low-income settings. Clinical Trials Registration: NCT01590095.

A Randomized Controlled Trial to Measure Spillover Effects of a Combined Water, Sanitation, and Handwashing Intervention in Rural Bangladesh.

Water, sanitation, and handwashing interventions may confer spillover effects on intervention recipients' neighbors by interrupting pathogen transmission. We measured geographically local spillovers in the Water Quality, Sanitation, and Handwashing (WASH) Benefits Study, a cluster-randomized trial in rural Bangladesh, by comparing outcomes among neighbors of intervention versus those of control participants. Geographically defined clusters were randomly allocated to a compound-level intervention (i.e., chlorinated drinking water, upgraded sanitation, and handwashing promotion) or control arm. From January 2015 to August 2015, in 180 clusters, we enrolled 1,799 neighboring children who were age matched to trial participants who would have been eligible for the study had they been conceived slightly earlier or later. After 28 months of intervention, we quantified fecal indicator bacteria in toy rinse and drinking water samples and measured soil-transmitted helminth infections and caregiver-reported diarrhea and respiratory illness. Neighbors' characteristics were balanced across arms. Detectable Escherichia coli prevalence in tubewell samples was lower for intervention participants' neighbors than control participants' (prevalence ratio = 0.83; 95% confidence interval: 0.73, 0.95). Fecal indicator bacteria prevalence did not differ between arms for other environmental samples. Prevalence was similar in neighbors of intervention participants versus those of control participants for soil-transmitted helminth infection, diarrhea, and respiratory illness. A compound-level water, sanitation, and handwashing intervention reduced neighbors' tubewell water contamination but did not affect neighboring children's health.