Measuring quality of life of adults with intellectual disabilities: Psychometric evaluation of the personal outcomes scale in the United Kingdom.

BACKGROUND: The Personal Outcomes Scale (POS) is a scale developed to measure quality of life of adults (18+) with intellectual disability. Previous studies have reported good fit for Spanish and Portuguese language versions of POS. AIMS: This study aimed to evaluate the factor structure of the English language version of POS when used to measure the quality of life of adults (18+) with intellectual disability in the UK. MATERIALS AND METHODS: Analysis was conducted on POS data from 310 adults with an intellectual disability. First and second order factor models and multi-level models were used to assess fit. RESULTS: There was poor fit to the data for all tested models. We estimated that 23% of variance in POS scores was accounted for by interviewer cluster. DISCUSSION: This was the first UK-based evaluation of POS and our data did not confirm the factor structure of the POS measure. The identification of systematic variability within the dataset indicates that inter-rater reliability is a potential limitation of the POS tool. CONCLUSION: Further research is needed to investigate inter-rater reliability of POS interviewers and to explore factor structure.

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.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia.

BACKGROUND: Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum. METHODS: Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours. RESULTS: Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge. CONCLUSIONS: Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial.

OBJECTIVES: To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children. METHODS: In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children's independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children's independent toothbrushing behaviour at home. RESULTS: Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857). CONCLUSIONS: Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children's uptake of independent hygiene behaviours.

Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria.

BACKGROUND: Newborns delivered in healthcare facilities in low- and middle-income countries are at an increased risk of healthcare associated infections. Facility-based studies have focused primarily on healthcare worker behaviour during labour & delivery with limited attention to hygiene practices in post-natal care areas and largely ignore the wide variety of actors involved in maternal and neonatal care. METHODS: This exploratory mixed-methods study took place in six healthcare facilities in Nigeria where 31 structured observations were completed during post-natal care, discharge, and the first 6 hours after return to the home. Frequency of hand hygiene opportunities and hand hygiene actions were assessed for types of patient care (maternal and newborn care) and the role individuals played in caregiving (healthcare workers, cleaners, non-maternal caregivers). Qualitative interviews with mothers were completed approximately 1 week after facility discharge. RESULTS: Maternal and newborn care were performed by a range of actors including healthcare workers, mothers, cleaners and non-maternal caregivers. Of 291 hand hygiene opportunities observed at health facilities, and 459 observed in home environments, adequate hand hygiene actions were observed during only 1% of all hand hygiene opportunities. Adequate hand hygiene prior to cord contact was observed in only 6% (1/17) of cord contact related hand hygiene opportunities at healthcare facilities and 7% (2/29) in households. Discharge advice was infrequent and not standardised and could not be remembered by the mother after a week. Mothers reported discomfort around telling non-maternal caregivers to practice adequate hand hygiene for their newborn. CONCLUSIONS: In this setting, hand hygiene practices during post-natal care and the first 6 hours in the home environment were consistently inadequate. Effective strategies are needed to promote safe hand hygiene practices within the post-natal care ward and home in low resource, high-burden settings. Such strategies need to target not just mothers and healthcare workers but also other caregivers.

Impact of an intervention to improve pit latrine emptying practices in low income urban neighborhoods of Maputo, Mozambique.

Safe fecal sludge management (FSM) - the hygienic emptying, transport, and treatment for reuse or disposal of fecal sludge - is an essential part of safely managed sanitation, especially in towns and cities in low- and middle-income countries with limited sewer coverage. The need for safe and affordable FSM services has become more acute as cities grow and densify. Hygienic pit-emptying uses equipment that limits direct human exposure with fecal sludge and hygienic transport conveys fecal sludge offsite for treatment. We evaluated whether a program of on-site sanitation infrastructure upgrades and FSM capacity development in urban Maputo, Mozambique resulted in more hygienic pit-emptying and safe transportation of fecal sludge. We compared reported emptying practices among multi-household compounds receiving sanitation upgrades with control compounds, both from the Maputo Sanitation (MapSan) trial at 24-36 months after the intervention. Intervention compounds (comprising 1-40 households, median = 3) received a subsidized pour-flush latrine to septic tank system that replaced an existing shared latrine; control compounds continued using existing shared latrines. We surveyed compound residents and analyzed available municipal data on FSM in the city. Due to the recent construction of the intervention, emptying was more frequent in control compounds: 5.6% (15/270) of intervention compounds and 30% (74/247) of controls had emptied their on-site sanitation system in the previous year. Among those compounds which had emptied a sanitation facility in the previous year, intervention compounds were 3.8 (95% CI: 1.4, 10) times more likely to have to done so hygienically. Results suggest that the construction of subsidized pour-flush sanitation systems increased hygienic emptying of fecal sludge in this setting. Further gains in hygienic emptying in urban Maputo may be limited by affordability and physical accessibility.

The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial.

BACKGROUND: Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level. METHODS: In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level. RESULTS: 20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality - between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035). CONCLUSION: Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure. TRIAL REGISTRATION: ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.

Behaviour settings theory applied to domestic water use in Nigeria: A new conceptual tool for the study of routine behaviour.

RATIONALE: Many behaviours relevant to public health are part of everyday routines. However, few tools exist to study such behaviours. Here we re-introduce the behaviour setting, an ecological psychological concept developed in the 1950s, as an approach to the study of routine behaviour. The setting concept bridges theoretical and applied approaches in sociology, psychology and social practice; its components include stage, infrastructure, props, roles, norms, competencies, objectives and resultant routines. METHODS: We applied settings theory to health-related water use behaviour in rural Nigeria. We captured the dimensions of water use behaviour settings in 23 households at varying distances from newly-introduced kiosks selling purified water. RESULTS: We found that routines concerning drinking, laundering, dish washing and handwashing were stable in their settings, varying little between households or by type of water source. Hygiene routines were suboptimal but drinking water was carefully segregated. The majority of water use behaviour was governed, not by an immediate desire to maximise health, but by long-established routines embedded in the social, technical and physical environment. Water kiosks are making only marginal improvements to the quantity and quality of water being used in homes. CONCLUSIONS: Improving public health will require the disruption of settings, for example, through bringing water infrastructure directly to the home, through the sale of new props that facilitate hygienic routines, or in the disruption of gender roles via the promotion of new norms. Settings are an ecologically valid, meso-level theoretical approach that link social and techno-physical environmental factors to behaviour. They provide a comprehensive framework within which to judge avenues for changing routine behaviours. The behaviour settings tool we developed was easy to use, provided a systematic means of capturing the determinants of routine behaviour, and the findings offered insight into methods for disrupting such behaviour.

Hygiene During Childbirth: An Observational Study to Understand Infection Risk in Healthcare Facilities in Kogi and Ebonyi States, Nigeria.

Background: Infections acquired during labour and delivery are a significant cause of maternal and child morbidity and mortality. Adherence to hand hygiene protocols is a critical component of infection prevention strategies, but few studies have closely examined the hand hygiene of health care providers with sufficient detail to understand infection risks and prioritize prevention strategies. Methods: This observational study was conducted in six healthcare facilities in Nigeria. In each, five women were observed from the onset of labour through to delivery of the placenta. Hand hygiene infection risk was estimated for all procedures requiring aseptic technique compared against adherence to proper hand hygiene protocol and potential recontamination events. Results: Hands were washed with soap and sterile gloves applied with no observed recontamination before only 3% of all observed procedures requiring aseptic technique. There was no significant difference in hygiene compliance between midwives and doctors nor facilities or states. Adherence to proper hygiene protocol was observed more in morning compared to afternoon and night shifts. Conclusions: This study highlights that hand hygiene remains a barrier to delivering high-quality and safe care in health facilities. Improving hygiene practices during labour and delivery will require strategies that extend beyond infrastructure provision.