Pavani K. Ram

Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale.

Introduction Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap. Methods and analysis WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation, handwashing and child nutrition—alone and in combination—to rural households with pregnant women in Kenya and Bangladesh. Geographically matched clusters (groups of household compounds in Bangladesh and villages in Kenya) will be randomised to one of six intervention arms or control. Intervention arms include water quality, sanitation, handwashing, nutrition, combined water+sanitation+handwashing (WSH) and WSH+nutrition. The studies will enrol newborn children (N=5760 in Bangladesh and N=8000 in Kenya) and measure outcomes at 12 and 24 months after intervention delivery. Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea. Secondary outcomes include stunting prevalence, markers of environmental enteropathy and child development scores (verbal, motor and personal/social). We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests. Ethics and dissemination Study protocols have been reviewed and approved by human subjects review boards at the University of California, Berkeley, Stanford University, the International Centre for Diarrheal Disease Research, Bangladesh, the Kenya Medical Research Institute, and Innovations for Poverty Action. Independent data safety monitoring boards in each country oversee the trials. This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California, Berkeley. Registration Trial registration identifiers (http://www.clinicaltrials.gov): NCT01590095 (Bangladesh), NCT01704105 (Kenya).

The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings

BackgroundPromotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance.MethodsWe completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH).ResultsWe identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual).ConclusionsA number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.

Optimal Recall Period for Caregiver-reported Illness in Risk Factor and Intervention Studies: A Multicountry Study

Many community-based studies of acute child illness rely on cases reported by caregivers. In prior investigations, researchers noted a reporting bias when longer illness recall periods were used. The use of recall periods longer than 2-3 days has been discouraged to minimize this reporting bias. In the present study, we sought to determine the optimal recall period for illness measurement when accounting for both bias and variance. Using data from 12,191 children less than 24 months of age collected in 2008-2009 from Himachal Pradesh in India, Madhya Pradesh in India, Indonesia, Peru, and Senegal, we calculated bias, variance, and mean squared error for estimates of the prevalence ratio between groups defined by anemia, stunting, and underweight status to identify optimal recall periods for caregiver-reported diarrhea, cough, and fever. There was little bias in the prevalence ratio when a 7-day recall period was used (<10% in 35 of 45 scenarios), and the mean squared error was usually minimized with recall periods of 6 or more days. Shortening the recall period from 7 days to 2 days required sample-size increases of 52%-92% for diarrhea, 47%-61% for cough, and 102%-206% for fever. In contrast to the current practice of using 2-day recall periods, this work suggests that studies should measure caregiver-reported illness with a 7-day recall period.

Clinical value of Tubex™ and Typhidot® rapid diagnostic tests for typhoid fever in an urban community clinic in Bangladesh

Tubex and Typhidot, rapid tests for typhoid fever, performed well in evaluations conducted in hospital settings among patients with culture-confirmed typhoid fever. We evaluated these tests in a community clinic in Bangladesh. Blood samples were obtained from 867 febrile patients for culture, Typhidot and Tubex tests. Considering the 43 blood culture-confirmed cases of typhoid fever as typhoid positive and the 24 other confirmed bacteremia cases as typhoid negative, Tubex was 60% sensitive and 58% specific, with 90% positive and 58% negative predictive values (NPVs); Typhidot was 67% sensitive and 54% specific, with 85% positive and 81% NPVs. When blood culture-negative patients and other bacteremia cases together were considered typhoid negative, positive predictive values were only 14% for Tubex and 13% for Typhidot, increasing to only 38% and 20% when restricted to patients with > or = 7 days of fever. We conclude that the value of Tubex and Typhidot tests for typhoid fever diagnosis in a community clinic in urban Bangladesh is low.

Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH)

BackgroundIn Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations – a dedicated, convenient location where both soap and water are available for handwashing – are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour.MethodsWe conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs.ResultsFactors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials.ConclusionsA number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.

Declines in case management of diarrhoea among children less than five years old

In the January 2007 Bulletin, Forsberg et al. present an elegant analysis of the trends in diarrhoea case management using data from national Demographic and Health Surveys (DHS) from 1986 to 2003.1 They conclude that despite global efforts to promote appropriate diarrhoea management during this time, only slow progress has been made in the proportion of children treated with oral rehydration salts (ORS), recommended home fluids (RHF) or increased fluids. The proportion of children given continued feeding during diarrhoea episodes actually decreased.

Seasonal concentrations and determinants of indoor particulate matter in a low-income community in Dhaka, Bangladesh

Indoor exposure to particulate matter (PM) increases the risk of acute lower respiratory tract infections, which are the leading cause of death in young children in Bangladesh. Few studies, however, have measured childrens exposures to indoor PM over time. The World Health Organization recommends that daily indoor concentrations of PM less than 2.5μm in diameter (PM(2.5)) not exceed 25μg/m(3). This study aimed to describe the seasonal variation and determinants of concentrations of indoor PM(2.5) in a low-income community in urban Dhaka, Bangladesh. PM(2.5) was measured in homes monthly during May 2009 to April 2010. We calculated the time-weighted average, 90th percentile PM(2.5) concentrations and the daily hours PM(2.5) exceeded 100μg/m(3). Linear regression models were used to estimate the associations between fuel use, ventilation, indoor smoking, and season to each metric describing indoor PM(2.5) concentrations. Time-weighted average PM(2.5) concentrations were 190μg/m(3) (95% CI 170-210). Sixteen percent of 258 households primarily used biomass fuels for cooking and PM(2.5) concentrations in these homes had average concentrations 75μg/m(3) (95% CI 56-124) greater than other homes. PM(2.5) concentrations were also associated with burning both biomass and kerosene, indoor smoking, and ventilation, and were more than twice as high during winter than during other seasons. Young children in this community are exposed to indoor PM(2.5) concentrations 7 times greater than those recommended by World Health Organization guidelines. Interventions to reduce biomass burning could result in a daily reduction of 75μg/m(3) (40%) in time-weighted average PM(2.5) concentrations.

Examining the Use of Oral Rehydration Salts and Other Oral Rehydration Therapy for Childhood Diarrhea in Kenya

Reductions in the use of oral rehydration therapy (ORT) in sub-Saharan Africa highlight the need to examine caregiver perceptions of ORT during diarrheal episodes. Qualitative research involving group discussions with childcare providers and in-depth interviews with 45 caregivers of children < 5 years of age who had experienced diarrhea was conducted in one rural and urban site in Kenya during July-December 2007. Diarrhea was considered a dangerous condition that can kill young children. Caregivers preferred to treat diarrhea with Western drugs believed to be more effective in stopping diarrhea than ORT. Inconsistent recommendations from health workers regarding use of oral rehydration solution (ORS) caused confusion about when ORS is appropriate and whether it requires a medical prescription. In the rural community, causal explanations about diarrhea, beliefs in herbal remedies, cost, and distance to health facilities presented additional barriers to ORS use. Health communication is needed to clarify the function of ORT in preventing dehydration.

Access to waterless hand sanitizer improves student hand hygiene behavior in primary schools in Nairobi, Kenya.

Handwashing is difficult in settings with limited resources and water access. In primary schools within urban Kibera, Kenya, we investigated the impact of providing waterless hand sanitizer on student hand hygiene behavior. Two schools received a waterless hand sanitizer intervention, two schools received a handwashing with soap intervention, and two schools received no intervention. Hand cleaning behavior after toilet use was monitored for 2 months using structured observation. Hand cleaning after toileting was 82% at sanitizer schools (N = 2,507 toileting events), 38% at soap schools (N = 3,429), and 37% at control schools (N = 2,797). Students at sanitizer schools were 23% less likely to have observed rhinorrhea than control students (P = 0.02); reductions in student-reported gastrointestinal and respiratory illness symptoms were not statistically significant. Providing waterless hand sanitizer markedly increased student hand cleaning after toilet use, whereas the soap intervention did not. Waterless hand sanitizer may be a promising option to improve student hand cleansing behavior, particularly in schools with limited water access.

Community Case Management of Childhood Diarrhea in a Setting with Declining Use of Oral Rehydration Therapy: Findings from Cross-Sectional Studies among Primary Household Caregivers, Kenya, 2007

We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management.