Identifying Potential Determinants of Faecal Contamination on Domestic Floors in Three Settings in Rural Kenya: A Mixed Methods Analysis.

Observational evidence suggests that household floors may be an important domain for the transmission of enteric and parasitic infections. However, little work has been done to investigate how household floors can become contaminated with human and animal faeces. This study uses a mixed methods approach to postulate the proximal and distal determinants of household floor contamination with faeces in groups of rural villages in 3 counties in Kenya (Bungoma, Kwale and Narok). Quantitative data was collected through a household census and analysed descriptively and using mixed effects logistic regression models. Qualitative data was collected through unstructured observations of daily routines and in-depth interviews. These data were analysed thematically with case memos produced for routine activities that were hypothesised to be determinants of floor contamination. Possible proximal determinants of floor contamination included; (1) animal contact with floors; (2) child faeces disposal, and; (3) floor cleaning routines. Distal determinants are suggested to be rooted in the socioeconomic, environmental, and cultural context in which households were located and included; (1) the type and number of animals owned by households; (2) presence/absence of dedicated shelters for housing animals at night, which impacted whether sleeping or cooking areas were exposed to animals; (3) Accessibility of inside spaces to poultry and other roaming animals; (4) ownership of an improved floor; (5) ability of animals to access neighbours compounds; (6) seasonal changes in weather. These results will be of use in identifying the contexts in which faecal contamination of domestic floors may be contributing towards transmission of enteric and parasitic infections and in designing effective interventions to prevent this exposure.

Understanding the role of household hygiene practices and foodborne disease risks in child stunting: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: Environmental hygiene and food safety are important determinants of child stunting. This research aims to explore the relationship between child stunting and household hygiene practices and behaviours, including the availability of water, sanitation and hygiene (WASH) facilities; the use of safe food and good quality drinking water (especially when used for complementary feeding); hygienic practices in food transport, storage and preparation and the control of cross-contamination from animals, their produce and waste. METHODS AND ANALYSIS: This study is part of a wider observational study which aims to investigate the interdisciplinary factors contributing to child stunting using a 'whole child' paradigm. The observational study recruits women during pregnancy in Hyderabad, India, Lombok, Indonesia and Kaffrine, Senegal, and dyads (ie, 500 mother-infant pairs per country) are followed longitudinally up to 24 months after birth. Within the interdisciplinary niche, the study here has developed tools to investigate the potential exposure pathways to environmental pathogen contamination of foods and water. Holistic WASH and food safety data collection tools have been developed to explore exposure pathways at the household level, including: (1) survey questionnaires; (2) spot-checks; (3) biological sampling of drinking water, food and domestic surfaces and (4) direct observation. An integrated analytical approach will be used to triangulate the evidence in order to examine the relationships between child stunting, WASH and food safety behaviours. ETHICS AND DISSEMINATION: Ethical approval of the study was granted by the ethics committee of the LSHTM, RVC, ILRI, ICMR, IIPHG, SEAMEO-RECFON, University of Cheikh Anta Diop. Findings of the study will be disseminated through publication in peer-reviewed journals, relevant international conferences, public engagement events, and policy-maker and stakeholder events.

Recommendations for hand hygiene in community settings: a scoping review of current international guidelines.

BACKGROUND: Hand hygiene is an important measure to prevent disease transmission. OBJECTIVE: To summarise current international guideline recommendations for hand hygiene in community settings and to assess to what extent they are consistent and evidence based. ELIGIBILITY CRITERIA: We included international guidelines with one or more recommendations on hand hygiene in community settings-categorised as domestic, public or institutional-published by international organisations, in English or French, between 1 January 1990 and 15 November 2021. DATA SOURCES: To identify relevant guidelines, we searched the WHO Institutional Repository for Information Sharing Database, Google, websites of international organisations, and contacted expert organisations and individuals. CHARTING METHODS: Recommendations were mapped to four areas related to hand hygiene: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures. Recommendations were assessed for consistency, concordance and whether supported by evidence. RESULTS: We identified 51 guidelines containing 923 recommendations published between 1999 and 2021 by multilateral agencies and international non-governmental organisations. Handwashing with soap is consistently recommended as the preferred method for hand hygiene across all community settings. Most guidelines specifically recommend handwashing with plain soap and running water for at least 20 s; single-use paper towels for hand drying; and alcohol-based hand rub (ABHR) as a complement or alternative to handwashing. There are inconsistent and discordant recommendations for water quality for handwashing, affordable and effective alternatives to soap and ABHR, and the design of handwashing stations. There are gaps in recommendations on soap and water quantity, behaviour change approaches and government measures required for effective hand hygiene. Less than 10% of recommendations are supported by any cited evidence. CONCLUSION: While current international guidelines consistently recommend handwashing with soap across community settings, there remain gaps in recommendations where clear evidence-based guidance might support more effective policy and investment.

Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Acute respiratory infection (ARI) is a leading cause of morbidity and mortality globally, with 83% of ARI mortality occurring in low-income and middle-income countries (LMICs) before the COVID-19 pandemic. We aimed to estimate the effect of interventions promoting handwashing with soap on ARI in LMICs. METHODS: In our systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, Global Health, and Global Index Medicus for studies of handwashing with soap interventions in LMICs from inception to May 25, 2021. We included randomised and non-randomised controlled studies of interventions conducted in domestic, school, or childcare settings. Interventions promoting hand hygiene methods other than handwashing with soap were excluded, as were interventions in health-care facilities or the workplace. The primary outcome was ARI morbidity arising from any pathogen for participants of any age. Secondary outcomes were lower respiratory infection, upper respiratory infection, influenza confirmed by diagnostic test, COVID-19 confirmed by diagnostic test, and all-cause mortality. We extracted relative risks (RRs), using random-effects meta-analysis to analyse study results, and metaregression to evaluate heterogeneity. We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale, and assessed the overall body of evidence using a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The study is registered with PROSPERO, CRD42021231414. FINDINGS: 26 studies with 161 659 participants met inclusion criteria, providing 27 comparisons (21 randomised). Interventions promoting handwashing with soap reduced any ARI compared with no handwashing intervention (RR 0·83 [95% CI 0·76-0·90], I2 88%; 27 comparisons). Interventions also reduced lower respiratory infections (0·78 [0·64-0·94], I2 64%; 12 comparisons) and upper respiratory infections (0·74 [0·59-0·93], I2 91%; seven comparisons), but not test-confirmed influenza (0·94 [0·42-2·11], I2 90%; three comparisons), test-confirmed COVID-19 (no comparisons), or all-cause mortality (prevalence ratio 0·95 [95% CI 0·71-1·27]; one comparison). For ARI, no heterogeneity covariates were significant at p<0·1 and the GRADE rating was moderate certainty evidence. INTERPRETATION: Interventions promoting handwashing with soap can reduce ARI in LMICs, and could help to prevent the large burden of respiratory disease. FUNDING: Bill & Melinda Gates Foundation, Reckitt Global Hygiene Institute, and UK FCDO.

Nongovernmental Organization Practitioners' Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study.

BACKGROUND: Increasing handwashing with soap (HWWS) among older children (aged 5-14 years) can achieve a substantial public health impact. However, HWWS interventions targeting older children have had mixed success. Recent research has attempted to quantitatively identify effective intervention techniques; however, success is likely also influenced by the wider context of implementation. We explore nongovernmental organization (NGO) practitioners' perspectives on the challenges and solutions to HWWS interventions targeting older children to enhance understanding of what is required, beyond intervention content, for them to be effective. METHODS: We conducted in-depth, semistructured interviews in April-November 2020 with 25 practitioners employed across 11 NGOs and involved in HWWS interventions targeting older children in development and humanitarian settings. We used purposive and snowball sampling to recruit participants in roles at the global, national/regional, and local levels. Interviews were audio-recorded, transcribed, and thematically analyzed to identify challenges and solutions to HWWS interventions targeting older children. Results were organized according to program development cycle stages. RESULTS: Twelve themes relating to perceived challenges emerged: (1) lack of prioritization, (2) funding inconsistency, (3) insufficient formative research, (4) demand on resources, (5) unengaging intervention content, (6) non-enabling physical environments, (7) availability of skilled implementers, (8) reaching out-of-school children, (9) community mistrust, (10) lack of coordination, (11) lack of evaluation rigor, and (12) failure to assign older children's HWWS as a primary outcome in evaluations of hygiene interventions. Recommended solutions were at the intervention, organization, and sector levels. CONCLUSION: Intervention design and delivery are important for the success of HWWS interventions for older children, but contextual factors, such as the availability of human and material resources and the level of coordination within and beyond the NGO sector, should also be considered. NGOs need to prioritize HWWS promotion among older children and support programs accordingly.

A Mixed Methods Process Evaluation of a Food Hygiene Intervention in Low-Income Informal Neighbourhoods of Kisumu, Kenya.

OBJECTIVES: Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding. METHODS: A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation. RESULTS: The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02-1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91-6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours. CONCLUSION: Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other.

A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia.

Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.

Lively Minds: improving health and development through play-a randomised controlled trial evaluation of a comprehensive ECCE programme at scale in Ghana.

INTRODUCTION: Many children in developing countries grow up in environments that lack stimulation, leading to deficiencies in early years of development. Several efficacy trials of early childhood care and education (ECCE) programmes have demonstrated potential to improve child development; evidence on whether these effects can be sustained once programmes are scaled is much more mixed. This study evaluates whether an ECCE programme shown to be effective in an efficacy trial maintains effectiveness when taken to scale by the Government of Ghana (GoG). The findings will provide critical evidence to the GoG on effectiveness of a programme it is investing in, as well as a blueprint for design and scale-up of ECCE programmes in other developing countries, which are expanding their investment in ECCE programmes. METHODS AND ANALYSIS: This study is a cluster randomised controlled trial, in which the order that districts receive the programme is randomised. A minimum sample of 3240 children and 360 schools will be recruited across 72 district school cohort pairs. The primary outcomes are (1) child cognitive and socioemotional development measured using the International Development and Early Learning Assessment tool, the Strengths and Difficulties Questionnaire, and tasks from the Harvard Laboratory for Development Studies; (2) child health (measured using height/weight for age, height-for-weight Z scores). Secondary outcomes include (1) maternal mental health, (using Kessler-10 and Warwick Edinburgh Mental Wellbeing Scale) and knowledge of ECCE practices; (2) teacher knowledge, motivation and teaching quality (measured with classroom observation); (3) parental investment (using the Family Care Index and Home Observation Measurement of the Environment and the Child-Parent Relationship Scale); (4) water, sanitation, and hygiene (WASH) practices; (5) acute malnutrition (using mid-upper arm circumference). We will estimate unadjusted and adjusted intent-to-treat effects. ETHICS AND DISSEMINATION: Study protocols have been approved by ethics boards at the University College London (21361/001), Yale University (2000031549) and Ghanaian Health Service Ethics Review Committee (028/09/21). Results will be made available to participating communities, funders, the wider public and other researchers through peer-reviewed journals, conference presentations, social and print media and various community/stakeholder engagement activities. TRIAL REGISTRATION NUMBER: ISRCTN15360698, AEARCTR-0008500.

Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study.

OBJECTIVES: The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources. DESIGN: Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial . SETTING: Kisumu, Kenya. PARTICIPANTS: A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring. RESULTS: Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure. CONCLUSION: Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya. TRIAL REGISTRATION NUMBER: NCT03468114.

How are hygiene programmes designed in crises? Qualitative interviews with humanitarians in the Democratic Republic of the Congo and Iraq.

BACKGROUND: Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions-all of which may also be rapidly evolving. METHODS: We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings-one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed. RESULTS: Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered. CONCLUSION: Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes.

Does a school-based intervention to engage parents change opportunity for handwashing with soap at home? Practical experience from the Mikono Safi trial in Northwestern Tanzania.

BACKGROUND: School-based de-worming is advocated as a strategy for reducing the burden of soil-transmitted helminth (STH) infections among children. However, re-infection tends to occur rapidly, suggesting that comprehensive water, sanitation, and hygiene (WASH) improvements may be needed to prevent this. We qualitatively assessed the influence of parental engagement activities on parents' motivation to improve WASH infrastructure and hygiene practices at home in the context of a school-based de-worming programme. METHODOLOGY: We conducted a longitudinal qualitative study nested within the Mikono Safi trial, designed to assess the effect of a WASH intervention on STH infection prevalence in children. Meetings were organized for parents/guardians at schools where they were given information about STH infection, the role of WASH in STH infection prevention, and actionable steps they could take at home. During the meetings, parents/guardians received information about their own child's STH infection status. Twenty purposively selected households were visited and interviewed 3 times over a period of about 8-months. We employed thematic analysis; findings are reported following the Capability-Opportunity-Motivation and Behaviour (COM-B) framework. PRINCIPAL FINDINGS: The engagement strategy improved parents'/guardians' knowledge and skills about handwashing with soap and its benefits. Parents/guardians reported that the sessions had motivated them to improve WASH infrastructure at home. Of 20 households included in this study, 17 renovated or built new latrines and 18 installed handwashing facilities. However, only 8 households established and maintained handwashing stations with both soap and water at 8 months. CONCLUSIONS: The engagement of parents/guardians in a school-based WASH education intervention as part of the Mikono Safi trial resulted in increased knowledge and motivation about handwashing and sanitation. This led to improvements in sanitation facilities and handwashing opportunities at home. However, long-term success in provision of water and soap was limited, indicating that sustained engagement may be required to encourage households to ensure these materials are consistently available at home.

How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo.

BACKGROUND: Handwashing with soap has the potential to curb cholera transmission. This research explores how populations experienced and responded to the 2017 cholera outbreak in the Democratic Republic of the Congo and how this affected their handwashing behaviour. METHODS: Cholera cases were identified through local cholera treatment centre records. Comparison individuals were recruited from the same neighbourhoods by identifying households with no recent confirmed or suspected cholera cases. Multiple qualitative methods were employed to understand hand hygiene practices and their determinants, including unstructured observations, interviews and focus group discussions. The data collection tools and analysis were informed by the Behaviour Centred Design Framework. Comparisons were made between the experiences and practices of people from case households and participants from comparison households. RESULTS: Cholera was well understood by the population and viewed as a persistent and common health challenge. Handwashing with soap was generally observed to be rare during the outbreak despite self-reported increases in behaviour. Across case and comparison groups, individuals were unable to prioritise handwashing due to competing food-scarcity and livelihood challenges and there was little in the physical or social environments to cue handwashing or make it a convenient, rewarding or desirable to practice. The ability of people from case households to practice handwashing was further constrained by their exposure to cholera which in addition to illness, caused profound non-health impacts to household income, productivity, social status, and their sense of control. CONCLUSIONS: Even though cholera outbreaks can cause disruptions to many determinants of behaviour, these shifts do not automatically facilitate an increase in preventative behaviours like handwashing with soap. Hygiene programmes targeting outbreaks within complex crises could be strengthened by acknowledging the emic experiences of the disease and adopting sustainable solutions which build upon local disease coping mechanisms.

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.

Urban Water Access and Use in the Kivus: Evaluating Behavioural Outcomes Following an Integrated WASH Intervention in Goma and Bukavu, Democratic Republic of Congo.

Increasing the availability and reliability of community water sources is a primary pathway through which many water supply interventions aim to achieve health gains in communities with limited access to water. While previous studies in rural settings have shown that greater access to water is associated both with increased overall consumption of water and use of water for hygiene related activities, there is limited evidence from urban environments. Using data collected from 1253 households during the evaluation of a community water supply governance and hygiene promotion intervention in the cities of Goma and Bukavu, Democratic Republic of Congo, we conducted a secondary analysis to determine the impact of these interventions on household water collection and use habits. Using multiple and logistic regression models we compared differences in outcomes of interest between households in quartiers with and without the intervention. Outcomes of interest included litres per capita day (lpcd) of water brought to the household, lpcd used at the household, and lpcd used for hygiene-related activities. Results demonstrated that intervention households were more likely to use community tapstands than households located in comparison quartiers and collected on average 16.3 lpcd of water, compared with 13.5 lpcd among comparison households (adj. coef: 3.2, 95 CI: 0.84 to 5.53, p = 0.008). However, reported usage of water in the household for domestic purposes was lower among intervention households (8.2 lpcd) when compared with comparison households (9.4 lpcd) (adj. coef: -1.11, 95 CI: -2.29 to 0.07), p = 0.066) and there was no difference between study groups in the amount of water allocated to hygiene activities. These results show that in this setting, implementation of a water supply governance and hygiene promotion intervention was associated with a modest increase in the amount of water being bought to the household, but that this did not translate into an increase in either overall per capita consumption of water or the per capita amount of water being allocated to hygiene related activities.

Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique.

Two billion people globally lack access to a basic toilet. While improving sanitation reduces infectious disease, toilet users often identify privacy, safety and dignity as more important. However, these outcomes have not been incorporated in sanitation-related economic evaluations. This illustrates the general challenge of outcome measurement and valuation in the economic evaluation of public health interventions, and risks misallocating the US$ 20 billion invested in sanitation in low- and middle-income countries every year. In this study in urban Mozambique, we develop an instrument to measure sanitation-related quality of life (SanQoL). Applying methods from health economics and the capability approach, we develop a descriptive system to measure five attributes identified in prior qualitative research: disgust, health, shame, safety and privacy. Sampling individuals from the intervention and control groups of a sanitation intervention trial, we elicit attribute ranks to value a SanQoL index and assess its validity and reliability. In combination with a measure of time using a sanitation service, SanQoL can quantify incremental benefits in a sanitation-focused cost-effectiveness analysis. After monetary valuation based on willingness to pay, QoL benefits could be summed with health gains in cost-benefit analysis, the most common method in sanitation economic evaluations.

Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries.

INTRODUCTION: Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. METHODS: Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation. RESULTS: An estimated US$12.2-US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for 'top-up' promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%). CONCLUSION: The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Using path analysis to test theory of change: a quantitative process evaluation of the MapSan trial.

BACKGROUND: Although theory-driven evaluations should have empirical components, few evaluations of public health interventions quantitatively test the causal model made explicit in the theory of change (ToC). In the context of a shared sanitation trial (MapSan) in Maputo, Mozambique, we report findings of a quantitative process evaluation assessing intervention implementation, participant response and impacts on hypothesised intermediary outcomes on the pathway to trial health outcomes. We examine the utility of path analysis in testing intervention theory using process indicators from the intervention's ToC. METHODS: Process data were collected through a cross-sectional survey of intervention and control compounds of the MapSan trial > 24-months post-intervention, sampling adult residents and compound leaders. Indicators of implementation fidelity (dose received, reach) and participant response (participant behaviours, intermediary outcomes) were compared between trial arms. The intervention's ToC (formalised post-intervention) was converted to an initial structural model with multiple alternative pathways. Path analysis was conducted through linear structural equation modelling (SEM) and generalised SEM (probit model), using a model trimming process and grouped analysis to identify parsimonious models that explained variation in outcomes, incorporating demographics of respondents and compounds. RESULTS: Among study compounds, the MapSan intervention was implemented with high fidelity, with a strong participant response in intervention compounds: improvements were made to intermediary outcomes related to sanitation 'quality' - latrine cleanliness, maintenance and privacy - but not to handwashing (presence of soap / soap residue). These outcomes varied by intervention type: single-cabin latrines or multiple-cabin blocks (designed for > 20 users). Path analysis suggested that changes in intermediary outcomes were likely driven by direct effects of intervention facilities, with little contribution from hygiene promotion activities nor core elements expected to mediate change: a compound sanitation committee and maintenance fund. A distinct structural model for two compound size subgroups (≤ 20 members vs. > 20 members) explained differences by intervention type, and other contextual factors influenced specific model parameters. CONCLUSIONS: While process evaluation found that the MapSan intervention achieved sufficient fidelity and participant response, the path analysis approach applied to test the ToC added to understanding of possible 'mechanisms of change', and has value in disentangling complex intervention pathways. TRIAL REGISTRATION: MapSan trial registration: NCT02362932 Feb-13-2015.

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.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review.

BACKGROUND: Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear. OBJECTIVES: To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change. METHODS: We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising. RESULTS: Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'. CONCLUSIONS: Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

Hand hygiene intervention to optimise soil-transmitted helminth infection control among primary school children: the Mikono Safi cluster randomised controlled trial in northwestern Tanzania.

BACKGROUND: Soil-transmitted helminth (STH) infections are highly prevalent in resource-limited countries. We assessed the effect of a combination intervention aiming to enhance handwashing with soap on STH reinfection following mass drug administration among primary school children in Kagera region, Northwestern Tanzania. METHODS: We conducted a cluster randomised trial in sixteen primary schools with known high STH prevalence. Schools were randomly assigned in a 1:1 ratio to either receive the intervention or continue with routine health education. The intervention included teacher-led classroom teaching, parental engagement sessions, environmental modifications and improved handwashing stations. The evaluation involved two cross-sectional surveys in a representative sample of students, with the end-line survey conducted 12 months after the baseline survey. The primary outcome was the combined prevalence of Ascaris lumbricoides and Trichuris trichiura infections at the end-line survey. Secondary outcomes included reported handwashing behaviour, the prevalence and intensity of individual STHs, and hand contamination with STH ova and coliform bacteria. End-line STH prevalence and intensity were adjusted for baseline differences of potential confounders. RESULTS: At the end-line survey, 3081 school children (1566 from intervention schools and 1515 from control schools) provided interview data and stool specimens. More school children in the intervention group reported the use of water and soap during handwashing compared to school children in the control group (58% vs. 35%; aOR=1.76, 95%CI 1.28-2.43, p=0.001). The combined prevalence of A. lumbricoides and T. trichiura infections was 39% in both trial arms (aOR = 1.19; 95%CI 0.74-1.91). The prevalence of A. lumbricoides was 15% in the intervention and 17% in the control arm (aOR =1.24, 95%CI 0.59-2.59) and that of T. trichiura was 31% in both arms (aOR=1.17, 95%CI 0.73-1.88). No significant differences were found for STH infection intensity in both the main study and the hand contamination sub-study. CONCLUSIONS: The intervention was effective in increasing reported handwashing behaviour at school, but failed to show a similar effect in the home. The intervention had no effect on STH infection, possibly due to infection in the home environment, other transmission routes such as contaminated water or food or limited changes in school children's handwashing behaviour. TRIAL REGISTRATION: The trial was registered on June 21, 2017, by the International Standard Randomised Controlled Trial Number ( ISRCTN45013173) .