Does Poor Mental Health Impair the Effectiveness of Complementary Food Hygiene Behavior Change Intervention in Rural Malawi?

Mental disorders have the potential to affect an individual's capacity to perform household daily activities such as water, sanitation, and hygiene (food hygiene inclusive) that require effort, time, and strong internal motivation. However, there is limited detailed assessment about the influence of mental health on food hygiene behaviors at household level. We conducted a follow-up study to detect the effects of mental health on food hygiene behaviors after food hygiene intervention delivery to child caregivers in rural Malawi. Face-to-face interviews, based on the Risk, Attitude, Norms, Ability, and Self-regulations (RANAS) model, were conducted with 819 participants (control and intervention group) to assess their handwashing and food hygiene-related behaviors. Mental health was assessed using the validated Self-Reporting Questionnaire. Study results showed a significant negative relationship between mental health and handwashing with soap behavior (r = -0.135) and keeping utensils in an elevated place (r = -0.093). Further, a significant difference was found between people with good versus poor mental health on handwashing with soap behavior (p = 0.050) among the intervention group. The results showed that the influence of the intervention on handwashing with soap behavior was mediated by mental health. Thus, integration of mental health in food hygiene interventions can result in improved outcomes for caregivers with poor mental health.

How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq.

This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq-a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

A Nutrition Behavior Change Program Moderately Improves Minimum Diet Diversity and Handwashing Behaviors Among Tea Workers in Assam and Tamil Nadu, India.

Many workers in global supply chains remain nutritionally vulnerable despite the income they earn. The Seeds of Prosperity (SOP) program was implemented in Tamil Nadu and Assam, India, for tea supply chain workers (estate workers, small holder farmers, and farm workers). The aim was to enhance demand for diverse and nutritious foods and improve practices related to handwashing. The program used a behavior change communication approach wherein participants received weekly 1-hour group sessions with messaging on dietary diversity for 5 weeks and handwashing for 4 weeks. An impact evaluation was conducted to estimate changes in reported dietary and hygiene knowledge and behaviors among women. The study used a longitudinal quasi-experimental design in a subsample of program participants at baseline and post-intervention among both intervention and comparison. There was a small but significant increase in mean dietary diversity (DD) for all 4 worker groups (ranging from DD score changes of 0.3 to 0.7; P < .05) and in the proportion of women meeting the minimum dietary diversity in 2 of the 4 groups. Similarly, a significant increase in the mean number of handwashing moments was observed in 2 of the worker groups. An increase in home garden use was observed in 1 of the 4 worker groups. While the SOP program resulted in improvements in dietary diversity, most tea farming women still do not achieve minimum dietary diversity. Nutritious food access may be an important constraint to further improvement.

Lessons from COVID-19 pandemic: teaching midwifery at the national level in Sierra Leone in the pandemic and post pandemic

The contents of this article are drawn from personal experiences and National response by the Ministry of Health and Sanitation during the COVID-19 pandemic in the midst of teaching in a midwifery training school. Teaching Midwifery in COVID-19 Pandemic and Post Pandemic periods impacted on the way student midwives were taught. Contextual issues are highlighted during the COVID-19 Pandemic in the Midwifery Education profession. But more speciacally, the impact of Covid-19 on midwifery education basically around the way students were taught, classroom spacing rearrangement and institutionalizing national protocols and guidelines on prevention of COVID-19 spread among staff and students.

Embracing challenging complexity: exploring handwashing behavior from a combined socioecological and intersectional perspective in Sierra Leone.

BACKGROUND: Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior. METHODS: This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data. RESULTS: The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions. CONCLUSION: This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital).

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study.

BACKGROUND: Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility -based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants. METHODS: This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours. RESULTS: Birth attendants' compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants' qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives' hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception. CONCLUSION: The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants' hand hygiene compliance in our study settings.

COVID-19: The experience from Iran.

The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology.

A holistic approach to promoting early child development: a cluster randomised trial of a group-based, multicomponent intervention in rural Bangladesh.

INTRODUCTION: In low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention. METHODS: We conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions ('group'); alternating groups and home visits ('combined'); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers. RESULTS: In July-August 2017, 621 pregnant women and primary caregivers of children<15 months were enrolled (group n=160, combined n=160, control n=301). At endline, immediately following intervention completion (July-August 2018), 574 participants were assessed (group n=144, combined n=149, control n=281). Primary caregivers in both intervention arms participated in more play activities than control caregivers (age-adjusted means: group 4.22, 95% CI 3.97 to 4.47; combined 4.77, 4.60 to 4.96; control 3.24, 3.05 to 3.39), and provided a larger variety of play materials (age-adjusted means: group 3.63, 3.31 to 3.96; combined 3.81, 3.62 to 3.99; control 2.48, 2.34 to 2.59). Compared with the control arm, children in the group arm had higher total ASQi scores (adjusted mean difference in standardised scores: 0.39, 0.15 to 0.64), while in the combined arm scores were not significantly different from the control (0.25, -0.07 to 0.54). CONCLUSION: Our findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale. TRIAL REGISTRATION NUMBER: The trial is registered in ISRCTN (ISRCTN16001234).

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi.

BACKGROUND: Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES: To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS: This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS: We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS: The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

"Was I asking for it?": An experimental investigation of perceived responsibility, mental contamination and workplace sexual harassment.

BACKGROUND AND OBJECTIVES: Mental contamination (i.e., contamination concerns that arise in the absence of direct contact with a contaminant) is a common symptom in obsessive-compulsive disorder (OCD). Cognitive theories suggest that it results from individuals' misinterpretations of perceived violations. Cognitive theories of OCD also highlight the importance of appraisals of inflated responsibility in the maintenance of other OCD symptoms. However, the role of responsibility in mental contamination has not yet been examined experimentally. The present study examined the role of perceived responsibility and violation in the relationship between workplace sexual harassment imagery and subsequent mental contamination. METHODS: One hundred and forty-nine participants listened to a workplace sexual harassment imagery task, wherein responsibility was manipulated. Participants were randomly assigned to one of three conditions (high responsibility (HR), low responsibility (LR), no responsibility (NR)). Participants completed questionnaires assessing mental contamination and completed a hand washing task. RESULTS: Those in the NR condition reported significantly lower levels of responsibility than those in the LR or HR conditions. Accordingly, those in the NR condition also reported significantly lower levels of anxiety and dirtiness than in the LR condition. There were no significant differences between the LR and HR condition on variables of interest. LIMITATIONS: The nature of the victim blaming used for the responsibility induction may have elicited compensatory responses from participants. CONCLUSIONS: Findings may highlight the central role of perceptions of violation in the understanding and treatment of mental contamination.