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.

Gamifying quantitative face-to-face interviews in rural India: An empirical evaluation based on the basic psychological needs theory.

OBJECTIVE: Standardized face-to-face interviews are widely used in low and middle-income countries to collect data for social science and health research. Such interviews can be long and tedious. In an attempt to improve the respondents' experience of interviews, we developed a concept of gamified interview format by including a game element. Gamification is reported to increase engagement in tasks, but results from rigorously developed research are equivocal, and a theory of gamification is still needed. MATERIALS & METHODS: We evaluated the proposed gamification with a randomized controlled trial based on self-determination theory, specifically on the basic psychological needs theory. In total, 1266 respondents were interviewed. Single and multiple mediation analyses were used to understand the effects of the gamified interview format. RESULTS: Our evaluation showed that the gamification we had developed did not improve the outcome, the experience of the interview reported by respondent. The effect of the gamified interview format depended on the ability of respondents: gamification can be counterproductive if it overburdens the respondents. However, the basic psychological needs theory explained the mechanisms of action of gamification well: feeling competent and related to others improved the reported experience of the interview. CONCLUSION: We emphasize the need to develop context-specific gamification and invite researchers to conduct equivalently rigorous evaluations of gamification in future studies.

Construction of a Low-cost Mobile Incubator for Field and Laboratory Use.

Incubators are essential for a range of culture-based microbial methods, such as membrane filtration followed by cultivation for assessing drinking water quality. However, commercially available incubators are often costly, difficult to transport, not flexible in terms of volume, and/or poorly adapted to local field conditions where access to electricity is unreliable. The purpose of this study was to develop an adaptable, low-cost and transportable incubator that can be constructed using readily available components. The electronic core of the incubator was first developed. These components were then tested under a range of ambient temperature conditions (3.5 °C - 39 °C) using three types of incubator shells (polystyrene foam box, hard cooler box, and cardboard box covered with a survival blanket). The electronic core showed comparable performance to a standard laboratory incubator in terms of the time required to reach the set temperature, inner temperature stability and spatial dispersion, power consumption, and microbial growth. The incubator set-ups were also effective at moderate and low ambient temperatures (between 3.5 °C and 27 °C), and at high temperatures (39 °C) when the incubator set temperature was higher. This incubator prototype is low-cost (< 300 USD) and adaptable to a variety of materials and volumes. Its demountable structure makes it easy to transport. It can be used in both established laboratories with grid power or in remote settings powered by solar energy or a car battery. It is particularly useful as an equipment option for field laboratories in areas with limited access to resources for water quality monitoring.

Enhancing handwashing frequency and technique of primary caregivers in Harare, Zimbabwe: A cluster-randomized controlled trial using behavioral and microbial outcomes.

RATIONALE: Consistent hand hygiene prevents diarrheal and respiratory diseases, but it is often not practiced. The disease burden is highest in low-income settings, which need effective interventions to promote domestic handwashing. To date, most handwashing campaigns have focused on promoting frequent handwashing at key times, whereas specifically promoting handwashing techniques proven to be effective in removing microbes has been confined to healthcare settings. METHODS: We used a cluster-randomized, factorial, controlled trial to test the effects of two handwashing interventions on the behavior of primary caregivers in Harare, Zimbabwe. One intervention targeted caregivers directly, and the other targeted them through their children. Outcome measures were surveyed at baseline and six weeks' follow-up and included observed handwashing frequency and technique and fecal hand contamination before and after handwashing. RESULTS: Combining the direct and indirect interventions resulted in observed handwashing with soap at 28% of critical handwashing times, while the corresponding figure for the non-intervention control was 5%. Observed handwashing technique, measured as the number of correctly performed handwashing steps, increased to an average of 4.2, while the control averaged 3.4 steps. Demonstrated handwashing technique increased to a mean of 6.8 steps; the control averaged 5.2 steps. No statistically significant group differences in fecal hand contamination before or after handwashing were detected. CONCLUSIONS: The results provide strong evidence that the campaign successfully improved handwashing frequency and technique. It shows that the population-tailored design, based on social-cognitive theory, provides effective means for developing powerful interventions for handwashing behavior change. We did not find evidence that children acted as strong agents of handwashing behavior change. The fact that the microbial effectiveness of handwashing did not improve despite strong improvements in handwashing technique calls for critical evaluation of existing handwashing recommendations. The aim of future handwashing campaigns should be to promote both frequent and effective handwashing.

Escherichia coli Contamination across Multiple Environmental Compartments (Soil, Hands, Drinking Water, and Handwashing Water) in Urban Harare: Correlations and Risk Factors.

Escherichia coli pathotypes (i.e., enteropathogenic and enterotoxigenic) have been identified among the pathogens most responsible for moderate-to-severe diarrhea in low- and middle-income countries (LMICs). Pathogenic E. coli are transmitted from infected human or animal feces to new susceptible hosts via environmental reservoirs such as hands, water, and soil. Commensal E. coli, which includes nonpathogenic E. coli strains, are widely used as fecal bacteria indicator, with their presence associated with increased likelihood of enteric pathogens and/or diarrheal disease. In this study, we investigated E. coli contamination in environmental reservoirs within households (N = 142) in high-population density communities of Harare, Zimbabwe. We further assessed the interconnectedness of the environmental compartments by investigating associations between, and household-level risk factors for, E. coli contamination. From the data we collected, the source and risk factors for E. coli contamination are not readily apparent. One notable exception is the presence of running tap water on the household plot, which is associated with significantly less E. coli contamination of drinking water, handwashing water, and hands after handwashing. In addition, E. coli levels on hands after washing are significantly associated with handwashing water contamination, hand contamination before washing, and diarrhea incidence. Finally, we observed that animal ownership increases E. coli contamination in soil, and E. coli in soil are correlated with contamination on hands before washing. This study highlights the complexity of E. coli contamination in household environments within LMICs. More, larger, studies are needed to better identify sources and exposure pathways of E. coli-and enteric pathogens generally-to identify effective interventions.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe.

BACKGROUND: This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change. METHODS: Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies. RESULTS: The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme. CONCLUSIONS: The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.

Contextual and Psychosocial Determinants of Effective Handwashing Technique: Recommendations for Interventions from a Case Study in Harare, Zimbabwe.

Handwashing has been shown to considerably reduce diarrhea morbidity and mortality. To decontaminate hands effectively, the use of running water, soap, and various scrubbing steps are recommended. This study aims to identify the behavioral determinants of effective handwashing. Everyday handwashing technique of 434 primary caregivers in high-density suburbs of Harare, Zimbabwe, was observed and measured as an 8-point sum score of effective handwashing technique. Multiple linear and logistic regression analyses were performed to predict observed handwashing technique from potential contextual and psychosocial determinants. Knowledge of how to wash hands effectively, availability of a handwashing station with functioning water tap, self-reported frequency of handwashing, perceived vulnerability, and action planning were the main determinants of effective handwashing technique. The models were able to explain 39% and 36% of the variance in overall handwashing technique and thoroughness of handscrubbing. Memory aids and guided practice are proposed to consolidate action knowledge, and personalized risk messages should increase the perceived vulnerability of contracting diarrhea. Planning where, when, and how to maintain a designated place for handwashing with sufficient soap and water is proposed to increase action planning. Since frequent self-reported handwashing was associated with performing more effective handwashing technique, behavior change interventions should target both handwashing frequency and technique concurrently.

Handwashing, but how? Microbial effectiveness of existing handwashing practices in high-density suburbs of Harare, Zimbabwe.

BACKGROUND: Consistent domestic hand hygiene can reduce diarrhea-related morbidity and mortality and the spread of other communicable diseases. However, it remains uncertain which technique of handwashing is most effective and practicable during everyday life. The goal of this study is to determine how the handwashing technique, as performed in the daily life by the participants of this case study in Harare, Zimbabwe, influences microbial handwashing effectiveness. METHODS: Handwashing technique of 173 primary caregivers was observed in their homes and hand rinse samples were collected before and after handwashing. Samples were analyzed for Escherichia coli and total coliform concentrations. Generalized linear models were used to predict fecal hand contamination after washing from observed handwashing technique. RESULTS: Cleaning under fingernails, scrubbing the fingertips, using soap, and drying hands through rubbing on clothes or a clean towel statistically significantly reduced E coli contamination of hands after washing. Tap use, scrubbing fingertips, and rubbing hands on clothes to dry them statistically significantly reduced total coliform contamination. CONCLUSIONS: Recommendations for effective and practicable domestic handwashing in Harare, Zimbabwe, should include performing specific handscrubbing steps (ie, cleaning under the fingernails and rubbing the fingertips), and soap and tap use. This calls for further research to develop behavior change interventions that explicitly promote effective handwashing technique at critical times.