Assessing the Effectiveness of a Multicomponent Intervention on Hand Hygiene and Well-Being in Primary Health Care Centers and Schools Lacking Functional Water Supply in Protracted Conflict Settings: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Hand hygiene is crucial in health care centers and schools to avoid disease transmission. Currently, little is known about hand hygiene in such facilities in protracted conflict settings. OBJECTIVE: This protocol aims to assess the effectiveness of a multicomponent hand hygiene intervention on handwashing behavior, underlying behavioral factors, and the well-being of health care workers and students. Moreover, we report our methodology and statistical analysis plan transparently. METHODS: This is a cluster randomized controlled trial with 2 parallel arms taking place in 4 countries for 1 year. In Burkina Faso and Mali, we worked in 24 primary health care centers per country, whereas in Nigeria and Palestine, we focused on 26 primary schools per country. Facilities were eligible if they were not connected to a functioning water source but were deemed accessible to the implementation partners. Moreover, health care centers were eligible if they had a maternity ward and ≥5 employees, and schools if they had ≤7000 students studying in grades 5 to 7. We used covariate-constrained randomization to assign intervention facilities that received a hardware, management and monitoring support, and behavior change. Control facilities will receive the same or improved intervention after endline data collection. To evaluate the intervention, at baseline and endline, we used a self-reported survey, structured handwashing observations, and hand-rinse samples. At follow-up, hand-rinse samples were dropped. Starting from the intervention implementation, we collected longitudinal data on hygiene-related health conditions and absenteeism. We also collected qualitative data with focus group discussions and interviews. Data were analyzed descriptively and with random effect regression models with the random effect at a cluster level. The primary outcome for health centers is the handwashing rate, defined as the number of times health care workers performed good handwashing practice with soap or alcohol-based handrub at one of the World Health Organization 5 moments for hand hygiene, divided by the number of moments for hand hygiene that presented themselves during the patient interaction within an hour of observation. For schools, the primary outcome is the number of students who washed their hands before eating. RESULTS: The baseline data collection across all countries lasted from February to June 2023. We collected data from 135 and 174 health care workers in Burkina Faso and Mali, respectively. In Nigeria, we collected data from 1300 students and in Palestine from 1127 students. The endline data collection began in February 2024. CONCLUSIONS: This is one of the first studies investigating hand hygiene in primary health care centers and schools in protracted conflict settings. With our strong study design, we expect to support local policy makers and humanitarian organizations in developing sustainable agendas for hygiene promotion. TRIAL REGISTRATION: ClinicalTrials.gov NCT05946980 (Burkina Faso and Mali); https://www.clinicaltrials.gov/study/NCT05946980 and NCT05964478 (Nigeria and Palestine); https://www.clinicaltrials.gov/study/NCT05964478. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52959.

Determination of Psychosocial Factors of Drinking Chlorinated Water to Design Behavior Change Interventions in Rohingya Camps in Bangladesh.

The purpose of this study was to identify the psychosocial factors of chlorinated water uptake and to design effective behavior change techniques applying the risk, attitude, norm, ability, and self-regulation (RANAS) behavior change model. This cross-sectional study was conducted in two Rohingya refugee camps in Cox's Bazar, Bangladesh. In total, 596 respondents were recruited through systematic random sampling. A structured interviewer-administered questionnaire was used to assess the psychosocial factors according to the RANAS model. We used correlation analysis and multivariable linear regression models to predict the psychosocial factors of the consumption of chlorinated water. The respondents in this study had a medium to high habit of drinking chlorinated water. For the overall sample, participants' habits were predicted by income, perceived vulnerability, like of chlorinated water, feelings of being healthy, action planning skills, and coping planning skills. In Camp 14, income, vulnerability, and coping planning were strongly influential in predicting habit; in Camp 16, liking chlorinated water and action planning were the most influential factors. Behavior change techniques against each factor with proper communication channels have been proposed for the overall sample and specific to each camp. The psychosocial factors identified and the behavior change strategies proposed in this study may help to promote chlorinated water consumption among the camp population. This study also recommends follow-up research that considers more contextual factors, uses larger sample sizes, and examines the effectiveness of the intervention.

The importance of collective and individual psychological ownership for safe sanitation: A multilevel analysis in rural Ghana.

Unsafe sanitation practices can severely affect public health. Strengthening psychological ownership, the feeling of owning an object (e.g. the latrine) individually or collectively, may promote safe sanitation practices, e.g. decreased open defecation. This study investigated psychological ownership in communities that participated in a sanitation intervention. We used follow-up survey data of a cluster-randomised controlled trial in rural Ghana (N = 2012 households), which assessed psychological ownership, and safe sanitation outcomes. The data were analysed using multilevel modelling and generalised estimating equations. In line with our assumptions, greater psychological ownership for the latrine related to decreased open defecation. Higher individual psychological ownership for the open defecation space related to safe sanitation outcomes, whereas collective ownership related to lesser safe sanitation. The present study shows that the concept of psychological ownership may play an important role in safe sanitation. Collective and individual psychological ownership seem to distinctly relate to safe sanitation outcomes, which has high relevance for promoting communities' health behaviour.

How does Community-Led Total Sanitation (CLTS) promote latrine construction, and can it be improved? A cluster-randomized controlled trial in Ghana.

RATIONALE: Open defecation is connected to poor health and child mortality, but billions of people still do not have access to safe sanitation facilities. Community-Led Total Sanitation (CLTS) promotes latrine construction to eradicate open defecation. However, the mechanisms by which CLTS works and how they can be improved remain unknown. The present study is the first to investigate the psychosocial determinants of CLTS in a longitudinal design. Furthermore, we tested whether CLTS can be made more effective by theory- and evidence-based interventions using the risks, attitudes, norms, abilities, and selfregulation (RANAS) model. METHODS: A cluster-randomized controlled trial of 3216 households was implemented in rural Ghana. Communities were randomly assigned to classic CLTS, one of three RANAS-based interventions, or to the control arm. Prepost surveys at 6-month follow-up included standardized interviews assessing psychosocial determinants from the RANAS model. Regression analyses and multilevel mediation models were computed to test intervention effects and mechanisms of CLTS. RESULTS: Latrine coverage increased pre-post by 67.6% in all intervention arms and by 7.9% in the control arm (p < .001). The combination with RANAS-based interventions showed non-significantly greater effects than CLTS alone. The effects of CLTS on latrine construction were significantly mediated by changes in four determinants: others' behaviour and approval, self-efficacy, action planning and commitment. Changes in vulnerability, severity, and barrier planning were positively connected to latrine construction but not affected by CLTS. CONCLUSION: This study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further. Behaviour change techniques within CLTS that strengthened the relevant factors should be maintained. The study also recommends interventions based on the RANAS approach to improve CLTS. Further research is needed to understand the effects of RANAS-based interventions combined with CLTS at longer follow-up.

The role of social identification for achieving an open-defecation free environment: A cluster-randomized, controlled trial of Community-Led Total Sanitation in Ghana.

Unsafe sanitation practices are a major source of environmental pollution and are a leading cause of death in countries of the Global South. One of the most successful campaigns to eradicate open defecation is "Community-Led Total Sanitation" (CLTS). It aims at shifting social norms towards safe sanitation practices. However, the effectiveness of CLTS is heterogeneous. Based on social identity theory, we expect CLTS to be most effective in communities with stronger social identification, because in these communities individuals should rather follow social norms. We conducted a cluster-randomized controlled trial with 3,216 households in 132 communities in Ghana, comparing CLTS to a control arm. Self-reported open defecation rates and social identification were assessed pre-post. Generalized Estimating Equations showed that CLTS achieved lower open defecation rates compared to controls. This effect was significantly stronger for communities with stronger average social identification. The results confirm the assumptions of social identity theory. They imply that pre-existing social identification needs to be considered for planning CLTS, and strengthened beforehand if needed.

Role of Implementation Factors for the Success of Community-Led Total Sanitation on Latrine Coverage. A Case Study from Rural Ghana.

Community-led total sanitation (CLTS) is an approach to improving sanitation to combat open defecation (OD). OD is a health threat to children under five. CLTS promotes the construction of latrines with the goal of declaring communities open defecation free. However, which factors of the implementation process are most important for the success has yet to be ascertained. The analysed sample comprised of 94 communities in rural Ghana, where CLTS was implemented and factors describing the implementation process of CLTS were assessed. Additionally, monitoring data from the implementation process were used. Multiple regression analysis revealed that latrine coverage was significantly related to attendance at the CLTS meeting, the number of supportive community leaders, the expectation of participants of receiving an incentive, and the number of follow-up visits. Implementers of CLTS should direct their attention to the processes following the community meeting. The success of CLTS can be improved by investing in follow-up visits, the support of local leaders, and the careful application of incentives.

Factors Associated with Levels of Latrine Completion and Consequent Latrine Use in Northern Ghana.

Open defecation is still a major health problem in developing countries. While enormous empirical research exists on latrine coverage, little is known about households' latrine construction and usage behaviours. Using field observation and survey data collected from 1523 households in 132 communities in northern Ghana after 16 months of implementation of Community Led Total Sanitation (CLTS), this paper assessed the factors associated with latrine completion and latrine use. The survey tool was structured to conform to the Risk, Attitude, Norms, Ability and Self-regulation (RANAS) model. In the analysis, we classified households into three based on their latrine completion level, and conducted descriptive statistics for statistical correlation in level of latrine construction and latrine use behaviour. The findings suggest that open defecation among households reduces as latrine construction approaches completion. Although the study did not find socio-demographic differences of household to be significantly associated with level of latrine completion, we found that social context is a significant determinant of households' latrine completion decisions. The study therefore emphasises the need for continuous sensitisation and social marketing to ensure latrine completion by households at lower levels of construction, and the sustained use of latrines by households.

Is Community-Led Total Sanitation connected to the rebuilding of latrines? Quantitative evidence from Mozambique.

To reduce open defecation, many implementers use the intervention strategies of Community-Led Total Sanitation (CLTS). But CLTS focuses on latrine construction and does not include latrine maintenance and repair damage or collapse. Some households rebuild their latrine while others return to open defecation. The reasons why are unknown. Using data from a cross-sectional survey, this article shows how physical, personal, and social context factors and psychosocial factors from the RANAS model are associated with CLTS participation, and how these factors connect to latrine rebuilding. In 2015, heavy rains hit the north of Mozambique and many latrines collapsed. Subsequently, 640 household interviews were conducted in the affected region. Logistic regression and mediation analyses reveal that latrine rebuilding depends on education, soil conditions, social cohesion, and a feeling of being safe from diarrhea, the perception that many other community members own a latrine, and high confidence in personal ability to repair or rebuild a broken latrine. The effect of CLTS is mediated through social and psychosocial factors. CLTS already targets most of the relevant factors, but can still be improved by including activities that would focus on other factors not yet sufficiently addressed.

How does Community-Led Total Sanitation (CLTS) affect latrine ownership? A quantitative case study from Mozambique.

BACKGROUND: Community-led total sanitation (CLTS) is a widely used, community-based approach to tackle open defecation and its health-related problems. Although CLTS has been shown to be successful in previous studies, little is known about how CLTS works. We used a cross-sectional case study to identify personal, physical, and social context factors and psychosocial determinants from the Risks, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) model of behavior change, which are crucial for latrine ownership and analyze how participation in CLTS is associated with those determinants. METHODS: Structured interviews were conducted with 640 households in 26 communities, where CLTS had been completed before and compared to 6 control communities, all located in northern Mozambique in 2015. To identify crucial factors for latrine ownership, logistic regression analysis were conducted and mediation analysis were used to analyse the relationship between CLTS participation and latrine ownership mediated by factors identified by the logistic regression analyses. RESULTS: Mediation analysis reveal that the relationship of CLTS participation with probability of owning a latrine is mediated by social context factors and psychosocial determinants. Data analysis reveal that the probability of building a latrine depends on existing social context factors within the village, the behavior of others in the community, the (dis)approval of others of latrine ownership, personal self-confidence in latrine building, and a precise communication of the benefits of latrine ownership during a CLTS triggering event. CONCLUSIONS: By including activities to focus on the mentioned factors, CLTS could be improved. Exemplary adaptations are discussed.