The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial.

OBJECTIVE: To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households. METHODS: Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars. RESULTS: The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (-1%, 95% CI -2%/+0.3%), or the control arm (+0.4%, 95% CI -1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation. CONCLUSION: The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.

Experimental pretesting of hand-washing interventions in a natural setting.

OBJECTIVES: We pretested interventions derived from different domains of behavior change theory to determine their effectiveness at increasing hand washing with soap in a natural setting. METHODS: We installed wireless devices in highway service station restrooms to record entry and soap use. Two text-only messages for each of 7 psychological domains were compared for their effect on soap-use rates. We collected data on nearly 200 000 restroom uses. RESULTS: The knowledge activation domain was most effective for women, with a relative increase in soap use of 9.4% compared with the control condition (P = .001). For men, disgust was the most effective, increasing soap use by 9.8% (P = .001). Disgust was not significantly better than the control condition for women, nor was knowledge activation for men. Messages based on social norms and social status were effective for both genders. CONCLUSIONS: Our data show that unobtrusive observation of behavior in a natural setting can help identify the most effective interventions for changing behaviors of public health importance. The gender differences we found suggest that public health interventions should target men and women differently.

Dietary nutrient intakes and skin-aging appearance among middle-aged American women.

BACKGROUND: Nutritional factors play a key role in normal dermatologic functioning. However, little is known about the effects of diet on skin-aging appearance. OBJECTIVE: We evaluated the associations between nutrient intakes and skin-aging appearance. DESIGN: Using data from the first National Health and Nutrition Examination Survey, we examined associations between nutrient intakes and skin aging in 4025 women (40-74 y). Nutrients were estimated from a 24-h recall. Clinical examinations of the skin were conducted by dermatologists. Skin-aging appearance was defined as having a wrinkled appearance, senile dryness, and skin atrophy. RESULTS: Higher vitamin C intakes were associated with a lower likelihood of a wrinkled appearance [odds ratio (OR) 0.89; 95% CI: 0.82, 0.96] and senile dryness (OR: 0.93; 95% CI: 0.87, 0.99). Higher linoleic acid intakes were associated with a lower likelihood of senile dryness (OR: 0.75; 95% CI: 0.64, 0.88) and skin atrophy (OR: 0.78; 95% CI 0.65, 0.95). A 17-g increase in fat and a 50-g increase in carbohydrate intakes increased the likelihood of a wrinkled appearance (OR: 1.28 and 1.36, respectively) and skin atrophy (OR: 1.37 and 1.33, respectively). These associations were independent of age, race, education, sunlight exposure, income, menopausal status, body mass index, supplement use, physical activity, and energy intake. CONCLUSIONS: Higher intakes of vitamin C and linoleic acid and lower intakes of fats and carbohydrates are associated with better skin-aging appearance. Promoting healthy dietary behaviors may have additional benefit for skin appearance in addition to other health outcomes in the population.

Variability in hand contamination based on serial measurements: implications for assessment of hand-cleansing behavior and disease risk.

Measuring hand contamination at critical times, such as eating, can be challenging. We examined whether hand contamination measured at random, such as on arrival (initial), predicts contamination at critical times. Mothers of young children in Bangladesh rinsed both hands in 200 mL of Ringer's solution. We compared results of serial samples with respect to fecal coliform counts. Among 39 mothers, the geometric mean of fecal coliforms was 307 colony-forming units (cfu)/100 mL at initial collection and 3,001 cfu/100 mL during critical times (P = 0.0006). There was no correlation between initial and critical time fecal coliform counts (R = 0.13, P = 0.43). The mean difference between initial and critical time counts was 3.5 (standard deviation = 1.4) on the log base-10 scale. Contamination of the same subjects' hands varied substantially within a few hours. Because hand contamination measured at random cannot reliably predict hand contamination at times of potential pathogen transmission, single random hand rinses are not valid proxy measures for handwashing behavior.

Environmental and lifestyle factors associated with perceived facial age in Chinese women.

Perceived facial age has been proposed as a biomarker of ageing with 'looking young for one's age' linked to physical and cognitive functioning and to increased survival for Caucasians. We have investigated the environmental and lifestyle factors associated with perceived facial ageing in Chinese women. Facial photographs were collected from 250 Chinese women, aged 25-70 years in Shanghai, China. Perceived facial age was determined and related to chronological age for each participant. Lifestyle and health information was collected by questionnaire. Bivariate analyses (controlling for chronological age) identified and quantified lifestyle variables associated with perceived facial age. Independent predictors of perceived age were identified by multivariate modelling. Factors which significantly associated with looking younger for one's chronological age included greater years of education (p<0.001), fewer household members (p=0.027), menopausal status (p=0.020), frequency of visiting one's doctor (p=0.013), working indoors (p<0.001), spending less time in the sun (p=0.015), moderate levels of physical activity (p=0.004), higher frequency of teeth cleaning (p<0.001) and more frequent use of facial care products: cleanser (p<0.001); moisturiser (p=0.016) or night cream (p=0.016). Overall, 36.5% of the variation in the difference between perceived and chronological age could be explained by a combination of chronological age and 6 independent lifestyle variables. We have thus identified and quantified a number of factors associated with younger appearance in Chinese women. Presentation of these factors in the context of facial appearance could provide significant motivation for the adoption of a range of healthy behaviours at the level of both individuals and populations.

Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation.

Structured observation is often used to evaluate handwashing behavior. We assessed reactivity to structured observation in rural Bangladesh by distributing soap containing acceleration sensors and performing structured observation 4 days later. Sensors recorded the number of times soap was moved. In 45 participating households, the median number of sensor soap movements during the 5-hour time block on pre-observation days was 3.7 (range 0.3-10.6). During the structured observation, the median number of sensor soap movements was 5.0 (range 0-18.0), a 35% increase, P = 0.0004. Compared with the same 5-hour time block on pre-observation days, the number of sensor soap movements increased during structured observation by ≥ 20% in 62% of households, and by ≥ 100% in 22% of households. The increase in sensor soap movements during structured observation, compared with pre-observation days, indicates substantial reactivity to the presence of the observer. These findings call into question the validity of structured observation for measurement of handwashing behavior.