Pilot of a Low-Cost Elementary School Handwashing Intervention in Bangladesh: Acceptability, Feasibility, and Potential for Sustainability.

Schoolchildren frequently transmit respiratory and gastrointestinal infections because of dense person-to-person contact in schools. We piloted a low-cost handwashing intervention among elementary schoolchildren in Bangladesh. We trained teachers to lead behavior change communication sessions using flipcharts to encourage students' handwashing before eating, after defecating, and after cleaning school toilets; provided handwashing stations (reservoirs with taps and stool + basin + soapy water solution [mix of 30 gm detergent with 1.5 L water] + pump top bottle with steel holder); and formed hygiene committees for maintenance and covering the recurrent cost of detergent. We evaluated intervention acceptability, feasibility, and potential for sustainability at 1 and 14 months after the intervention. At baseline, of 300 before eating events, no one washed hands with soap, and 99.7% (299) did not wash hands at all as soap was unavailable. Out of 269 after toileting events, 0.7% (2) washed hands with soap, and 88% (237) did not wash hands. After 4 weeks of the intervention, 45% (87/195 before eating events), 83% (155/186 after toileting events), and 100% (15/15 after cleaning toilet events) washed both hands with soapy water as children found it accessible, low cost, and child friendly. After 14 months, 9.4% (55/586 before eating events) and 37% (172/465 after toileting events) washed both hands with soapy water for health benefits. The intervention was acceptable and feasible; it overcame limited access to soap and water and was affordable as schools covered the recurrent costs of detergent. Further research should explore long-term habit adoption and impact on health and attendance.

Pathways to antibiotics in Bangladesh: A qualitative study investigating how and when households access medicine including antibiotics for humans or animals when they are ill.

BACKGROUND: To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals. METHODS: In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines. FINDINGS: People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important. CONCLUSIONS: In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people.

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.