What can machine learning teach us about habit formation? Evidence from exercise and hygiene.

We apply a machine learning technique to characterize habit formation in two large panel data sets with objective measures of 1) gym attendance (over 12 million observations) and 2) hospital handwashing (over 40 million observations). Our Predicting Context Sensitivity (PCS) approach identifies context variables that best predict behavior for each individual. This approach also creates a time series of overall predictability for each individual. These time series predictability values are used to trace a habit formation curve for each individual, operationalizing the time of habit formation as the asymptotic limit of when behavior becomes highly predictable. Contrary to the popular belief in a "magic number" of days to develop a habit, we find that it typically takes months to form the habit of going to the gym but weeks to develop the habit of handwashing in the hospital. Furthermore, we find that gymgoers who are more predictable are less responsive to an intervention designed to promote more gym attendance, consistent with past experiments showing that habit formation generates insensitivity to reward devaluation.

Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis.

National action plans enumerate many interventions as potential strategies to reduce the burden of bacterial antimicrobial resistance (AMR). However, knowledge of the benefits achievable by specific approaches is needed to inform policy making, especially in low-income and middle-income countries (LMICs) with substantial AMR burden and low health-care system capacity. In a modelling analysis, we estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337 000 (95% CI 250 200-465 200) AMR-associated deaths annually. Ensuring universal access to high-quality water, sanitation, and hygiene services would prevent 247 800 (160 000-337 800) AMR-associated deaths and paediatric vaccines 181 500 (153 400-206 800) AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. These estimates translate to prevention of 7·8% (5·6-11·0) of all AMR-associated mortality in LMICs by infection prevention and control, 5·7% (3·7-8·0) by water, sanitation, and hygiene, and 4·2% (3·4-5·1) by vaccination interventions. Despite the continuing need for research and innovation to overcome limitations of existing approaches, our findings indicate that reducing global AMR burden by 10% by the year 2030 is achievable with existing interventions. Our results should guide investments in public health interventions with the greatest potential to reduce AMR burden.

Drug-resistant bacterial infections: We need urgent action and investment that focus on the weakest link.

Despite high mortality and morbidity, drug-resistant bacterial infections remain the forgotten pandemic. We argue for strengthening of diagnostics, WASH (water, sanitation, and hygiene) and infection prevention and control to reduce drug-resistant infections, as an integral part of sustainable high-quality health services, particularly in low- and middle-income countries.

Dissecting Water, Sanitation, and Hygiene (WaSH) to Assess Risk Factors for Cholera in Shashemene, Oromia Region, Ethiopia.

BACKGROUND: Cholera outbreaks have afflicted Ethiopia, with nearly 100 000 cases and 1030 deaths reported from 2015 to 2023, emphasizing the critical need to understand water, sanitation, and hygiene (WaSH) risk factors. METHODS: We conducted a cross-sectional household (HH) survey among 870 HHs in Shashemene Town and Shashemene Woreda, alongside extracting retrospective cholera case data from the Ethiopian Public Health Institute database. Relationships between WaSH and sociodemographic/economic-levels of HHs were examined. WaSH status and cholera attack rates (ARs) were described at kebele-level using geospatial mapping, and their association was statistically analyzed. RESULTS: Access to basic drinking water, sanitation, and hygiene facilities was limited, with 67.5% (95% confidence interval, 64.4-70.6), 73.4% (70.3-76.3), and 30.3% (27.3-33.3) of HHs having access, respectively. Better WaSH practices were associated with urban residence (adjusted odds ratio, 1.7, [95% confidence interval, 1.1-2.7]), higher educational levels (2.7 [1.2-5.8]), and wealth (2.5 [1.6-4.0]). The association between cholera ARs and at least basic WaSH status was not statistically significant (multiple R2 = 0.13; P = .36), although localized effects were suggested for sanitation (Moran I = 0.22; P = .024). CONCLUSIONS: Addressing gaps in WaSH access and hygiene practices is crucial for reducing cholera risk. Further analyses with meaningful covariates and increased sample sizes are necessary to understand the association between cholera AR and specific WaSH components.

Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria.

BACKGROUND: Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited. METHODS AND FINDINGS: We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group. CONCLUSIONS: CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.

Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes.

BACKGROUND: Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels. METHODS: We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure-response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH. FINDINGS: We estimate that 1·4 (95% CI 1·3-1·5) million deaths and 74 (68-80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65-0·72), 0·14 (0·13-0·17) for acute respiratory infections, and 0·10 (0·09-0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH. INTERPRETATION: WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns. FUNDING: WHO and Foreign, Commonwealth & Development Office.

Impact of a school-based water and hygiene intervention on child health and school attendance in Addis Ababa, Ethiopia: a cluster-randomised controlled trial.

BACKGROUND: School-based water, sanitation and hygiene (WASH) may improve the health and attendance of schoolchildren, particularly post-menarcheal girls, but existing evidence is mixed. We examined the impact of an urban school-based WASH programme (Project WISE) on child health and attendance. METHODS: The WISE cluster-randomised trial, conducted in 60 public primary schools in Addis Ababa, Ethiopia over one academic year, enrolled 2-4 randomly selected classes per school (~ 100 pupils) from grades 2 to 8 (aged 7-16) in an 'open cohort'. Schools were assigned 1:1 by stratified randomisation to receive the intervention during the 2021/2022 or the 2022/2023 academic year (waitlist control). The intervention included improvements to drinking water storage, filtration and access, handwashing stations and behaviour change promotion. Planned sanitation improvements were not realised. At four unannounced classroom visits post-intervention (March-June 2022), enumerators recorded primary outcomes of roll-call absence, and pupil-reported respiratory illness and diarrhoea in the past 7 days among pupils present. Analysis was by intention-to-treat. RESULTS: Of 83 eligible schools, 60 were randomly selected and assigned. In total, 6229 eligible pupils were enrolled (median per school 101.5; IQR 94-112), 5987 enrolled at study initiation (23rd November-22nd December 2021) and the remaining 242 during follow-up. Data were available on roll-call absence for 6166 pupils (99.0%), and pupil-reported illness for 6145 pupils (98.6%). We observed a 16% relative reduction in odds of pupil-reported respiratory illness in the past 7 days during follow-up in intervention vs. control schools (aOR 0.84; 95% CI 0.71-1.00; p = 0.046). There was no evidence of effect on pupil-reported diarrhoea in the past 7 days (aOR 1.15; 95% CI 0.84-1.59; p = 0.39) nor roll-call absence (aOR 1.07; 95% 0.83-1.38; p = 0.59). There was a small increase in menstrual care self-efficacy (aMD 3.32 on 0-100 scale; 95% CI 0.05-6.59), and no evidence of effects on other secondary outcomes. CONCLUSIONS: This large-scale intervention to improve school WASH conditions city-wide had a borderline impact on pupil-reported respiratory illness but no effect on diarrhoeal disease nor pupil absence. Future research should establish relationships between WASH-related illness, absence and other educational outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT05024890.

The baseline immunological and hygienic status of pigs impact disease severity of African swine fever.

African Swine Fever virus (ASFV) is a large double-enveloped DNA virus of the Asfarviridae family that causes a lethal hemorrhagic disease in domestic pigs and wild boars. Since 2007, a highly virulent genotype II strain has emerged and spread in Europe and South-East Asia, where millions of animals succumbed to the disease. Field- and laboratory-attenuated strains of ASFV cause highly variable clinical disease severity and survival, and mechanisms remain unclear. We hypothesized that the immunological and hygienic status of pigs is a determinant of ASF disease course. Here we compared the immunological profile at baseline and in response to ASFV infection in specific pathogen-free (SPF) and farm-raised Large White domestic pigs. At steady state, SPF pigs showed lower white blood cell counts and a lower basal inflammatory and antiviral transcriptomic profile compared to farm pigs, associated with profound differences in gut microbiome composition. After inoculation with a highly virulent ASFV genotype II strain (Armenia 2008), severe clinical signs, viremia and pro-inflammatory cytokines appeared sooner in SPF pigs, indicating a reduced capacity to control early virus replication. In contrast, during infection with an attenuated field isolate (Estonia 2014), SPF pigs presented a milder and shorter clinical disease with full recovery, whereas farm pigs presented severe protracted disease with 50% lethality. Interestingly, farm pigs showed higher production of inflammatory cytokines, whereas SPF pigs produced more anti-inflammatory IL-1ra early after infection and presented a stronger expansion of leukocytes in the recovery phase. Altogether, our data indicate that the hygiene-dependent innate immune status has a double-edge sword impact on immune responses in ASF pathogenesis. While the higher baseline innate immune activity helps the host in reducing initial virus replication, it promotes immunopathological cytokine responses, and delays lymphocyte proliferation after infection with an attenuated strain. Such effects should be considered for live vaccine development and vigilance.

Identification and antimicrobial susceptibility profiles of Staphylococcus species isolated from raw cow milk, and swabs in smallholder dairy farms in Meta district, Eastern Ethiopia.

BACKGROUND: The safety of milk production in terms of foodborne infections is a worldwide issue, particularly in developing countries where production is often unhygienic. A cross-sectional study was conducted from December 2018 to August 2019 in the Meta District of Eastern Hararghe Zone, Oromia Regional State, Ethiopia. We aim to assess milk hygiene practices among smallholder dairy farmers, estimate the prevalence of Staphylococcus aureus in raw cow milk and swabs, assess associated risk factors, and the antimicrobial susceptibility test of S. aureus isolates. Face-to-face interviews with 30 respondents randomly selected from smallholder dairy farmers were used to assess the potential risk factors for S. aureus contaminations in milk. A total of 177 samples were examined using standard microbiological testing. The disc diffusion technique was also employed to assess the antibiotic susceptibility of the isolates. The data was analyzed using STATA® version 14.0 statistical software. RESULTS: According to the milk hygiene assessment, 80% of respondents did not wash cow udder before milking, did not use detergent to clean milk containers, and did not keep milk refrigerated before consumption or sale, while 63.3% of milk consumers ingested raw milk. They had never heard of staphylococci foodborne disease. Likewise, the overall prevalence of S. aureus was 12.42% (95%CI: 8.32-18.98). The prevalence of S. aureus in udder milk, equipment swabs, and milkers' hands was 18.8%, 26.7%, and 30%, respectively. The prevalence of S. aureus in milk is significantly associated with age, and mastitis history (p < 0.05). Moreover, old and mastitis positive animals were eight (OR: 8.40; 95%CI: 1.68-41.89) and four (OR: 4.33; 95%CI: 1.37-13.66) times more likely to be infected by S. aureus than adult, and mastitis negative animal. The isolates were resistant to penicillin G (97.4%) and tetracycline (69.2%) whereas susceptible to kanamycin, streptomycin, vancomycin, and cefotaxime, at 84.6%, 71.8%, 64%, and 58.8%, respectively. CONCLUSION: This study revealed the presence of antimicrobial-resistant patterns of S. aureus on commonly used antibiotics, as well as inadequate milk handling practices in the study area. Thus, awareness should be created on proper milk handling and hygiene as well as appropriate uses of antibiotics should be encouraged.

Carl Flügge, one of the last holistic hygienists and discoverer of droplet transmission of infectious diseases.

Carl Flügge is best known for the promotion of studies demonstrating the transmission of all manner of infections, but particularly tuberculosis, by coughed droplets. But it is seldom recognised that Flügge was also influential in a number of other fields comprising the practice of hygiene. One-hundred years following his death in 1923, we review literature related to the studies of Flügge and his colleagues and students and illustrate the particular emphasis he laid upon the environment within which disease and its transmission might be fostered or prevented, embracing and studying aspects essential to the health of any community ranging from fundamental microbiology in the laboratory to subjects as disparate as housing, clean water supply, nutrition, sanitation, socio-economic circumstances and climate. Very early in his career he promoted breast feeding for the prevention of seasonal gastro-enteritis and later the sheltering of cough as a means of preventing the transmission of infected respiratory droplets, not only as regards tuberculosis, but also concerning all manner of other respiratory infections. By the time of Flügge's death the complexification of available scientific methodologies comprising hygiene made it difficult for any individual to comprehend and study the wide range of hygiene-related subjects such as Flügge did. Carl Flügge was one of the last holistic hygienists and an originator of the study of environmental health as a pillar of hygiene.

How Does Personal Hygiene Influence Indoor Air Quality?

Humans are known to be a continuous and potent indoor source of volatile organic compounds (VOCs). However, little is known about how personal hygiene, in terms of showering frequency, can influence these emissions and their impact on indoor air chemistry involving ozone. In this study, we characterized the VOC composition of the air in a controlled climate chamber (22.5 m3 with an air change rate at 3.2 h-1) occupied by four male volunteers on successive days under ozone-free (∼0 ppb) and ozone-present (37-40 ppb) conditions. The volunteers either showered the evening prior to the experiments or skipped showering for 24 and 48 h. Reduced shower frequency increased human emissions of gas-phase carboxylic acids, possibly originating from skin bacteria. With ozone present, increasing the number of no-shower days enhanced ozone-skin surface reactions, yielding higher levels of oxidation products. Wearing the same clothing over several days reduced the level of compounds generated from clothing-ozone reactions. When skin lotion was applied, the yield of the skin ozonolysis products decreased, while other compounds increased due to ozone reactions with lotion ingredients. These findings help determine the degree to which personal hygiene choices affect the indoor air composition and indoor air exposures.

Personal hygiene practice and associated factors among elementary school students in Fiche Town, Oromia, Ethiopia.

BACKGROUND: Students in school are more likely to be sick from communicable diseases like diarrheal illnesses, acute respiratory infections, and other illnesses linked to poor personal hygiene. Poor hygiene practices are common among school children and put their health at risk, which in turn has several consequences. These include significant school absences, transmission of infectious diseases to other students, and missed workdays for parents and guardians. However, there is limited evidence on the level of personal hygiene practice and its associated factors among school students. Thus, this study was aimed at determining personal hygiene practice level and its associated factors among elementary school grade (5-8) students in Fiche town, Oromia, Ethiopia, in 2022. METHODS: A cross-sectional study design was conducted from April 29 to May 29, 2022, in Fiche town, Oromia regional state, among 534 elementary school students. A multi-stage probability sampling technique was used to select the individual students. A structured questionnaire was used to collect the data. The data was entered into epi-data version 4.6 and analyzed by SPSS version 26.0. Variables that scored a p-value less than 0.2 during bivariate analysis were included in multilevel logistic regression models to determine factors associated with personal hygiene practice. The odds ratio with a 95% confidence interval was estimated, and the level of significance was set at [Formula: see text] 0.05. RESULTS: The magnitude of good personal hygiene (scored above the mean) was 59.2% (95% confidence interval (CI)) (55.1-63.0). A considerable proportion of students scored more than 50% in latrine use (62.5%), regular hand-washing (55.4%), and oral hygiene (55.20%) practices. Being female, having good personal hygiene knowledge, doing hygiene inspections at school, and having latrine accessibility was significantly associated with good personal hygiene among elementary school students. CONCLUSION: Considerable proportion of elementary school students in Fiche town have score poor personal hygiene practice. Interventions aimed that target improving knowledge of personal hygiene and hygiene inspection at school are crucial to enhance the personal hygiene among elementary school students.

Enterococcus contamination of infant foods and implications for exposure to foodborne pathogens in peri-urban neighbourhoods of Kisumu, Kenya.

We collected infant food samples from 714 households in Kisumu, Kenya, and estimated the prevalence and concentration of Enterococcus, an indicator of food hygiene conditions. In a subset of 212 households, we quantified the change in concentration in stored food between a morning and afternoon feeding time. In addition, household socioeconomic characteristics and hygiene practices of the caregivers were documented. The prevalence of Enterococcus in infant foods was 50% (95% confidence interval: 46.1 - 53.4), and the mean log10 colony-forming units (CFUs) was 1.1 (SD + 1.4). No risk factors were significantly associated with the prevalence and concentration of Enterococcus in infant foods. The mean log10 CFU of Enterococcus concentration was 0.47 in the morning and 0.73 in the afternoon foods with a 0.64 log10 mean increase in matched samples during storage. Although no factors were statistically associated with the prevalence and the concentration of Enterococcus in infant foods, household flooring type was significantly associated with an increase in concentration during storage, with finished floors leading to 1.5 times higher odds of concentration increase compared to unfinished floors. Our study revealed high prevalence but low concentration of Enterococcus in infant food in low-income Kisumu households, although concentrations increased during storage implying potential increases in risk of exposure to foodborne pathogens over a day. Further studies aiming at investigating contamination of infant foods with pathogenic organisms and identifying effective mitigation measures are required to ensure infant food safety.

Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020-2021: a cross-sectional study.

BACKGROUND: Water, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area. METHODS: In this cross-sectional binational study, we interviewed PWID (age 18+) in 2020-2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates. RESULTS: Of 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02-2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28-1.64), and bathing (aRR: 1.21, 95%CI: 1.06-1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07-3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52-2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55-6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36-4.89) than participants living in permanent housing. CONCLUSION: WASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID-especially those who are unsheltered.

Hygiene-based measures for the prevention of cytomegalovirus infection in pregnant women: a systematic review.

BACKGROUND: Human Cytomegalovirus (HCMV) is the most frequent congenital infection worldwide causing important sequelae. However, no vaccine or antiviral treatments are currently available, thus interventions are restricted to behavioral measures. The aim of this systematic review was to assess evidence from available intervention studies using hygiene-based measures to prevent HCMV infection during pregnancy. METHODS: Studies published from 1972 to 2023 were searched in Medline, PsycInfo, and Clinical Trials (PROSPERO, CRD42022344840) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Methodological quality was assessed by two authors, using ROBE-2 and MINORS. RESULTS: After reviewing 6 selected articles, the outcome analysis suggested that implementation of hygiene-based interventions during pregnancy prevent, to some extent, the acquisition of congenital HCMV. CONCLUSIONS: However, these conclusions are based on limited and low-quality evidence available from few studies using this type of intervention in clinical practice. Thus, it would be necessary to perform effective and homogeneous intervention studies using hygiene-based measures, evaluated in high-quality randomized controlled trials (RCTs).

Sexual activity, vaginal symptoms, maternal perineal hygiene behavior, and constipation on ano-vaginal colonization of group B streptococcus in near term pregnancy.

BACKGROUND: Maternal Group B Streptococcus (GBS) colonization is influenced by many factors but results are inconsistent. Consideration of antenatal risk factors may help inform decision making on GBS microbiological culture screening where universal screening is not standard of care. We sought to identify independent predictors of GBS colonization at 34-37 weeks gestation incorporating vaginal symptoms, perineal hygiene measures, sexual activity, and a potential novel factor, constipation. METHODS: In this prospective cross-sectional study, 573 women at 34-37 weeks gestation had an ano-vaginal swab taken and sent for selective culture for GBS. Women were asked about vaginal bleeding, discharge, irritation and candidiasis, antibiotic use during pregnancy, ano-vaginal hygiene practices such as douching and perineal cleansing after toileting, sexual intercourse related activities, and a potential novel factor for GBS carriage, constipation. Maternal basic demographics and obstetric-related characteristics were also collected. Bivariate analyses were performed to identify associates of GBS colonization. All variables with p < 0.05 found on bivariate analysis were then included into a model for multivariable binary logistic regression analysis to identify independent risk factors for GBS colonization. RESULTS: GBS colonization was found in 235/573 (41.0%) of participants. Twenty six independent variables were considered for bivariate analysis. Eight were found to have p < 0.05. Following adjusted analysis, six independent predictors of GBS colonization were identified: ethnicity, previous neonatal GBS prophylaxis, antenatal vaginal irritation, antibiotic use, recent panty liner use, and frequency of sexual intercourse. Vaginal discharge and perineal cleansing were not associated after adjustment. Recent douching and constipation were not associated on bivariate analysis. CONCLUSION: The identification of independent predictors of GBS colonization in late pregnancy may inform the woman and care provider in their shared decision making for microbiological screening at 35-38 weeks gestation in locations where universal GBS screening is not standard of care. ETHICS OVERSIGHT: This study was approved by the Medical Ethics Committee of University Malaya Medical Centre (UMMC) on August 9, 2022, reference number 2022328-11120.

Menstrual health and hygiene amongst adolescent girls and women of reproductive age: a study of practices and predictors, Odisha, India.

BACKGROUND: Menstruation is a major physiological change in a woman's life, but lack of knowledge, poor practices, socio-cultural barriers, poor access to products and their improper disposal have significant consequences on health, dignity and well-being of women and adolescent girls. OBJECTIVES: This study aimed to assess the knowledge and practices related to menstrual health and hygiene amongst females of 10-49 years of age; explore the experiences and challenges of women during menstruation; and identify the key predictors of healthy menstrual health and hygiene. METHODS: Using a cross-sectional study design, we adopted a mixed methods approach for data collection. For quantitative household survey, a total of 921 respondents were selected from three districts of Odisha. Qualitative findings through focus group discussions and in-depth interviews supplemented the survey findings and helped to identify the barriers affecting good menstrual practices. Epi data version 2.5 and R 4.2.2 was used for data entry and data analysis, respectively. Descriptive statistics was used to calculate proportion, mean and standard deviation; Chi square test was used to measure the association between categorical variables. Bivariate and multivariate logistics analyses were done to identify predictors of healthy menstrual health and hygiene. For qualitative data analysis, thematic analysis approach was adopted using software Atlas.ti 8. RESULTS: For 74.3% respondents, mothers were the primary source of information; about 61% respondents were using sanitary pad. The mean age at menarche was 12.9 years and almost 46% of respondents did not receive any information about menstruation before menarche. Lower age and education up to higher secondary level or above had statistically significant associations with the knowledge about menstruation. Age, caste, respondent's education, mother's education, sanitation facility, availability of water, accessibility and affordability for sanitary pads were found to be strongly associated with good menstrual hygiene practices. CONCLUSION: Traditional beliefs regarding menstruation still persists at the community level. Educating mothers, increasing awareness about safe menstrual hygiene, providing adequate water and sanitation facilities and ensuring proper disposal of menstruation products need priority attention.

Utilization of modern menstrual methods and related unmet needs among college going women in Coimbatore district: a descriptive cross-sectional study.

OBJECTIVES: The primary objectives were to determine the proportion of modern menstrual method (MMM) users among college going women in Coimbatore district, Tamil Nadu; and to estimate the unmet needs associated with use of MMMs in comparison with other menstrual hygiene methods (MHMs). We also assessed the factors that determine MMM use among college going women. METHODS: This was a descriptive cross-sectional study conducted among college going women in Coimbatore district, Tamil Nadu, India between October 2022 and January 2023 using a purpose predesigned, pretested, semi-structured proforma that included validated Menstrual Practice Needs Scale (MPNS-36). RESULTS: Only 1.4% of the study participants used MMMs - menstrual cups (1.3%) and tampons (0.1%). Sanitary pads were the most common MHM of choice (96.3%); of which majority (98.6%) used disposable pads and more than half (50.4%) used non-biodegradable pads. Importantly, one in six (16.5%) were not aware of nature of sanitary pads (biodegradable or nonbiodegradable) used. The unmet needs associated with MMMs (menstrual cups and tampons) were significantly lower than that for other MHMs (including sanitary pads), in particular, the unmet material and home environment needs, unmet material reliability concerns, unmet reuse needs and unmet reuse insecurity. However, we found no significant difference between MMMs, sanitary pads and other MHMs in terms of unmet transport, college environment, change and disposal insecurity needs. The significant predictors of use of MMMs were age (more than 21 years of age), residence (urban), type of stay (off campus including home), socioeconomic status (upper), fathers' and mothers' education (high school and above), and presence of personal income. Discussions with friends (or peers) both before and after menarche regarding menstruation resulted in higher adoption of modern menstrual methods. CONCLUSION: MMMs provided comparative advantage with lesser unmet needs for material reliability and reuse insecurity concerns, particularly in home environment. However, none of the MHMs fulfilled the user expectations for transport and disposal insecurity concerns, particularly outdoors.

Assessment of water, sanitation, and hygiene among women living in precarious households in a Turkish urban area.

BACKGROUND: This study aimed to identify the determinants of water, sanitation, and hygiene (WASH) behaviors and conditions among women in poor neighborhoods in Izmir, Turkey, and to develop a scale for assessing WASH behaviors and conditions that is specifically designed for use in precarious urban areas. METHODS: The study used a cross-sectional design, as well as a methodological feature for developing the scale. The sample size was calculated as 243 households out of 2667 households in the Basmane neighborhood, with a 95% confidence interval and a 6% margin of error, and a woman who was responsible for cleaning was invited to participate from each household. The scales for WASH behaviors and conditions, which served as dependent variables, were developed in a four-stage process, yielding two distinct scales. The WASH-Behaviors Scale had 14 items about hand, body, and home hygiene, whereas the WASH-Conditions in Households Scale included 16 items about variables like area per capita, physical structure, and cleaning tool availability. Age, ethnicity, number of children, education, work status, and income were among the independent variables. Data was collected through household visits. The scales' validity was evaluated using exploratory factor analysis. Linear logistic regression analysis was employed to assess the determinants of WASH behaviors. RESULTS: The women, with an average age of 40.65 ± 14.35 years, faced economic challenges, as a substantial portion earned an income below the minimum wage. More than half of them were uninsured, and 72.6% were identified as migrants or refugees. Factor analysis confirmed the compatibility of both scales (KMO = 0.78-0.80, p < 0.05), elucidating 52-54% of the total variance. Factors such as ethnicity, number of children, husband's education level, income perception, and WASH conditions explained 48% of WASH behaviors. CONCLUSIONS: WASH-Behaviors and WASH-Conditions in Households scales met the validity criterion, and their scores were related to basic sociodemographic and economic characteristics like education, income, household size, and ethnicity. The scale development process emphasized the importance of considering both behaviors and household conditions, albeit using different techniques. The findings indicated that WASH conditions are more problematic than behaviors, and that behavioral interventions will not work unless the conditions are corrected.

Prevalence and factors associated with unmet need for menstrual hygiene management in six countries in Sub-Saharan Africa: A multilevel analysis.

BACKGROUND: Menstruation is a normal biological process experienced by more than 300 million women globally every day. Women require clean menstrual absorbents that can be changed as often as needed in a private and safe place with proper hygiene and disposal facilities. These needs must be met consistently throughout the duration of the menstrual cycle. Access to menstrual needs is crucial for women's health, wellbeing, and dignity. This study assessed the prevalence and factors associated with unmet need for menstrual hygiene management (MHM) in Ethiopia, Kenya, Uganda, Burkina Faso, Ghana, and Niger. METHODS: We used data from the Performance Monitoring for Action (PMA) 2020 surveys. We defined the unmet need for MHM as the "lackof resources, facilities and supplies for MHM." Sample characteristics were summarised using frequencies and percentages, while prevalence was summarised using proportions and their respective confidence intervals (CI). Factors associated with unmet need for MHM were assessed using multilevel logistic regression models. RESULTS: The study included 18,048 women of reproductive age from the six countries. The prevalence of unmet need for MHM was highest in Burkina Faso (74.8%), followed by Ethiopia (69.9%), Uganda (65.2%), Niger (57.8%), Kenya (53.5%), and lowest in Ghana (34.2%). Unmet need for MHM was consistently higher among uneducated and multiparous women, those who reused MHM materials, practiced open defecation, and lived in rural areas across all six countries. The odds of unmet need for MHM were higher among younger women under 35 years, unmarried women, those with lower education levels, and those from poorer households. Similarly, the reuse of MHM materials, use of shared or non-improved toilet facilities, and open defecation increased the odds of unmet need for MHM. In contrast, the presence of handwashing facilities reduced the odds of unmet need for MHM. CONCLUSION: More than half of the women in five of the six countries have an unmet need for MHM, with significantly higher odds among younger women, those with low wealth status, the unmarried, and those with inadequate access to sanitary facilities. This study highlights the state of period poverty in Sub-Saharan Africa. Efforts to end period poverty should consider MHM needs as an integrated whole, as addressing each need in isolation is insufficient.