Overview of Handwashing in Research (2010-2012)

1. Overview of Handwashing in Research (2010-2012) Jelena Vujcic, MPH Dept. of Social & Preventive Medicine

2. Presentation Content • Health impacts • Behavioral impacts • Behavioral determinants and theory • Alternatives to soap • Measuring behavior • Implications of recent research

3. Health impacts Preventing childhood diarrhea • Luby et al., 2011 (Bangladesh) • Before preparing food, after defecation particularly important • Handwashing with water alone • Huda et al. 2011 (Bangladesh) • No difference between control and intervention households after 18 months Preventing influenza and school absenteeism • Talaat et al., 2011 (Cairo, Egypt) • Reduced absences by 40% caused by ILI, 30% by diarrhea, 67% by conjunctivitis, and 50% by lab-confirmed influenza • Freeman et al., 2011 (Nyanza Province, Kenya) • 58% fewer absences for girls in some schools. Reduction in neonatal morbidity and mortality • Blencowe et al., 2011 (Review) • Birth attendant handwashing: reductions in all-cause neonatal mortality (19% ), in cord infection (30%), and neonatal tetanus (49%). • Postnatal maternal handwashing: reductions in all-cause mortality (44%) & in cord infection (24%) • Low quality evidence

4. Behavioral impacts Vindigni et al., 2011 (Review) • Paucity in documenting long-term behavior change Huda et al., 2011 (Bangladesh) • Handwashing with soap < 3% around food related events • Washing both hands with soap or ash after cleaning a child’s bottom increased from 22% to 36%

5. Behavioral determinants Aunger et al., 2010 (Kenya) • Psychological determinants associated with observed hand-washing behavior: • Having the habit of hand-washing at particular junctures of the day • Motivated need for personal/household cleanliness • Lack of cognitive concern about the cost of soap use • Multiple types of strategies to increase handwashing behavior

6. Behavioral theory and programming Briscoe & Aboud, 2012 (Review) • Most successful interventions use 3-4 behavior change techniques • Engage participants at behavioral, social, sensory and cognitive levels • Behavior change techniques rarely linked to theories of behavior change • Theory missing from logic models Aboud & Singla, 2012 (Overview) • Questions current approach of using formative research for intervention development • Recommends inclusion of behavior change theories to address determinants at multiple levels (individual, community, etc) How to integrate/use behavioral theory in programming?

7. Behavioral theory and programming Curtis et al., 2011

8. Alternatives to soap Waterless hand sanitizer • Reduced hand contamination but did not improve the frequency of handwashing compared with soap. (Luby et al., 2010) • Significantly better than handwashing at reducing fecal streptococci on hands (Pickering et al., 2010) • No significant difference in efficacy between hands that were clean versus dirty or oily. (Pickering et al., 2011) Water alone • Reduction in diarrhea among children of mothers who wash hands with water alone compared to mothers who do not wash hands (Luby et al., 2011)

9. Handwashing ladder? Luby, PLOS Med, 2011

10. Measuring behavior Validating HW indicators against health outcomes (Luby et al., 2011) • Measures associated with less diarrhea • mothers reporting usually washing hands with soap before feeding a child • mothers using soap when asked to show how they usually washed their hands after defecation • children having visibly clean finger pads • Measures associated with fewer respiratory infections • mothers allowing their hands to air dry after the handwashing demonstration • presence of water where the respondents usually wash hands after defecation Updates on indicators • Validity of structured observation (Ram et al., 2010) • Substantial reactivity detected by soap sensors during structured observation compared to pre-observation days. • Validity of hand contamination • Varies substantially within a short time (Ram et al., 2011) • Can be increased by various household activities, including those involving the use of soap and water (Pickering et al., 2011)

11. Implications of recent research • Promotion of handwashing with water alone • Feasibility/scalability of sanitizer • Better measures of handwashing behavior • Using behavioral theory in the logical framework and to inform intervention design • Defining reasonable approaches for program implementers • Designing interventions to promote handwashing habit • Research priorities (see Curtis et al, Lancet, 2011)

12. Thank you. Jelena Vujcic, MPH Dept. of Social & Preventive Medicine jelenavu@buffalo.edu

13. References Aboud, F.E. and D.R. Singla, Challenges to changing health behaviours in developing countries: A critical overview.SocSci Med, 2012. Aunger, R., et al., Three kinds of psychological determinants for hand-washing behaviour in Kenya.SocSci Med, 2010. 70(3): p. 383-91. Blencowe, H., et al., Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health, 2011. 11 Suppl 3: p. S11. Briscoe, C. and F. Aboud, Behaviour change communication targeting four health behaviours in developing countries: A review of change techniques.SocSci Med, 2012. Curtis, V., et al., Hygiene: new hopes, new horizons. Lancet Infect Dis, 2011. 11(4): p. 312-21. Freeman, M.C., et al., Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health, 2011. Huda, T.M., et al., Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh.SocSci Med, 2011. Luby, S.P., et al., The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study.PLoS Med, 2011. 8(6): p. e1001052.

14. References (cont’d) Luby, S.P., et al., Using child health outcomes to identify effective measures of handwashing. Am J Trop Med Hyg, 2011. 85(5): p. 882-92. Luby, S.P., et al., A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh. Trop Med Int Health, 2010. 15(12): p. 1508-16. Pickering, A.J., et al., Efficacy of waterless hand hygiene compared with handwashing with soap: a field study in Dar es Salaam, Tanzania. Am J Trop Med Hyg, 2010. 82(2): p. 270-8. Pickering, A.J., et al., Bacterial hand contamination among Tanzanian mothers varies temporally and following household activities. Trop Med Int Health, 2011. 16(2): p. 233-9. Ram, P.K., et al., Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg, 2010. 83(5): p. 1070-6. Ram, P.K., et al., Variability in hand contamination based on serial measurements: implications for assessment of hand-cleansing behavior and disease risk. Am J Trop Med Hyg, 2011. 84(4): p. 510-6. Talaat, M., et al., Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt.Emerg Infect Dis, 2011. 17(4): p. 619-25. Vindigni, S.M., P.L. Riley, and M. Jhung, Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance. Tropical Medicine & International Health, 2011. 16(4): p. 466-477.