Water sanitation and hygiene at households and its implications on diarrhoea among under-five children of slums at field practice area of a Peripheral Medical College of West Bengal.

Background: Inadequate water, sanitation and hygiene (WASH) may lead to an increase in water-borne diseases like diarrhoea. The objective of the study was to assess water, sanitation and hygiene in the urban slums of Patpur, Bankura and to determine the implications of WASH on the occurrence of diarrhoea among under-five (U-5) children. Materials and Methods: A cross-sectional observational study was conducted during January-March 2020 by interviewing persons involved in water collection from each of the 182 slum households of Patpur, by two-stage sampling using a pre-designed structured schedule and the core questions on drinking WASH for household surveys: 2018 update by UNICEF and WHO. For testing the association between categorical variables, a Chi-square test was done. Binary logistic regression and the Hosmer Lemeshow test were done to know the predictors of diarrhoea in U-5 children. A P value of < 0.05 was considered statistically significant. Results: The proportion of diarrhoea among U-5 children was 0.34. Limited drinking WASH services were found in 3.30, 45.05 and 24.18% of households, respectively. Mobile objects users for handwashing were 14.05 times more prone to diarrhoea in U-5 children than those who had fixed handwashing facilities at their dwellings, yards or plots. Feeding children without handwashing had 5.70 times increased chances of diarrhoea among U-5 children than those who washed their hands before feeding. Conclusion: Handwashing facilities (fixed, mobile object or no facility) and handwashing with soap and water before feeding the child significantly affected the occurrence of diarrhoea among U-5 children.

Internal and External Barriers to Bladder Management in Persons with Neurologic Disease Performing Intermittent Catheterization.

People living with neurogenic lower urinary tract dysfunction (NLUTD) often have to use clean intermittent catheters (CIC) to manage their bladder function. The use of catheters presents multiple unique challenges, based on both the person's inherent characteristics and on the external limitations imposed by public toilets. We review the impact of age, sex, upper limb function, caregiver assistance, time required to perform CIC, and urinary incontinence on CIC in NLUTD, with special reference to their interaction with societal and public health factors. Public toilet limitations, such as lack of availability, adequate space and special accommodation for CIC, cleanliness, and catheter design are also reviewed. These potential barriers play a significant role in the perception and performance of bladder care in people living with NLUTD.

Association between Norovirus epidemics and school toilets design and management in Chengdu City / 中国学校卫生

Objective@#To analyze the relationship between the toilet design and sanitary condition of primary and secondary schools in Chengdu and the epidemic situation of Norovirus infection, so as to provide scientific references for school toilet design and Norovirus prevention and control.@*Methods@#A total of 78 cases of norovirus epidemics from 2019 to 2020 were included in this study. These epidemics happened in 78 schools and the causes were indicated as human-to-human transmission. The Chi square and Mann-Whitney U test were used to compare categorical and continuous data respectively. Unconditional binary Logistic regression was used to examine the multivariate associations.@*Results@#Most epidemics happened from October in 2019 to March in 2020(79.49%, 62 cases), in primary schools (71.79%, 56 cases) and in the center area (52.56%, 41 cases). The median of the case number in each epidemic was 10. Overall, 56 schools (71.79%) were equipped with toilets which were flushed independently, and 22 schools (28.21%) were equipped with toilets which were flushed uniformly. There were 27 schools (34.62%) that did not have enough water taps. Logistic regression analysis found that those with toilets flushed uniformly had a stronger epidemic, compared to the schools with toilets flushed independently( OR=5.53, 95%CI=1.63-18.76, P <0.05).@*Conclusion@#In order to prevent intestinal infectious diseases , it is suggested that schools should design or reconstruct independent flushing toilets with adequate faucets.

Lower Urinary Tract Symptoms and Related Factors in Iranian Female Nurses.

Background: Lower Urinary Tract Symptom (LUTS) are common among female nurses. High levels of job stress in nurses may be associated with the prevalence of these symptoms. This study aimed to investigate the prevalence of LUTS and factors related to these symptoms in female nurses. Materials and Methods: A cross-sectional study in which 460 nurses and nursing assistants participated was conducted. A questionnaire consisting of socio-demographic data, International Consultation on Incontinence Questionnaire - Female Lower Urinary Tract Symptoms, and Toileting Behavior - Women's Elimination Behavior Scale was used. Data analysis was performed by descriptive and inferential statistical tests at a significant level of p < 0.05. Results: The highest and lowest scores of LUTS were related to the urgency and nocturnal enuresis with a mean (SD) score of 1.85 (1.03) and 0.05 (0.26), respectively. Concerning toileting behaviors, the highest score was for the place preference for voiding with a mean (SD) score of 4.13 (0.66), which correlated with LUTS. Among controllable variables, years of practice, urinary tract infections, use of perineal pads for urinary leakage, lifting heavy objects at work, and medical history were identified as predictors of LUTS (p < 0.05). Conclusions: LUTS was highly prevalent in the female nurses. The results revealed that unhealthy toileting behaviors may contribute to the prevalence of LUTS. Early identification of these symptoms and the development of an educational intervention program to enhance the knowledge of healthy toileting behaviors may prevent the occurrence of urinary symptoms.

Assessing the prevalence of young children living in households prepared for COVID-19 in 56 low- and middle-income countries.

BACKGROUND: The COVID-19 pandemic and governments' attempts to contain it are negatively affecting young children's health and development in ways we are only beginning to understand and measure. Responses to the pandemic are driven largely by confining children and families to their homes. This study aims to assess the levels of and associated socioeconomic disparities in household preparedness for protecting young children under the age of five from being exposed to communicable diseases, such as COVID-19, in low- and middle-income countries (LMICs). METHODS: Using data from nationally representative household surveys in 56 LMICs since 2016, we estimated the percentages of young children under the age of five living in households prepared for communicable diseases (e.g., COVID-19) and associated residential and wealth disparities at the country- and aggregate-level. Preparedness was defined on the basis of space for quarantine, adequacy of toilet facilities and hand hygiene, mass media exposure at least once a week, and phone ownership. Disparities within countries were measured as the absolute gap in two domains-household wealth and residential area - and compared across regions and country income groups. RESULTS: The final data set included 766,313 children under age five. On average, 19.4% of young children in the 56 countries lived in households prepared for COVID-19, ranging from 0.6% in Ethiopia in 2016 to 70.9% in Tunisia in 2018. In close to 90% of countries (50), fewer than 50% of young children lived in prepared households. Young children in rural areas or in the poorest households were less likely to live in prepared households than their counterparts. CONCLUSIONS: A large portion of young children under the age of five in LMICs were living in households that did not meet all preparedness guidelines for preventing COVID-19 and caring for patients at home. This study highlights the need to ensure all families in LMICs have the means to prevent the spread of the pandemic or other communicable illnesses to young children during pandemics.

Situation of school toilets in rural areas of Laibin City in 2018 / 中国学校卫生

Objective@#To understand the sanitary condition of rural school toilets in Laibin City, and to provide scientific basis for the government and education departments to improve the sanitary condition of rural school toilets and to rebuild and build new harmless sanitary toilets.@*Methods@#The sanitary condition of toilets and feces treatment of the rural areas of 6 counties of Laibin City were thoroughly investigated through file review, on-site inspection and interviews.@*Results@#There were 36 schools without toilets, all of which were primary schools. Those schools distributed in Jinxiu County (31), accounting for 35.63% in its primary schools(31/87). Among the 651 schools with toilets, there were 1 559 sanitary toilets and 90 unsanitary toilets (all distributed in primary schools). and the percentage of unsanitary toilets in primary schools was that Jinxiu County 44.64% and Heshan City 31.25%. The proportion of sanitary toilets in teaching buildings, offices or dormitory buildings in primary schools, middle schools and nine-year schools was 77.36%, 94.20% and 30.95%, respectively. Hierarchical analysis found that outdoor toilets accounted for the largest proportion of middle schools in Xiangzhou County (72.46%), followed by nine-year schools in Xingbin District (71.79%). Among sanitary toilets, the proportion of harmless sanitary toilets was 95.51%, which was 100% in middle schools and nine-year schools, and 94.30% in primary schools. Four of the six counties (cities and districts) accounted for 100%, and the proportion of primary schools of Xingbin District was lowest, which accounted for 89.79%.@*Conclusion@#At present, the sanitary condition of toilets in rural schools in Laibin City has been obviously improved, but there are still many schools lack of toilets or sanitary toilets, in some counties (cities, districts), especially in primary schools. Quality of toilet management should be improved while strengthening the construction of harmless sanitary toilets in schools.

Availability of school health staff and health equipment in primary and secondary schools in Jinan / 中国学校卫生

Objective@#To understand the situation of school health staff and the allocation of health equipment in primary and secondary schools in Jinan.@*Methods@#A questionnaire survey was conducted in CDC and public primary and secondary schools to describe the situation of the school health staff and health equipment in primary and secondary schools.@*Results@#There were 23 school health staffs in CDC, among which 26.1% were full time. The total staffing ratio of school doctors was 13.9%, with the compliance rate of 19.8%. The total allocation rate of health care teachers was 74.7%, 92.2% of them were part time. The total staffing ratio of school doctors in boarding schools was 20.0%, with a staffing compliance rate of 12.5%. The total allocation rate of school doctors and health care teachers in boarding schools was 66.7%. 16.8% of public primary and secondary schools and 23.3% of public boarding primary and secondary schools did not have any health staffs. 27.6% of public primary and secondary schools are equipped with infirmary, 70.8% with health rooms, and 10.3% without any. The configuration of necessary equipment in infirmary and health care rooms were less than 100%.@*Conclusion@#There is a serious shortage of school health staffs and health equipment in primary and secondary schools in Jinan. Attention and investment in school health should be strengthened, and resources should be rationally allocated to ensure the health of primary and secondary school students.

Piloting an acceptable and feasible menstrual hygiene products disposal system in urban and rural schools in Bangladesh.

BACKGROUND: Access to washroom facilities and a place to dispose of menstrual waste are prerequisites for optimal menstrual hygiene management in schools. Like other low- and middle-income countries, Bangladeshi schools lack facilities for girls to change and dispose of their menstrual absorbents. We explored existing systems for disposing of menstrual absorbent wastes in urban and rural schools of Bangladesh and assessed the feasibility and acceptability of alternative disposal options. METHODS: We explored how girls dispose of their menstrual products, identified girls' preferences and choices for a disposal system and piloted four disposal options in four different schools. We then implemented one preferred option in four additional schools. We explored girls', teachers', and janitors' perspectives and evaluated the acceptability, feasibility, and potential for sustainability of the piloted disposal system. RESULTS: Barriers to optimal menstrual hygiene management included lack of functional toilets and private locations for changing menstrual products, and limited options for disposal. Girls, teachers, and janitors preferred and ranked the chute disposal system as their first choice, because it has large capacity (765 L), is relatively durable, requires less maintenance, and will take longer time to fill. During implementation of the chute disposal system in four schools, girls, teachers, and janitors reported positive changes in toilet cleanliness and menstrual products disposal resulting from the intervention. CONCLUSIONS: The chute disposal system for menstrual products is a durable option that does not require frequent emptying or regular maintenance, and is accepted by schoolgirls and janitors alike, and can improve conditions for menstrual hygiene management in schools. However, regular supervision, motivation of girls to correctly dispose of their products, and a long-term maintenance and management plan for the system are necessary.

Odour reduction interventions for simple pit latrines in rural Ethiopia: a randomized study.

Pit latrines are promoted in resource-limited settings, but unpleasant odours may deter their use. In this study, latrines in rural Ethiopia were randomized to the addition of cooking ash, the addition of boiling water or neither. Study staff ranked odour on a 6-point scale before and approximately 24 h after intervention. Following intervention, odour grades were on average 0.2 points lower (95% confidence interval [CI] 0.7 lower to 0.3 higher) in ash-treated latrines and 0.4 points lower (95% CI 0.9 lower to 0.1 higher) in boiled water-treated latrines, although the difference between the three groups was not statistically significant (p = 0.21). Larger studies might detect a smaller difference.

Women's Perceptions of Public Restrooms and the Relationships with Toileting Behaviors and Bladder Symptoms: A Cross-Sectional Study.

PURPOSE: Because current knowledge about public restroom use and bladder health is limited, we sought to identify why women avoid public restrooms and the associations of lower urinary tract symptoms and toileting behaviors. MATERIALS AND METHODS: Between October and December 2017 we recruited a convenience sample of U.S. women to complete a cross-sectional, anonymous questionnaire about public restroom use, lower urinary tract symptoms (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms [ICIQ-FLUTS]) and toileting behavior (Web-Based Toileting Behavior [TB-WEB]). We compared women who reported limiting public restroom use all or most of the time to those who did not limit or did so occasionally or sometimes. RESULTS: Of the 6,004 women in the study 26% limited public restroom use most or all of the time and were more concerned with cleanliness than those who did not limit public restroom use. They also reported more often using nonsitting positions when away from home and holding urine to avoid public restrooms, higher ICIQ-FLUTS scores, more frequent overactive bladder and fewer than 7 voids a day. CONCLUSIONS: A large number of women reported avoiding public restrooms, often over concerns of cleanliness, availability of amenities and privacy. Women who habitually limit public restroom use more frequently reported unhealthy toilet behaviors and lower urinary tract conditions. These findings will help guide future research and inform public policy and bladder health awareness.

Drinking water and toilet sanitation of rural schools in Anhui during 2014-2018 / 中国学校卫生

Objective@#To understand current status of drinking water and toilet sanitation in rural schools of Anhui Province, and to provide basic knowledge for environmental sanitation improvement among rural schools in Anhui.@*Methods@#One primary school and one secondary school from each of the 5 villages from 24 counties in Anhui were selected during 2014-2018. Data was collected through information review, on-site inspections and interviews.@*Results@#School water supply methods were mainly based on local water supply from villages and towns, the rate was 58.16%, 58.95%, 65.07%, 62.78%, 67.69% from 2014 to 2018, respectively. Self-supplied water in some schools was initially untreated. The proportion of schools with sanitary toilets was 66.39%, 74.88%，76.26%，82.30%，94.20% during 2014 to 2018, respectively. The proportion of schools with toilets in the teaching building is lower than 30%. Proportions of schools with squatting toilets for girls was highest in 2017 (62.78%). The number of schools with no water faucets and no soap decreased by year, the lowest of 4.02% and 56.70% in 2018.@*Conclusion@#During the past five years, improvement has been observed in drinking water supply in rural schools in Anhui Province, however, the construction of toilets and surrounding environmental facilities still needs to be strengthened. The number of female toilet squats and the number of toilets in the teaching building and in the dormitory are relatively insufficient. While increasing the scale of toilet construction, it is also necessary to strengthen the quality of toilet management, and should pay attention to the relevant health education to teachers and students.

Delaying voiding, limiting fluids, urinary symptoms, and work productivity: A survey of female nurses and midwives.

AIM: To examine the relationships between workplace bladder practices, urinary symptoms, and work productivity. DESIGN: Cross-sectional observational survey. METHODS: Surveys were distributed June-November 2016 to at least 600 female nurses and midwives at three urban hospitals in New South Wales, Australia. Nurses self-reported restricted workplace access to toilets, delaying voiding, limiting of fluid intakes and urinary symptoms at work. Logistic modelling was used to examine whether nurses' bladder practices impaired their time management, ability to concentrate or perform physical demands. RESULTS: Of 353 useable surveys, one in five nurses (22.4%; N = 79) reported restricted access to toilets at work, most (77.1%; N = 272) delayed voiding and one in four (26.9%; N = 95) limited fluid intakes to delay voiding at work. Almost half the sample had urinary symptoms at work (46.7%; N = 165); delaying voiding increased the likelihood of impaired mental concentration and limiting fluid intakes increased the likelihood of impaired time management. CONCLUSION: As workplace access to toilets and related bladder practices are modifiable, associated urinary symptoms and productivity loss may be preventable. IMPACT: Nurses' often experience restricted accesses to amenities due to job demands and workplace environments. The impact of nurses' poor bladder practices in the workplace is not known. In this study most nurses delayed voiding and many purposefully limited fluid intakes at work. These behaviours impacted a nurse's ability to manage time and/or concentrate at work. Results have implications for nurses' personal health, the design of workplace environments, workforce management, occupational health policy, and patient care.

An Internet of Things Buttons to Measure and Respond to Restroom Cleanliness in a Hospital Setting: Descriptive Study.

BACKGROUND: Restroom cleanliness is an important factor in hospital quality. Due to its dynamic process, it can be difficult to detect the presence of dirty restrooms that need to be cleaned. Using an Internet of Things (IoT) button can permit users to designate restrooms that need cleaning and in turn, allow prompt response from housekeeping to maintain real-time restroom cleanliness. OBJECTIVE: This study aimed to describe the deployment of an IoT button-based notification system to measure hospital restroom cleanliness reporting system usage and qualitative feedback from housekeeping staff on IoT button use. METHODS: We deployed IoT buttons in 16 hospital restrooms. Over an 8-month period, housekeeping staff received real-time notifications and responded to button presses for restroom cleaning. All button presses were recorded. We reported average button usage by hospital area, time of day, and day of week. We also conducted interviews with housekeeping supervisors and staff to understand their acceptance of and experience with the system. RESULTS: Over 8 months, 1920 requests to clean restrooms in the main hospital lobby and satellite buildings were received. The hospital lobby IoT buttons received over half (N=1055, 55%) of requests for cleaning. Most requests occurred in afternoon hours from 3 PM to midnight. Requests for cleaning remained stable throughout the work week with fewer requests occurring over weekends. IoT button use was sustained throughout the study period. Interviews with housekeeping supervisors and staff demonstrated acceptance of the IoT buttons; actual use was centered around asynchronous communication between supervisors and staff in response to requests to clean restrooms. CONCLUSIONS: An IoT button system is a feasible method to generate on-demand request for restroom cleaning that is easy to deploy and that users will consistently engage with. Data from this system have the potential to enable responsive scheduling for restroom service and anticipate periods of high restroom utilization in a hospital.

Toileting Behaviors and Bladder Symptoms in Women Who Limit Restroom Use at Work: A Cross-Sectional Study.

PURPOSE: While lower urinary tract symptoms and bladder behaviors are known to be associated with certain occupations, little is known about restroom access or environmental factors which may contribute to this relationship. We aimed to characterize reasons that women limit restroom use at work. We also sought to determine whether women who limit use at work report more unhealthy bladder habits and lower urinary tract symptoms. MATERIALS AND METHODS: We performed a cross-sectional study of full-time working women in the United States. Women completed validated questionnaires recording toileting behaviors, lower urinary tract symptoms and perceptions of the occupational toilet environment. We compared women who limited restroom use at work most or all of the time to those who did not limit or did so occasionally or sometimes. RESULTS: Of the 3,062 women in the final analytical sample 11% reported limiting restroom use at work most or all of the time. This group reported lower satisfaction with restroom cleanliness and privacy in particular. They more frequently identified toilet factors of poor quality, limited accessibility and restricted use by employer. The prevalence of unhealthy bladder habits was significantly higher among women who limited restroom use, as was the prevalence of urgency, monthly urinary incontinence and infrequent voiding. CONCLUSIONS: In this cross-sectional study of women working full time those who limited restroom use at work reported a higher prevalence of unhealthy bladder habits and certain urinary disorders. Future studies should determine whether limited restroom use at work is a modifiable risk factor for unhealthy bladder habits and bladder health outcomes.

Culture, teams, and organizations: A qualitative exploration of female nurses' and midwives' experiences of urinary symptoms at work.

AIM: To explore nurses' and midwives' experiences of urinary symptoms at work. BACKGROUND: Lower urinary tract symptoms are common in female nurses and midwives. There is limited understanding of the relationship between urinary symptoms, bladder health practices, and work. DESIGN: Qualitative design providing in-depth exploration of nurses' and midwives' experiences of urinary symptoms at work through focus group discussions. METHODS: Twelve focus groups were held July-September 2016 with 96 Registered Nurses and midwives working at two tertiary-referral hospitals in urban New South Wales, Australia. A semi-structured question schedule was used. An inductive process guided thematic analysis of data using a socioecological framework of health behaviours. RESULTS: Nurses' and midwives' experiences of urinary symptoms at work primarily relate to delaying voiding. This practice is explained by a work culture of "patient-first" care at expense of self-care, relationships in the nursing team, demands of the nursing role, and inadequacy of workplace amenities. The first two themes reflect cultural and social caring dilemmas central to nursing. The second two themes identify issues with workforce management and physical workplace environments. CONCLUSION: Nurses' and midwives' urinary symptoms and behaviours in response to sensory cues for bladder emptying are dependent on several socioecological influences. Occupational health initiatives in the workforce are required to break cultural norms that deter self-care and to promote work environments that support healthy bladder practices. Workforce management and physical workplace environments are key influences on nurses' timely and dignified access to amenities.

Rural school toilet sanitation in Chongqing during 2015-2017 / 中国学校卫生

Objective@#To understand rural school toilet sanitation conditions in Chongqing during the year of 2015 to 2017.@*Methods@#One primary school and one secondary school from each village were selected from five villages of each district. A total of 265 rural schools from 10 districts of Chongqing including 144 primary and 121 secondary schools were selected. Data was collected through access to information, field observations and onsite interview.@*Results@#The sanitation coverage rate was 78.45%, 92.99%, 100% from 2015 to 2017, respectively. The coverage rate in teaching building was the lowest(43.02%, 51.65% and 57.95% from 2015 to 2017, respectively). Male toilets in secondary schools showed high quality(92.38%, 92.86%, 100.00% for the year of 2015, 2016 and 2017, respectively). However, the quality of female toilets in middle schools was poor(33.33%, 53.06% and 68.00% for the year of 2015, 2016 and 2017, respectively). Daily sanitation management enhanced by year(29.07%, 40.66% and 69.32% during 2015 to 2017). Soap provision in school toilets decreased with year (53.49%, 40.66% and 1.14% for the year of 2015 to 2017, respectively).@*Conclusion@#In the past three years, sanitation condition of rural school toilets in Chongqing has significantly improved. However, toilets in the teaching buildings and dormitories are relatively insufficient. More femalefriendly toilet seats and daily sanitation management require further investment.

Toilet facilities and student toilet-using behavior in rural primary schools / 中国学校卫生

Objective@#To understand the current situation of toilet facilities among rural primary schools and toilet-using behavior among primary students,and to provide a reference for improving school environment.@*Methods@#Totally 149 students in 2 rural non-boarding primary schools in northern China were selected. and on-site observation and questionnaire survey were used to obtain the current situation of toilet hygiene, toilet time and toilet behavior, as well as feelings towards school toilet. The results of the survey were statistically analyzed by using SAS 9.4.@*Methods@#Both two schools were deep pit latrine, the number of pit in female toilets is lower than the requirements of the “Code for design of school”, and the urinal trough and the number of pit in male toilet meet the standard requirements. The average total time of toilet-using was (28.46±11.72)s for boys and (42.48±15.52)s for girls, the difference was of significant difference (t=-7.96, P<0.01). The average actual time of toilet-using is (24.27±9.13)s for boys and (24.69±9.40)s for girls, with no statistical difference. The result showed that school 2 was better than school 1 in the behavior of urinating frequency in toilet, queuing when using toilet, and the way to express needs of toilet-using in class(χ2=11.70,27.19,17.74,P<0.05); senior students use less toilets than lower grade students. The main complains for students in school toilet hygiene is its bad smell(χ2=5.28，13.18，P<0.05).@*Conclusion@#Primary school students in northern China always take bathroom breaks in the morning, and the average time of toilet-using is different from that of adults. Senior students are more willing to express their toilet needs than lower grade students. Students are not satisfied with the hygiene of school toilets, and the toilet experience is poor.

Beyond ADA Accessibility Requirements: Meeting Seniors' Needs for Toilet Transfers.

PURPOSE: To identify the optimal spatial and dimensional requirements of grab bars that support independent and assisted transfers by older adults and their care providers. BACKGROUND: Although research has demonstrated that toilet grab bars based on the Americans with Disabilities Act (ADA) Accessibility Standards do not meet the needs of older adults, the specific dimensional requirements for alternative configurations are unknown. METHODS: A two-phased study with older adults and care providers in residential facilities was conducted to determine the optimal requirements for grab bars. Seniors and caregivers in skilled nursing facilities performed transfers using a mock-up toilet. In Phase 1, participants evaluated three grab bar configurations to identify optimal characteristics for safety, ease of use, comfort, and helpfulness. These characteristics were then validated for using ability-matched samples in Phase 2. RESULTS: The optimal configuration derived in Phase 1 included fold-down grab bars on both sides of the toilet (14" from centerline [CL] of toilet, 32" above the floor, and extended a minimum of 6" in front of the toilet) with one side open and a sidewall 24" from CL of toilet on the other. Phase 2 feedback was significantly positive for independent and one-person transfers and somewhat lower, albeit still positive, for two-person transfers. CONCLUSION: The study provides substantial evidence that bilateral grab bars are significantly more effective than those that comply with current ADA Accessibility Standards. Findings provide specific spatial and dimensional attributes for grab bar configurations that would be most effective in senior facilities.

Drivers of sustained hygiene behaviour change: A case study from mid-western Nepal.

Behaviour change is central to the prevention of many population health problems, yet it is typically difficult to initiate and sustain. This paper reports on an evaluation of a water, sanitation and hygiene (WASH) intervention in mid-western Nepal, with particular focus on the drivers and barriers for handwashing with soap/ash and elimination of open defecation. The research was conducted during October-November 2014, two and half years following the intervention's end-point. Qualitative data were collected from the target community (n = 112) via group discussions, interviews and drawings/stories of 'most significant change'. Households' handwashing/water facilities and toilets were observed. Analysis was informed by a model that highlights environmental, psychosocial and technological factors that shape hygiene behaviours across multiple levels, from the habitual to the structural (Dreibelbis et al. 2013). Findings indicate the intervention has supported development of new norms around hygiene behaviours. Key drivers of sustained hygiene behaviour were habit formation, emotional drivers (e.g. disgust, affiliation), and collective action and civic pride; key constraints included water scarcity and socio-economic disadvantage. Identifying and responding to the drivers and constraints of hygiene behaviour change in specific contexts is critical to sustained behaviour change and population health impact.