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OBJECTIVE: To estimate the national costs relating to diarrhoea and acute respiratory infections from not handwashing with soap after contact with excreta and the costs and benefits of handwashing behaviour change programmes in India and China. METHODS: Data on the reduction in risk of diarrhoea and acute respiratory infection attributable to handwashing with soap were used, together with World Health Organization (WHO) estimates of disability-adjusted life years (DALYs) due to diarrhoea and acute respiratory infection, to estimate DALYs due to not handwashing in India and China. Costs and benefits of behaviour change handwashing programmes and the potential returns to investment are estimated valuing DALYs at per capita GDP for each country. RESULTS: Annual net costs to India from not handwashing are estimated at US$ 23 billion (16-35) and to China at US$ 12 billion (7-23). Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per DALY avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided - a 35-fold return on investment. CONCLUSION: Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households.
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Diarrea/economía , Diarrea/prevención & control , Desinfección de las Manos , Infecciones del Sistema Respiratorio/economía , Infecciones del Sistema Respiratorio/prevención & control , Enfermedad Aguda , China/epidemiología , Gastos en Salud/estadística & datos numéricos , Humanos , India/epidemiología , Modelos Econométricos , JabonesRESUMEN
BACKGROUND: Diarrhoea is a leading cause of child death in Zambia. As elsewhere, the disease burden could be greatly reduced through caregiver uptake of existing prevention and treatment strategies. We recently reported the results of the Komboni Housewives intervention which tested a novel strategy employing motives including affiliation and disgust to improve caregiver practice of four diarrhoea control behaviours: exclusive breastfeeding; handwashing with soap; and correct preparation and use of oral rehydration salts (ORS) and zinc. The intervention was delivered via community events (women's forums and road shows), at health clinics (group session) and via radio. A cluster randomised trial revealed that the intervention resulted in a small improvement in exclusive breastfeeding practices, but was only associated with small changes in the other behaviours in areas with greater intervention exposure. This paper reports the findings of the process evaluation that was conducted alongside the trial to investigate how factors associated with intervention delivery and receipt influenced caregiver uptake of the target behaviours. METHODS: Process data were collected from the eight peri-urban and rural intervention areas throughout the six-month implementation period and in all 16 clusters 4-6 weeks afterwards. Intervention implementation (fidelity, reach, dose delivered and recruitment strategies) and receipt (participant engagement and responses, and mediators) were explored through review of intervention activity logs, unannounced observation of intervention events, semi-structured interviews, focus groups with implementers and intervention recipients, and household surveys. Evaluation methods and analyses were guided by the intervention's theory of change and the evaluation framework of Linnan and Steckler. RESULTS: Intervention reach was lower than intended: 39% of the surveyed population reported attending one or more face-to-face intervention event, of whom only 11% attended two or more intervention events. The intervention was not equally feasible to deliver in all settings: fewer events took place in remote rural areas, and the intervention did not adequately penetrate communities in several peri-urban sites where the population density was high, the population was slightly higher socio-economic status, recruitment was challenging, and numerous alternative sources of entertainment existed. Adaptations made by the implementers affected the fidelity of implementation of messages for all target behaviours. Incorrect messages were consequently recalled by intervention recipients. Participants were most receptive to the novel disgust and skills-based interactive demonstrations targeting exclusive breastfeeding and ORS preparation respectively. However, initial disgust elicitation was not followed by a change in associated psychological mediators, and social norms were not measurably changed. CONCLUSIONS: The lack of measured behaviour change was likely due to issues with both the intervention's content and its delivery. Achieving high reach and intensity in community interventions delivered in diverse settings is challenging. Achieving high fidelity is also challenging when multiple behaviours are targeted for change. Further work using improved tools is needed to explore the use of subconscious motives in behaviour change interventions. To better uncover how and why interventions achieve their measured effects, process evaluations of complex interventions should develop and employ frameworks for investigation and interpretation that are structured around the intervention's theory of change and the local context. TRIAL REGISTRATION: The study was registered as part of the larger trial on 5 March 2014 with ClinicalTrials.gov: NCT02081521 .
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Cuidadores/psicología , Diarrea/prevención & control , Conductas Relacionadas con la Salud , Promoción de la Salud/métodos , Lactancia Materna/psicología , Cuidadores/estadística & datos numéricos , Preescolar , Análisis por Conglomerados , Femenino , Fluidoterapia/métodos , Fluidoterapia/psicología , Grupos Focales , Desinfección de las Manos , Humanos , Lactante , Motivación , Evaluación de Programas y Proyectos de Salud , Teoría Psicológica , Soluciones para Rehidratación/uso terapéutico , Sales (Química)/uso terapéutico , Jabones/uso terapéutico , Zambia , Zinc/uso terapéuticoRESUMEN
BACKGROUND: A theoretically grounded formative research study was carried out to investigate behaviour related to the use of Oral Rehydration Salts (ORS) and zinc tablets. The purpose was to inform the design of the behaviour change component of the Programme for Awareness and Elimination of Diarrhoea in Lusaka Province, Zambia, which aims to reduce childhood morbidity and mortality from diarrhoeal disease. METHODS: Fourteen behaviour trials were conducted among caregivers of children under-five with diarrhoea. Caregivers were recruited from two clinics situated in rural and peri-urban Lusaka. Trials took ten days and data were captured using video, observation and repeated interviews. Additional data were collected through focus group discussions with mothers, observations in clinics and pharmacies and interviews with clinic and pharmacy staff. Findings were organised according to categories of behavioural determinants from Evo-Eco theory. RESULTS: Participants were all familiar with ORS and most knew its purpose. ORS use was motivated by symptoms of dehydration, rather than the start of a diarrhoea episode, and was stopped when the child had visibly recovered energy. Only four of 14 behaviour trial participants were observed to correctly prepare ORS. Errors were mainly associated with measurement, resulting in a solution that was too concentrated. ORS was not observed to be given to children at clinics. Although zinc was unknown in this population, it was positively received by mothers keen to learn whether zinc would work better than alternative treatments to stop diarrhoea. CONCLUSIONS: ORS was sub-optimally prepared and used at home. It was not used while waiting to be seen at a clinic. In homes, the behaviour change intervention should promote early and continued use of correctly prepared ORS. In the longer-term, these behaviours may best be encouraged by changing the product design or sachet size. Despite its unfamiliarity, this population was well disposed to the use of zinc as a treatment for diarrhoea; when zinc is new to a population, promoting zinc as a solution to stopping diarrhoea, which mothers seek, may drive initial trial. Ensuring the availability of zinc in public clinics and private pharmacies prior to commencement of any promotion activities is crucial.
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Diarrea/terapia , Fluidoterapia/métodos , Soluciones para Rehidratación/uso terapéutico , Sales (Química)/uso terapéutico , Zinc/uso terapéutico , Adolescente , Adulto , Cuidadores/psicología , Cuidadores/estadística & datos numéricos , Preescolar , Deshidratación/psicología , Deshidratación/terapia , Femenino , Teoría Fundamentada , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Madres/psicología , Madres/estadística & datos numéricos , Motivación , Farmacias , Investigación Cualitativa , Adulto Joven , ZambiaRESUMEN
BACKGROUND: An intervention trial of the 'SuperAmma' village-level intervention to promote handwashing with soap (HWWS) in rural India demonstrated substantial increases in HWWS amongst the target population. We carried out a process evaluation to assess the implementation of the intervention and the evidence that it had changed the perceived benefits and social norms associated with HWWS. The evaluation also aimed to inform the design of a streamlined shorter intervention and estimate scale up costs. METHODS: Intervention implementation was observed in 7 villages. Semi-structured interviews were conducted with the implementation team, village leaders and representatives of the target population. A questionnaire survey was administered in 174 households in intervention villages and 171 households in control villages to assess exposure to intervention activities, recall of intervention components and evidence that the intervention had produced changes in perceptions that were consistent with the intervention core messages. Costs were estimated for the intervention as delivered, as well as for a hypothetical scale-up to 1,000 villages. RESULTS: We found that the intervention was largely acceptable to the target population, maintained high fidelity (after some starting problems), and resulted in a high level of exposure to most components. There was a high recall of most intervention activities. Subjects in the intervention villages were more likely than those in control villages to cite reasons for HWWS that were in line with intervention messaging and to believe that HWWS was a social norm. There were no major differences between socio-economic and caste groups in exposure to intervention activities. Reducing the intervention from 4 to 2 contact days, in a scale up scenario, cut the estimated implementation cost from $2,293 to $1,097 per village. CONCLUSIONS: The SuperAmma intervention is capable of achieving good reach across men and women of varied social and economic status, is affordable, and has the potential to be effective at scale, provided that sufficient attention is given to ensuring the quality of intervention delivery.
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Desinfección de las Manos , Evaluación de Procesos, Atención de Salud , Jabones , Adulto , Niño , Control de Enfermedades Transmisibles/métodos , Servicios de Salud Comunitaria , Diarrea/prevención & control , Femenino , Desinfección de las Manos/economía , Educación en Salud , Humanos , India , Masculino , Neumonía/prevención & control , Población Rural , Encuestas y CuestionariosRESUMEN
There is currently no single, easy-to-use, reliable indicator to assess whether a face has been washed with soap in the context of trachoma elimination. This study aimed to compare survey report, script-based pictorial recall and facial cleanliness indicators as alternatives to structured observation for measuring face washing behaviour. This method validation study was nested in the Stronger-SAFE trial, Oromia Region, Ethiopia. Structured observation was conducted in randomly selected households for three hours from dawn. The primary caregiver in each household participated in a survey to capture (self)-reported behaviour and/or script-based pictorial recall, a routine-based diary activity to covertly capture information on face washing behaviour of themself and any children aged 1-12. Children 4-12 years old directly participated in the survey and pictorial recall in a subset of households. The facial cleanliness of children aged 1-12 was assessed qualitatively and using the quantitative Personal Hygiene Assessment Tool (qPHAT). Prevalence estimates, sensitivity, specificity and predictive values were computed for each behavioural indicator with observation data as the gold standard. The appropriateness of script-based pictorial recall was assessed using baseline and 3-month follow-up data. Baseline data were collected from 204 households in 68 clusters. Survey estimates of face washing and face washing with soap among caregivers and children were 32% to 60% and 5% to 31% higher than observed behaviour, respectively. Face washing prevalence estimates from pictorial recall were lower than survey estimates and comparable with observations for some face washing with soap indicators (0.3% to 13% higher than observations). Specificity of pictorial recall indicators was high (85% to 99%), but the sensitivity was low (0% to 67%), resulting in a low positive predictive value for all indicators. Both qualitative facial cleanliness indicators and qPHAT scores were poorly correlated with observed face washing earlier that morning. Pictorial recall overestimated face washing with soap among both caregivers and children following intervention delivery but not at baseline. Survey (self)-reported data on face washing is highly inaccurate. Script-based pictorial recall does not correctly classify those who wash their face with soap, and is subject to differential bias following intervention exposure, and facial cleanliness is a poor indicator of recent face washing in settings where faces become rapidly dirty again after washing. Alternatives to structured observation cannot be recommended to monitor the effectiveness of face washing interventions in community settings. Trial Registration ISRCTN registry ISRCTN40760473, https://doi.org/10.1186/ISRCTN40760473.
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Higiene , Tracoma , Humanos , Tracoma/prevención & control , Tracoma/epidemiología , Preescolar , Niño , Masculino , Femenino , Lactante , Etiopía , Jabones , Cara , Adulto , Encuestas y Cuestionarios , Prevalencia , Sensibilidad y Especificidad , CuidadoresRESUMEN
During the COVID-19 pandemic in Kenya, 5,311 handwashing stations were distributed by the National Business Compact Coalition (NBCC) to help combat the virus. This study evaluated 316 of these stations across five counties, assessing functionality, usability, and accessibility. Quantitative data, including spot checks and surveys, revealed that 83.9% of the evaluated stations were functional, with paid caretakers, which is associated with higher functionality rates. Qualitative insights underscored challenges such as inadequate signage and limited soap and water availability, particularly affecting individuals with disabilities. Despite initial success, only 61% of stations remained functional 6-8 months post-distribution, often due to relocation by caretakers. Future distributions should prioritize long-term support for caretakers to sustain station functionality. This study highlights the importance of ongoing monitoring and support for public handwashing facilities in pandemic response efforts.
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COVID-19 , Desinfección de las Manos , Pandemias , COVID-19/epidemiología , COVID-19/prevención & control , Humanos , Kenia/epidemiología , Estudios Transversales , Pandemias/prevención & control , SARS-CoV-2/aislamiento & purificaciónRESUMEN
There is major untapped potential to improve health in low-income communities through improved housing design, fittings, materials and construction. Adverse effects on health from inadequate housing can occur through a range of mechanisms, both direct and indirect, including as a result of extreme weather, household air pollution, injuries or burns, the ingress of disease vectors and lack of clean water and sanitation. Collaborative action between public health professionals and those involved in developing formal and informal housing could advance both health and development by addressing risk factors for a range of adverse health outcomes. Potential trade-offs between design features which may reduce the risk of some adverse outcomes whilst increasing the risk of others must be explicitly considered.
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Promoción de la Salud/organización & administración , Vivienda , Pobreza , Salud Pública , Contaminación del Aire Interior , Animales , Análisis Costo-Beneficio , Países en Desarrollo , Vectores de Enfermedades , Calefacción/efectos adversos , Calefacción/métodos , Humanos , Características de la Residencia , Factores de Riesgo , Saneamiento , Población Urbana , Abastecimiento de Agua , Tiempo (Meteorología)RESUMEN
BACKGROUND: This article reports on formative research into the context and practice of handwashing with soap by new mothers, which can substantially impact child morbidity and mortality. New mothers are an important target group for handwashing interventions: they are considered particularly susceptible to behaviour change and their actions can directly affect a child's health. METHODS: Twenty-seven mothers of infants (including neonates) from urban and rural sub-districts of Serang were recruited and filmed over a period of eight hours. Video footage was used to identify handwashing occasions and to understand the context in which behaviour took place. Each woman was subsequently interviewed. RESULTS: Handwashing with soap was found to be infrequent, typically occurring after eating, cooking and household chores or after cleaning a child's bottom. Handwashing before preparing food or eating was rare. Pre-pregnancy routines were reported to have been disrupted. Advice on child care comes from many sources, particularly the midwife and new child's grandmother. CONCLUSIONS: Developing interventions to change perceptions and practice of handwashing would seed an important behaviour and could save lives. New mothers represent an ideal target group for such an intervention. We suggest that interventions target an increase in handwashing with soap after contact with own and a baby's faecal matter as part of the post-defecation hygiene routines. As the child's grandmother is an authoritative source of information about parenting, interventions focussed on improving newborn care could target grandmothers as well as midwives.
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Desinfección de las Manos/tendencias , Conocimientos, Actitudes y Práctica en Salud , Higiene/educación , Control de Infecciones , Madres/educación , Adolescente , Adulto , Estudios Transversales , Países en Desarrollo , Femenino , Desinfección de las Manos/métodos , Conductas Relacionadas con la Salud , Educación en Salud/métodos , Humanos , Indonesia , Lactante , Recién Nacido , Relaciones Madre-Hijo , Embarazo , Investigación Cualitativa , Medición de Riesgo , Población Rural , Factores Socioeconómicos , Adulto JovenRESUMEN
Current theories in moral psychology do not agree about the kinds and range of offenses that people should moralize. In this study, a new approach to defining the moral domain, Human Superorganism Theory (HSoT), is presented and tested. HSoT proposes that the primary function of moral action is the suppression of cheaters in the unusually large societies recently established by our species (i.e., human 'superorganisms'). It suggests that a broad range of moral concerns exist beyond traditional notions of harm and fairness, including actions that inhibit functions such as group-level social control, physical and social structuring, reproduction, communication, signaling and memory. Roughly 80,000 respondents completed a web-based experiment hosted by the British Broadcasting Corporation, which elicited a suite of responses to characteristics of a set of 33 short scenarios representing the areas identified by the HSoT perspective. Results indicate that all 13 superorganism functions are moralized, while violations of scenarios falling outside this area (social customs and individual decisions) are not. Several hypotheses derived specifically from HSoT were also supported. Given this evidence, we believe this new approach to defining a broader moral domain has implications for fields ranging from psychology to legal theory.
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BACKGROUND: Trachoma, the leading infectious cause of blindness, is caused by the bacterium Chlamydia trachomatis (Ct). Despite enormous disease control efforts and encouraging progress, trachoma remains a significant public health problem in 44 countries. Ethiopia has the greatest burden of trachoma worldwide, however, robust data exploring transmission risk factors and the association between socio-economic status is lacking from some regions. This is the first study to investigate these factors in this South-Eastern region of Oromia, Ethiopia. METHODOLOGY/PRINCIPAL FINDINGS: A total of 1211 individuals were enrolled from 247 households in Shashemene Rural district in Oromia Region between 11th April and 25th June 2018, of whom 628 (51.9%) were female and 526 (43.4%) were children aged 1-9 years. Three standardised ophthalmic nurses examined each participant for the presence of active trachoma using the WHO simplified trachoma grading system. Conjunctival swab samples were collected from the upper tarsal conjunctiva of the left eye of each participant. Ct was detected using quantitative PCR. Risk factor data were collected through structured interviews and direct observations. Clinical signs of trachomatous inflammation-follicular among children aged 1-9 (TF1-9) were observed in at least one eye of 106/526 (20.2%) and trachomatous inflammation-intense among children aged 1-9 (TI1-9) were observed in at least one eye of 10/526 (1.9%). We detected Ct by PCR in 23 individuals, of whom 18 (78.3%) were in children aged 1-9 years. Among the 106 children aged 1-9 years with TF, 12 (11.3%) were Ct PCR positive and among 20 children aged 1-9 years with TI, 4 (20.0%) were Ct PCR positive. In a multivariable model, adjusting for household clustering, active trachoma was associated with younger age, the poorest households (aOR = 2.56, 95% CI 1.21-5.51), presence of flies on the face (aOR = 2.87, 95% CI 1.69-6.46), and ocular discharge (aOR = 1.89, 95% CI 1.03-3.24). Pre-school children face washing more than once a day had lower odds of having active trachoma (aOR = 0.59, 95% CI 0.19-0.84). The same was true for washing children's clothing at least once per week (aOR = 0.27, 95% CI 0.33-1.02). CONCLUSION/SIGNIFICANCE: Younger age, personal hygiene in this age group (presence of ocular and nasal discharges, infrequent washing of faces and clothing) and fly-eye contacts are potential risk factors for trachoma in this setting, suggesting that hygiene interventions and environmental improvements are required to suppress transmission to ensure sustained reduction in disease burden Further studies are needed to evaluate these interventions for trachoma control and elimination. Trachoma remains a disease associated with lower socio-economic status, emphasising the need for continued implementation of control measures in addition to poverty reduction interventions in this region.
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Tracoma , Humanos , Femenino , Preescolar , Lactante , Niño , Masculino , Tracoma/microbiología , Etiopía/epidemiología , Chlamydia trachomatis , Factores de Riesgo , Inflamación , Conjuntiva , PrevalenciaRESUMEN
The prevalence of overweight and obesity is increasing among reproductive-age women in sub-Saharan Africa. Whether maternal body mass index (BMI) influences the risk of infant infections in low- and middle-income countries (LMIC) is uncertain. We used data from a birth cohort of 5344 HIV-unexposed Zimbabwean infants with available data on maternal BMI, to calculate rates of sick clinic visits for infections during the first 12 months postpartum, and adjusted hazard ratios (aHR) for each maternal BMI group. Compared to infants of mothers with normal BMI, the rate of sick clinic visits for any infection progressively rose among infants of overweight (aHR 1.05; 95%CI 0.99, 1.11) and obese women (aHR 1.15; 95%CI 1.05, 1.25). Excess clinic attendances were particularly due to skin, respiratory and ear infections. Maternal obesity may therefore influence infant infectious morbidity in LMIC over the first year after birth.
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Obesidad Materna , Índice de Masa Corporal , Femenino , Humanos , Lactante , Morbilidad , Sobrepeso/complicaciones , Sobrepeso/epidemiología , Embarazo , Zimbabwe/epidemiologíaRESUMEN
If facial hygiene practices vary seasonally this could have important implications for the design of interventions for trachoma control. This observational study was conducted to explore seasonal variation in hygiene behaviours in 9 households with at least one child aged 1-9 years-of-age in the West Arsi zone in rural Oromia, Ethiopia. Sixty-one household members were observed intensively over two days in the dry season (January), the rainy season (July) and during the harvest period (October) in 2018. Structured record forms were used to document household water availability and use. Daily water use per capita was very low in all seasons (3.1-4.2 litres). Around one third of water consumed in households in all seasons was associated with body washing. Soap was used during 44 of 677 (6%) of these observed occasions and half of all body washes (n = 340; 50%) included face washing. Overall, 95% of 58 individuals washed their faces at least once between 06:30h and 21:30h in the dry season (21% with soap), compared with 79% in the rainy season (2% with soap) (p = 0.013). Sixty-five percent of householders washed their faces during the harvest observation period (06:30h to 17:30h), none of whom used soap. Twenty-eight percent of 204 children aged 11 and under still had ocular or nasal discharge on their faces after washing. Seventy-three percent of those who washed their faces did so more than once in the dry season, compared with 33% in the rainy season (p<0.001). Face washing occurred throughout the day during the dry season, with a clear peak in the early morning and extra washes in the early evening. Face washing mainly took place in the early morning in the other two seasons. Genuine water scarcity in this area is likely to limit the impact of face washing interventions for trachoma control in the absence of water supply interventions. However, face washing was most common at the time of year when water is the hardest to come by, and seasonal differences in behaviour should be considered in any resulting intervention design.
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Enfermedades del Recién Nacido , Tracoma , Niño , Preescolar , Etiopía/epidemiología , Humanos , Higiene , Lactante , Recién Nacido , Factores de Riesgo , Estaciones del Año , Jabones , Tracoma/epidemiología , Tracoma/prevención & control , AguaRESUMEN
BACKGROUND: The study assessed the acceptability of internet-based Chlamydia screening using home-testing kits among 16- to 29-year-old participants and nonparticipants in the first year of a Chlamydia Screening Implementation program in the Netherlands. METHODS: Questionnaire surveys were administered to randomly selected participants (acceptability survey) and nonparticipants (nonresponse survey) in 3 regions of the Netherlands where screening was offered. Participants received email invitations to an online survey; nonparticipants received postal questionnaires. Both surveys enquired into opinions on the screening design, reasons for (non-) participation and future willingness to be tested. RESULTS: The response rate was 63% (3499/5569) in the acceptability survey and 15% (2053/13,724) in the nonresponse survey. Primary motivation for participating in the screening was "for my health" (63%). The main reason for nonresponse given by sexually active nonparticipants was "no perceived risk of infection" (40%). Only 2% reported nonparticipation due to no internet access. Participants found the internet (93%) and home-testing (97%) advantages of the program, regardless of test results. Two-thirds of participants would test again, 92% via the screening program. Half of nonparticipants were appreciative of the program design, while about 1 in 5 did not like internet usage, home-testing, or posting samples. CONCLUSIONS: The screening method was highly acceptable to participants. Nonparticipants in this survey were generally appreciative of the program design. Both groups made informed choices about participation and surveyed low-risk nonparticipants accurately perceived their low-risk status. Although many nonparticipants were not reached by the nonresponse survey, current insights on acceptability and nonresponse are undoubtedly valuable for evaluation of the current program.
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Infecciones por Chlamydia/diagnóstico , Internet , Tamizaje Masivo/métodos , Aceptación de la Atención de Salud , Negativa a Participar/psicología , Adolescente , Adulto , Infecciones por Chlamydia/epidemiología , Infecciones por Chlamydia/prevención & control , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Países Bajos/epidemiología , Participación del Paciente , Juego de Reactivos para Diagnóstico , Conducta Sexual , Enfermedades Bacterianas de Transmisión Sexual/diagnóstico , Enfermedades Bacterianas de Transmisión Sexual/epidemiología , Enfermedades Bacterianas de Transmisión Sexual/prevención & control , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs). METHODS: This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data. RESULTS AND CONCLUSIONS: Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.
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BACKGROUND: Trachoma elimination efforts are hampered by limited understanding of Chlamydia trachomatis (Ct) transmission routes. Here we aimed to detect Ct DNA at non-ocular sites and on eye-seeking flies. METHODS: A population-based household survey was conducted in Oromia Region, Ethiopia. Ocular and non-ocular (faces, hands, clothing, water containers and sleeping surfaces) swabs were collected from all individuals. Flies were caught from faces of children. Flies, ocular swabs and non-ocular swabs were tested for Ct by quantitative PCR. RESULTS: In total, 1220 individuals in 247 households were assessed. Active trachoma (trachomatous inflammation-follicular) and ocular Ct were detected in 10% and 2% of all-ages, and 21% and 3% of 1-9-year-olds, respectively. Ct was detected in 12% (95% CI:8-15%) of tested non-ocular swabs from ocular-positive households, but in none of the non-ocular swabs from ocular-negative households. Ct was detected on 24% (95% CI:18-32%) of flies from ocular-positive households and 3% (95% CI:1-6%) of flies from ocular-negative households. CONCLUSION: Ct DNA was detected on hands, faces and clothing of individuals living in ocular-positive households suggesting that this might be a route of transmission within Ct infected households. In addition, we detected Ct on flies from ocular-positive households and occasionally in ocular-negative households suggesting that flies might be a vector for transmission within and between Ct infected and uninfected households. These potential transmission routes may need to be simultaneously addressed to suppress transmission.
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Infecciones por Chlamydia/diagnóstico , Infecciones por Chlamydia/transmisión , Chlamydia trachomatis/aislamiento & purificación , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/transmisión , Transmisión de Enfermedad Infecciosa , Adolescente , Adulto , Animales , Niño , Preescolar , Chlamydia trachomatis/genética , Vestuario , Estudios Transversales , Dípteros/microbiología , Etiopía , Heces/microbiología , Femenino , Fómites/microbiología , Mano/microbiología , Humanos , Lactante , Masculino , Persona de Mediana Edad , Reacción en Cadena en Tiempo Real de la Polimerasa , Adulto JovenRESUMEN
Eye-to-eye transmission of Chlamydia trachomatis, the causative agent of trachoma, may be plausibly interrupted if faces are kept free of ocular and nasal discharge. Between April and June 2018, 83 children aged 1-9 years with active trachoma were recruited from 62 households and allocated to a face cleaning protocol: face washing with water, face washing with water and soap, or face wiping. Faces were examined for the presence of ocular and nasal discharge, and swabs were taken from faces and hands to test for C. trachomatis at baseline, immediately post protocol, and after 1, 2, and 4 hours (washing protocols). Washing with soap was more effective at removing ocular discharge than either washing with water (89% and 27% of discharge removed, respectively, P = 0.003) or wiping with a hand (42%, P = 0.013). The reduction in prevalence of ocular discharge was sustained for at least four hours. The prevalence of C. trachomatis on face swabs was reduced by all washing protocols. The importance of soap should not be overlooked during facial cleanliness promotion.
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Cara , Higiene , Tracoma/prevención & control , Niño , Preescolar , Humanos , Lactante , Proyectos Piloto , JabonesRESUMEN
Population movement is a major driver for infectious disease transmission and can impact the success of disease control and elimination strategies. The relationship between disease transmission and permanent migration is well documented, but fewer studies have considered how different types of population mobility affects disease transmission and control programmes. This qualitative study was conducted on two islands of the Bijagós archipelago, Guinea Bissau to understand spatial and temporal population movement, and reasons for these movements, within, between and away from the Bijagós islands. Data were collected on two islands using key informant interviews (nâ¯=â¯8), daily activity-location interviews (nâ¯=â¯30) and focus group discussions (nâ¯=â¯6). Data were analysed thematically using an adapted typology of mobility. Findings revealed that movement within and between islands, and from islands to the mainland, was a common feature of island life for men and women alike. It was usual for trips away from home to last for several months at a time. Five key reasons for travel were identified: subsistence activities; family events; income generating activities; cultural festivities and healthcare. These movements often occurred erratically all year round, with the exception of seasonal travel within and between islands for agricultural purposes. Our study characterised detailed patterns of human mobility in the Bijagós islands as a first step towards understanding the potential impact of different types of mobility on disease exposure, transmission and public health programmes. Short-term mobility may have a significant impact on the spread of infectious diseases with short incubation periods. Predictable movements, such as travel for seasonal agricultural work, should be taken into account for tailoring and increasing the reach of public health interventions. Further research is needed to understand the role of human behaviour and mobility in disease transmission and control across the archipelago.
Asunto(s)
Transmisión de Enfermedad Infecciosa , Enfermedades Desatendidas/epidemiología , Salud Pública , Viaje , Adulto , Anciano , Femenino , Grupos Focales , Guinea Bissau , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Investigación CualitativaRESUMEN
BACKGROUND: Trachoma is the leading infectious cause of blindness. However, little is known about the behavioural and environmental determinants of transmission of the causative organism, Chlamydia trachomatis. We conducted formative research in a trachoma hyper-endemic area of Ethiopia to explore the behaviours which are likely to contribute to trachoma transmission and map their determinants. METHODOLOGY/PRINCIPAL FINDINGS: Data on water use, hygiene, defecation, and sleeping arrangements were collected from five communities during the dry and rainy seasons in 2016. Data collection involved direct observation in households (n = 20), interviews with caregivers (n = 20) and focus group discussions (n = 11). Although several behaviours that likely contribute to trachoma transmission were identified, no single behaviour stood out as the dominant contributor. Hygiene practices reflected high levels of poverty and water scarcity. Face washing and soap use varied within and between households, and were associated with other factors such as school attendance. Children's faces were rarely wiped to remove nasal or ocular discharge, which was not perceived to be socially undesirable. Bathing and laundry were performed infrequently due to the amount of time and water required. Open defecation was a normative practice, particularly for young children. Latrines, when present, were poorly constructed, maintained and used. Young children and parents slept closely together and shared bedding that was infrequently washed. CONCLUSIONS/SIGNIFICANCE: Existing norms and enabling factors in this context favour the development of interventions to improve facial cleanliness as more feasible than those that reduce unsafe faeces disposal. Interventions to increase the frequency of bathing and laundry may also be infeasible unless water availability within the home is improved.
Asunto(s)
Higiene , Saneamiento/métodos , Tracoma/prevención & control , Tracoma/transmisión , Adolescente , Niño , Preescolar , Chlamydia trachomatis , Defecación , Salud Ambiental , Etiopía , Cara/microbiología , Composición Familiar , Femenino , Grupos Focales , Conductas Relacionadas con la Salud , Humanos , Lactante , Masculino , Factores de Riesgo , Población Rural , Tracoma/microbiologíaRESUMEN
Changing hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever's school-based "School of 5" handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts. We randomized a total of 32 villages with at least one eligible school to intervention and control groups (1:1) and recruited 338 households in each group for outcome measurement. We used structured observation in households to measure HWWS at target occasions (after defecation, soap use during bathing, and before each main meal) in schoolchildren and their mothers. Observers were blinded to intervention status. We observed 636 target occasions (297 in the intervention arm and 339 in the control arm) in mothers and school-going children. After the intervention, HWWS prevalence at target occasions was 22.4% in the control arm and 26.6% in the intervention arm (prevalence difference +4.4%, 95% confidence interval: -4.0, 12.8). The difference was similar in children and mothers. Observers appeared to be adequately blinded to intervention status, whereas observed households were successfully kept unaware of the purpose of observations. To conclude, we found no evidence for a health-relevant effect of the School of 5 intervention on HWWS in schoolchildren and their mothers. Qualitative research suggested that reasons for the low impact of the intervention included low campaign intensity, ineffective delivery, and a model possibly not well tailored to these challenging physical and social environments.