14. Environmental health including water, sanitation and hygiene education
14.1 General environmental health interventions
14.2 Water and sanitation
14.3 Cholera prevention
14.4 Hygiene education interventions
14.5 School-based hygiene education
Click on link for background information on Leeds Database Project, a list of all entries and details of environmental health interventions reviewed but not considered suitable for inclusion database.
14.1 General Environmental health interventions
Montazeri, A. and McEwen, J. (1998) Health education campaign on environmental health: a pilot study. International Journal of Environmental Health Research 8, 35-41.Ref ID : 8489
Target Group/Country Residents in Teheran, Iran
Intervention Methodology Health education campaign on environmental health (no details provided on actual campaign). The campaign consisted of billboard (no number provided of numbers/locations) with three illustrations asking people to (1) keep away flies from foods, (2) to use a dustbin with a lid and (3) to chlorinate vegetables and fruits.
Evaluation Method A sample of 183 adults aged 18 to 56 years participated in the study. Each respondent was shown a picture related to the campaign (illustrating keeping flies away from foodstuffs, using dustbins with lids, and chlorinating vegetables and fruits), and then filled in a short questionnaire. The main objective of the study was to measure recall rates.
Impact Achieved The results showed that recalls were high (73%), 53% of respondents were either "very positive" or "positive" about the campaign, and almost all participants perceived the main idea of the campaign correctly. The study findings showed that there were some significant associations between demographic variables, recall and perception of the campaign. The study concludes that health education campaigns are useful tools for launching environmental health related topics and the focus should be on getting the attention of as many of the target population as possible
14.2 General water supply/sanitation programmes
Aziz, K.M., Hoque, B.A., Hasan, K.Z., Patwary, M.Y., Huttly, S.R., Rahaman, M.M., and Feachem, R.G. Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications. Transactions of the Royal Society of Tropical Medicine & Hygiene 84(3):433-438, 1990. Ref ID : 3113
Blum, D., Emeh, R.N., Huttly, S.R., Dosunmu-Ogunbi, O., Okeke, N., Ajala, M., Okoro, J.I., Akujobi, C., Kirkwood, B.R., and Feachem, R.G. The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 1. Description of the project, evaluation methods, and impact on intervening variables. Transactions of the Royal Society of Tropical Medicine & Hygiene 84(2):309-315, 1990. Ref ID : 3114
Target Group/Country Imo State Drinking Water Supply and Sanitation Project in Nigeria
Intervention Methodology The project consisted of a package of water supply, sanitation delivered through a community participation strategy involving setting up of water committees and training of village based workers (VBWs). Hygiene education was provided by VBWs and the evaluation team.
Evaluation Method Data were collected through surveys in intervention (801 households) and control villages (402 households) at baseline 1983, at regular intervals during 1984 while the intervention was taking place and for 1.5 years afterwards
Impact Achieved By end of study period 96% of households in the intervention area were using boreholes - use was higher with those living closest to borehole. Median time spent collecting water in dry season decreased from 6hrs to 45 minutes. Data from a small sample of households showed that borehole water became heavily contaminated during collection and storage, and that there was no significant change in consumption of water per person. Adults in 46% of household units in the intervention area were using ventilated improved pit latrines by the end of the study period. Use by young children (2-5 years old), however, was low. Changes were found in knowledge, attitudes and practices related to water and sanitation, and in management of childhood diarrhoea, this occurred in both the intervention and control areas and raw data and significance tests for these are not presented.
A. 2013. Fighting arsenic at the grassroots: experience of BRAC's community
awareness initiative in Bangladesh. Health Policy and Planning, vol.
18, no. 1, pp. 93-100. Ref ID: 9030 Borderline
for inclusion in database
Rural communities in south-western Bangladesh
A 12 month arsenic mitigation by the NGO BRAC sought to raise awareness of arsenic
poisoning. Activities involve providing training to community members to test
all tube-wells using field kings; involving community members in choosing, implementing
and maintaining a source of arsenic-free drinking water; installing demonstration
units of different alternative safe water options; identification and treatment
of arsenic-affected patients; and continued promotion of safe water use.. Key
features of the communication strategy included meetings with community leaders,
workshops for health service providers, group meetings with neighbors while
testing tube wells for arsenic and the distribution of posters at key public
places. A two day training was provided to village women used as community health
workers who were expected to visit each household in their village to identify
the patients and contaminated tube wells and provide health education.
A total of 1240 randomly selected adults aged 15-74 were interviewed at the
end of the 12 month programme. Project villages (n=636) and comparison villages
(n=604) from the same region. A test instrument was developed of arsenic knowledge,
comprising 12 items in the four categories - safe water options, signs of arsenicosis,
mode of transmission and type of treatment. 24 in-depth interviews were also
carried out. There was no baseline.
Persons from the mitigation villages were better-informed about arsenic-free
water sources. Knowledge of at least two sources of arsenic-free water was higher
in the mitigation (41.8%) than the comparison (9.8%) p<0.01. Nearly 44% in
the mitigation villages were able to report at least two signs in the mitigation
villages compared with only 7.8%in the comparison villages (p<0.01. In the
mitigation villages 8.8% were able to correctly mention at least two measures
compared with only 2.2% in the comparison villages. In-depth interviews suggested
that the key change agents were the community health workers. The main limitation
(which the authors acknowledge) in this study is the lack of baseline data While
both groups had a similar level of exposure to mass media (which also carried
information on arsenic) of about 40%, families in the mitigation area had higher
level of schooling (3.4 mean years compared with 2.3 in comparison p<0.01)
and owned more land (63.2% landowners compared to 38.7 % p<0.01). It is therefore
possible that some of the difference between the two communities could be attributed
to their higher level of education and wealth which might result in their being
able to derive more information from other sources and respond more efficiently
to the information presented in the intervention.
S., Nahar, Q., Van Agthoven, A., Geers, C., & Rezvi, M. D. 2015. Increasing
awareness of arsenic in Bangladesh: lessons from a public education programme.
Health Policy and Planning, vol. 17, no. 4, pp. 393-401. Ref ID: 9072.
Borderline for inclusion in database
General public in 16 towns in Bangladesh
1999 campaign by the 18 District Towns Project to educate the public about the
arsenic problem in six Bangladesh towns, where half of the population was estimated
to be using arsenic-contaminated domestic water: (1). Water users were advised
not to consume arsenic-affected tube-well water; (2). A simple, temporary water
treatment method was recommended for those using such water, if they had no
safe alternative source; (3). Caretakers of tube-wells having arsenic-free water
were advised to share their water sources with others. Following testing, all
tubewells found to contain high levels of arsenic had their spouts painted red
and the safe water painted green and a red question mark was painted on the
intermediate water sources. The project organized an "Arsenic Week"
in each town. Local government official, local project teams, skilled caretakers,
primary school teachers, community leaders all had an orientation to the programme.
Primary school children received colourful stickers with cartoon figures warning
each other not to drink from taps painted red. Handpump caretakers received
copies of a brochure demonstrating safe water practices in both pictures and
The evaluation study was carried out three months after the last Arsenic Week.
694 adults using tube wells were interviewed in a questionnaire survey ( at
least five users of 102 wells of a total of 4621 tested wells). Respondents
were divided into two groups as a result of the questionnaire. There were 420
classified as 'programme influenced' PI because they mentioned learning something
abut arsenic from a project shourse such as a community meeting, a project staff
member a pump caretaker or a brochure or sticker. 274 'non programme influenced'
NPI had not had any contact with the programme. a combination of quantitative
and qualitative social research methods. Two focus group discussions were held
in each town - one was for the red tubewell users and other for the green (non-arsenic)
tube wells. Interviews of 48 primary school students. There was no baseline
People who had been influenced by the programme (PI respondents) were found
to be more likely than NPIs to understand the health risks of drinking arsenic-contaminated
water (no significant data provided). The meanings of spout colours were understood
by 80% pf PI respondents compared with 25% pf NPI. PI respondent were significantly
less likely to consume contaminated water than the others (p<0.01) or cook
with contaminated water (p<0.01). However drinking of, and cooking with,
contaminated water by PI users was still 56.6% and 53.9% respectively indicating
that while the programme appeared to reduce consumption of contaminated water
, it had not eliminated it. Focus groups found that, despite the campaign, confusion
persisted as to what constituted safe water. The evaluation found that the red
question marks were not understood by the illiterate persons. A further problem
came from the fact that the paint faded over a six month period. The main problems
with this study are the lack of a baseline and controls. The lower consumption
of contaminated water could be explained by the fact that persons motivated
and interested in Arsenic might be more likely to seek out and remember the
campaign. However, mix of quantitative and qualitative data partly over comes
this although no information is provided of how the qualitative data was analyzed.
Hoque,B.A., Aziz,K.M., Hasan,K.Z. and Sack,R.B. (1994) Women's involvement in a rural Bangladesh water and sanitation project. Southeast Asian J. Trop. Med. Public Health 25, 67-73. Ref ID 7753
Target Group/Country An integrated water, sanitation and hygiene education intervention in a rural area of Bangladesh.- impact on diarrhoea of under fives.
Intervention Methodology In the intervention area the project provided 148 handpumps (32 persons per handpump) an 754 twin pit latrines (one latrine per household). in the comparison area, people did not receive these project inputs. In the intervention area women were directly involved in the site selection of handpumps and latrines, their installation, construction, and maintenance. Hygiene education was carried out with mother and caretakers of under 5s emphasising exclusive use of hand pumps for all water uses and the need for all household members including children to use latrines.
Evaluation Method Data on diarrhoeal morbidity of under 5s were collected by weekly visits throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention (5000 total population, 820 households) and a control area (4600, 750) without the water/sanitation/hygiene education activities.Data on handpump performance was determined from two weekly monitoring visits. Regular' questionnaire surveys combined with occasional observation to confirm accuracy of responses were done to investigate the use of new facilities. Details of measuring instruments not provided. The study was done in two intervention villages and a control area of 3 villages 5 km away each with a population of 5000.
Impact Achieved About 89% of the pumps maintained by women (n = 30), and 86% of those maintained by project workers (n = 49) were found to be in good working condition. Women supervised the construction of all 754 latrines, fenced 58% of the projects- supported latrines (n = 268) and emptied the pits of 65% of the 276 filled-up latrines. Data are not presented from the control villages. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area (p<0.01). This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to hand pumps or where better sanitation habits were practised experienced lower rates of diarrhoea.
Prihartono, N., Damayanti, R., Adisasmita, A., and Tarigan, L. (1994) A community trial involving religious leaders to improve water preparation hygiene as part of diarrheal disease prevention in South Kalimantan, Indonesia. International Quarterly of Community Health Education 14(4):391-402. Ref ID : 3548 Borderline for inclusion in database
Target Group/Country Religious leaders in South Kalimantan, Indonesia
Intervention Methodology A health educational campaign over 2 months to promote clean drinking water in Indonesia using local ulamas (influential Islamic religious leaders) and Koranic reading clubs. The ulamas met with women at the the Koranic reading clubs to discuss the proper preparation and treatment of clean drinking water and also made direct household visits to mothers. A message and intervention development was designed by the ulamas and the investigators
Evaluation Method 3 0 mothers received in Sei Lulut village education through Al Quran (Koranic) reading clubs and 30 in Murung Keraton village received education at both home visits and reading clubs and 30 mothers from a 3rd area served as the control.. Pre-and post-test data collected through observation and interviews. The observer visited each mother 3 times for periods of 2 hours and observed the practice of drinking water preparation and water boiling.
Impact Achieved More health camapaign activities were carried out in Murung Keraton but the religious leaders in Sei Lulut delivered and discussed more educational messages (information not provided of how this was measured). In Sei Lulut there was an increase in practice of boiling >3 minutes (p=0.01), knowledge and attitudes (tNeither of the latter two defined). In tMurung Keraton only attitude showed a significant increase and there was no significant change in the control area. Raw data is not provided and details of measurement of knowledge and attitudes are not provided. However the intervention is noteworthy for the creative use of religious leaders
Thevos,A.K., Quick,R.E. and Yanduli,V. (2011) Motivational interviewing enhancesthe adoption of water disinfection practices in Zambia. Health Promotion International 15, 207-214. Ref ID 8807
Target Group/Country Communities taking water from shallow dug wells in two peri-urban areas of Kitwe, Zambia.
Intervention Methodology Two interventions are reported as trials of the Motivational Interviewing (MI) method which draws on the Transtheoretical Model of behaviour change and other psychological theories including social learning theory (self efficacy). A microenterprise for the production, bottling, sale and distribution of sodium hypochlorite (chlorine) disinfectant was established at a health clinic using a SANILEC on-site hypochlorite generator. And operated by three Neighbourhood Health Committees (NHCs) . In the first intervention (March - June, 1998) the chlorine disinfectant was provided for free, in the second the disinfectant was sold. In the intervention groups members of the In the first intervention members of NHCs were trained to use MI interviewing techniques and members of NHC carrying out health education were not trained. The actual duration of the MI education provided by the field staff to the community is not given. Note that in the first intervention field workers in the intervention group and control both received some form of training which was also disrupted and delayed. In the second intervention only the intervention group fieldworkers received any training.
Evaluation Method In the first intervention an intervention group receiving MI (n=32) was compared with a control group receiving health education (n=93). Pre-and post-test (9 weeks) data collection included interviews about water handling practices and sampling of water storage containers for chlorine residues. In the second intervention the intervention group receiving MI (n=200) was compared with the control group receiving health education (n=132).
Impact Achieved In the second intervention the outcome measure was sales of chlorine disinfectant over n 8 months period.
In the first intervention a high level of detectable chlorine (71.1-94.7%) was found with 96.6% claiming to have used chlorine and 90% claiming an intention to continue to use chlorine. There was no significant difference between households receiving MI and health education. In the second intervention sales of chlorine in the group receiving health education was 0.5 bottles/household compared with 1.3 for the households receiving MI (p<0.01). A possible explanation might be that when provided free bleach use is high despite the educational method, and that MI is more important when communities are expected to purchase bleach (a more realistic and sustainable intervention). However the authors also comment that field staff in both MI and health education groups received some training in the first intervention, and the likelihood of the control group receiving improved health education as a result was eliminated in the second intervention when only the MI group received training. The authors also commented that it is possible that the communities in the first intervention may have been more advanced in the stages of change and thereby more receptive to a simple intervention. Two further problems with their evaluations are that there is no description/monitoring of the quality of the heath education provided in the control groups (or for that matter the actual use of the MI by the field staff) and that lack of funds prevented them measuring chlorine residues in the households of the second intervention. While this study has established that a high level of use of chlorine by communities can be achieved, the methodology by which this high use can be achieved has not been established and further work needs to be done before something as time-consuming as MI can be recommended.
Tonon, M.A. (1980) Concepts in community participation: a case of sanitary change in a Guatemalan village. International Journal of Health Education 23 Suppl:1-16. Ref ID : 180
Tonon, M.A. (1982) A longitudinal study of the impact of village health education on environmental education. International Quarterly of Community Health Education 2:311-27. Ref ID 1167.
Target Group/Country Families in a village in Guatemala
Intervention Methodology The project used a participatory approach working thought local leaders to promote the construction/use of latrines and hygiene behaviours including: washing hands with soap, washing raw foods, excluding animals from the kitchen, cleaning, storage and use of water and building/using a latrine. Activities started with the formation of a betterment committee consisting of men who received training to run household discussion groups. A set of 73 discussion posters using cartoons were developed so support the heath education activities. A sanitary package consisting of a wash basin, bar of soap, a soap holder and a towel was given out to families who demonstrated interest.
Evaluation Method Using a time-series design, this study followed all the families (n=298) in the intervention village and all the families in control village (n=293) over a four year period using an observational checklist of behaviours. Observations were made during visits to collect non-controversial census information to reduce possible bias due to presence of observers.. A cohort of 80 families were randomly selected in both the experimental and control villages and six interviews were carried out with the female head of household at four month intervals over the two year period to determine perceptions about benefits of the various sanitation and hygiene interventions in the programme.
Impact Achieved 80 households, about one quarter of the village participated actively in the educational activities. Significant increases in intervention villages over control was found in 79 new latrines were constructed and shown to be regularly used in intervention villages compared to none in control village. Other significant behaviour changes (p<0.01) were a decline in the frequency of faecal matter on the floor and an increase in patio cleaning and use of appropriate storage facilities for water and food. At baseline the perceptions about hygiene in the two villages were the same and after the increase there was a significant improvement in perception of hygiene in the experimental village (p<0.001). However increased perception of health benefits of health measures was not associated with adoption of hygiene behaviours. Participation in the women's health activities and adoption of innovations was highly significant (p<0.0001).
14.3 Hygiene education/Cholera programmes
Deb, B.C., Sircar, B.K., Sengupta, P.G., De, S.P., Mondal, S.K., Gupta, D.N., Saha, N.C., Ghosh, S., Mitra, U., and Pal, S.C. (1986). Studies on interventions to prevent eltor cholera transmission in urban slums. Bull.World Health Organ. 64(1):127-131. Ref ID : 3100
Target Group/Country Urban slums in India
Intervention Methodology The giving of chlorine tablets and instructions on use were compared with the giving of a narrow-necked earthenware vessel (called a 'sorai') for storing the water
Evaluation Method 31 families with chlorine tablets and 30 families with sorais. 30 families were controls and received nothing. 466 individuals from these families were monitored
Impact Achieved The cholera carrier rates in the chlorination and 'sorai' intervention groups were 7.3% (11 cases out of 151 persons )and 4.4% ( 7 cases out of 159 persons) respectively, compared with 17.3% (27 persons out of 156 persons) in the control group. Chlorination vs. control groups p<0.01, sorai vs. control groups p<0.001).
Murthy, G.V., Goswami, A., Narayanan, S., and Amar, S. (1990) Effect of educational intervention on defaecation habits in an Indian urban slum. Journal of Tropical Medicine & Hygiene 93(3):189-193. Ref ID : 3018
Target Group/Country Urban slum populations during cholera epidemic, India
Intervention Methodology A community latrine facility was constructed in this area in February 1988. Later that year there was a cholera epidemic during which there was an intensive educational campaign using radio, television newspapers, scooter-rickshaws fitted with audio-equipment broadcasting audio-cassettes and group talks.
Evaluation Method The defaecation habits of 172 adults before and 170 of the same respondents seven months later after the educational campagn and cholera epidemic. There was no baseline of latrine use before construction of public latrines.
Impact Achieved There was no significant difference in the numbers using the latrine facility before th education (105) and afterwards ( 116 ). Cost and distance were the main reasons cited for non-utilization of latrines. 91.4% of respondents stated that they had faced some problem in using latrines. Most children were found to be defaecating in the open around the dwelling units at both rounds of the investigation.
14.4 Hygiene education programmes
Ahmed, N.U., Zeitlin, M.F., Beiser, A.S., Super, C.M., and Gershoff, S.N. (1993) A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh. Social Science & Medicine 37(2):159-171. Ref ID : 1842
Ahmed, N.U., Zeitlin, M.F., Beiser, A.S., Super, C.M., Gershoff, S.N., and Ahmed, M.A. (1994) Assessment of the impact of a hygiene intervention on environmental sanitation, childhood diarrhoea, and the growth of childen in rural Bangladesh. Food and Nutrition Bulletin 15(1):40-52,. Ref ID : 3157
Ahmed, N.U. and Zeitlin, M.F. (1993) Assessment of the effects of teaching germ theory on changes in hygiene behaviours, cleanliness and diarhoeal incidence in rural Bangladesh. International Quarterly of Community Health Education 14(3):283-297. Ref ID:: 2883
Ahmed, N.U., Zeitlin, M.F., Beiser, A.S., Super, C.M. and et al. (1991) Community-based trial and ethnographic techniques for the development of hygiene intervention in rural Bangladesh. International Quarterly of Community Health Education 12, 183-202. Ref ID: 3679
Target Group/Country Families of children aged 9-18 months in rural Bangladesh
Intervention Methodology A community-based intervention was developed in five villages following an enthnographic study and trials of proposed behaviour changes. Volunteer mothers taught other community mothers interactively in small groups using demonstration and teaching aids developed by a community working group. The intervention activities started in January 1986 and lasted for 7 months.
Evaluation Method 185 households with children 9-18 month in five intervention villages and 185 in five control villages were selected. Observation of cleanliness and interviews of illnesses and understandings of hygiene were carried out weekly and weighings were carried out monthly during six months of intervention. Baseline questionnaire and examination carried out on subset of families in the intervention villages (n=90) In July 1985 and control villages (n=78) September 1995 and final survey was then conducted at both sites in August 1986.
Impact Achieved The results of between-site longitudinal analyses showed that after the intervention, the intervention site had higher cleanliness scores, lower diarrhoeal morbidity, and better growth status compared to those of the control site (but p values not provided), with differences increasing over time. Although both sites were cleaner with lower levels of diarrhoeal morbidity and better growth status (weight for age) at the end of the study period, the improvement was greater at the intervention site (p<0.05 for growth, n.s. for diarrhoea rate). At final measurement 91% of mothers could explain five simple messages defining germ theory. Using germ theory in groups they identified forty high risk day-to-day practices and modified them to reduce diarrhoeal transmission. They adopted these new hygiene practices at rates ranging form 65% to 100%. Regression analysis suggests that understanding of germ theory was an important determinant of hygiene practices, cleanliness, and reduction in diarrhoeal incidence. A disappointing feature of these studies is the lack of significance data for improvements in hygiene practices
Alam, N., Wojtyniak, B., Henry, F.J., and Rahaman, M.M. (1989) Mothers' personal and domestic hygiene and diarrhoea incidence in young children in rural Bangladesh. International Journal of Epidemiology 18(1):242-247. Ref ID : 2686
Target Group/Country Mothers of children ages 6-23 months from rural areas around Teknaf, Bangladesh.
Intervention Methodology Health education was given continuously in two month blocks by female health visitors to communities receiving hand pump through home visits, group discussions and demonstrations during the study period 1980-1983 The main objectives of health education were promotion of consistent and exclusive use of handpump water, improvement of water handling and storage practicesl disposal of the child's faeces soon after defaecation. Washing hands before handling food and rubbing hands in ash or using soap after defaecation..
Evaluation Method Weekly visits to collect information of diarrhoea incidence of children aged 6-23 months in intervention community (n=314) and adjacent control community (n=309) receiving neither handpumps or health education.
Impact Achieved A child in intervention area had 3.4 diarrhoea episodes in a year compared to 4.1 in control (p<0.01). Significant improvement of hygiene practices in intervention community (p<0.001)
Results show that in both areas the use of hand pump water for drinking and washing, removal of child's feces from the yard, and maternal handwashing before handling of food and after defecation of child and self, observed together, decreased yearly diarrhoea incidence in children by more than 40% compared to children living in households where none or only 1 of these practices was observed. Note as only the intervention area received the handpumps it is difficult to separate out the influence of the health education from that of provision of handpumps.
Araya, M., Espinoza, J., Brunser, O., and Cruchet, S. (1994) Effect of health education and primary care on diarrhoeal disease morbidity in children: evaluation of a predictive intervention model. Journal of Diarrhoeal Diseases Research 12(2):103-107. Ref ID : 4389
Target Group/Country Mothers of infants at health clinic in Santiago, Chile whose child was identified to be at risk of persistent diarrhoea
Intervention Methodology Mothers in the intervention group received information about prevention and treatment of diarrhoea during weekly home visits by a nurse and at well baby clinic attendances by a paediatrician. Mothers were encouraged to seek help in the field station when their children became ill. Mothers also received a set of coloured posters.
Evaluation Method Two groups of infants (intervention group n = 66, and control group n = 45) at risk of persistent diarrhoea (PD) as identified by a predictive model were followed for 12 months. Families were visited at home weekly
Impact Achieved Children in the intervention group suffered fewer days with any illness, diarrhoea, or respiratory episodes (p < 0.00001 each). The main emphasis of the paper is on development of the predictive model and it is disappointing that no intermediate variables such as knowledge and practices were recorded. Programme inputs appeared high but might be justified where a screen process allowed targeting the intervention to high risk families.
Curtis,V., Kanki,B., Cousens,S., Diallo,I., Kpozehouen,A., Sangare,M. and Nikiema,M. (2012) Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization. 79, 518-527. REF ID 8859
Target Group/Country Carers of small children in rural communities in Burkino Faso
Intervention Methodology The programme was designed following an extensive research on local practices, motivation and facilities. Using both qualitative and quantitative methods. Monthly house-to-house visits and community meetings were carried out by community volunteers . Health centre staff were trained in participatory discussion and gave talks at health centres. A youth theatre group performed each week a comic play about cleanliness and the need to dispose of stools. A series of 12 comic radio spots with an evolving story was developed, tested and broadcast in local languages and French at local radio stations. A curriculum and materials for six primary school hygiene lessons were developed, teachers trained and provided with lesson guides, 6 posters and a box of soap and buckets.
Evaluation Method There were no controls (because mass media used) and a time series approach was used for evaluation . Two population surveys recorded the coverage of the programme among target audiences (mothers of children aged 0-35 months). Four surveys were carried out: three prior to the programme and one in 1998 (after the programme had been running for 3 years). , using structured observation of hygiene behaviours of young children and their carers using a pre-coded form recorded over a 3 hour period
Impact Achieved After the programme had run for 3 years, three- quarters of the mothers targeted had had contact with programme activities. Half could cite the two main messages of the programme correctly. Although the safe disposal of children's stools changed little between 1995 and 1998 (80% pre-intervention, 84% post- intervention), hand-washing with soap after cleaning a child's bottom rose from 13% to 31%(p<0.01). The proportion of mothers who washed their hands with soap after using the latrine increased from 1% to 17% (p<0.001). Lack of a control is the main limit to the validity of this study. Even with the tree pre-test studies the authors conclude that it is not possible to show from the data state that the change in washing hands after using the latrine was a change from the underlying trend. It is unfortunate that the data on coverage was not related to the impact - to show a relative take-up of behaviours by those persons who reported hearing the messages from radio or volunteers.
Haggerty, P.A., Muladi, K., Kirkwood, B.R., Ashworth, A., and Manunebo, M. (1994). Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. International Journal of Epidemiology 23(5):1050-1059. Ref ID: 2121
Target Group/Country Young children in in 18 geographically separate villages in Bandundu Province, rural Zaire
Intervention Methodology Intervention messages given by trained female community volunteers who conducted home visits, group discussion and meetings. The education addressed disposal of animal faeces from the yard, hand washing after defecation and before meal preparation and eating, and disposal of children's faeces. Control communities received an educational intervention on oral rehydration and the need for continuation of breast feeding for children with diarrhoea.
Evaluation Method A randomized, controlled trial. For 12 weeks, baseline information on the diarrhoeal morbidity of 2082 children aged 3-35 months was collected at weekly home visits, and structured observations of hygiene practices related to diarrhoea were made on a subset of 300 families clusters (sites) in rural Zaire. Three months after the start of the intervention and exactly 1 year after the baseline studies, a second diarrhoeal morbidity study and a second observational study were conducted in order to evaluate the intervention.
Impact Achieved Children in intervention communities experienced an 11% reduction in the risk of reporting diarrhoea during the peak diarrhoeal season, compared to controls (p < 0.025). The largest differences were seen among children aged 24-35 months, with those from intervention communities reporting significantly fewer episodes, shorter mean durations, and hence fewer days of diarrhoea. There was some evidence that greater reductions in diarrhoea occurred in sites where the quality of the intervention, a scored measure of volunteer efficacy and community participation, was highest..
Jongpiputvanich, S., Veeravongs, S. and Wonsekiarttirat, W. (1998) Difficulties in conducting participatory action research to prevent diarrhoea in a slum area of Bangkok. J. Diarrhoeal. Disease Research 16, 187-193. Ref ID : 8389 Borderline for inclusion in database
Target Group/Country Communities in slums in Bankok, Thailand during April 1988-April 1990
Intervention Methodology Participatory action research as a method of intervening on unhygienic practices. This involved group discussions and setting up a community committee and mothers groups to facilitate the following processes: problem identification and diagnosis, planning of activities in the community, management and administration of the programme by the community and monitoring and evaluation.
A study was conducted during April 1988-April 1990 in two communities in the Klong Toey slum of Bangkok (intervention group) and compared these practices in two other communities of the same slum where there was no intervention (control group). The following variables were compared in two groups: hygiene behaviour and factors associated with participation of community leaders and mothers with children aged less than five years. Two hundred and twenty-one mothers of the original 606 (36%) were still available at the end of the study
Impact Achieved It was found that the mothers in the intervention groups were more likely to wash their hands before feeding (p=0.03) and use cupboards and covered containers for keeping food (p=0.03). Several factors negatively affected community participation: matters concerning the slum culture and organization, community leadership, family problems, occupational problems, and physical environment of the community. The conclusions of the study are limited because of the considerable proportion of the subjects that was lost to follow-up. The study points at some of the methodological issues when conducting research in challenging and difficult to reach communities that have important health problems. It is disappointing that so little information is provided of the participatory processes involved.
Lee, W., Stoeckel, J., Jintaganont, P., Romanarak, T., and Kullavanijaya, S. (1991) The impact of a community based health education program on the incidence of diarrheal disease in southern Thailand. Southeast Asian J.Trop.Med.Public Health 22(4):548-556. Ref ID : 2477
Target Group/Country Villages were in the districts of Kok Pho and Nong Chik in Pattani Province, Southern Thailand
Intervention Methodology The six month intervention included a 2-day training program on diarrhoea prevention for existing village health communicators (VHCs), village health volunteers (VHVs), local Moslem leaders, and village heads; monthly meetings with the above and 30-40 mothers in the villages; and regular home visits by the VHV/VHCs
Evaluation Method Baseline and six month follow-up study of mothers of under-fives .9N=743)Teachers monitored diarrhoea among children under five years (N=904) every two weeks for six months. Data not provided of numbers across control and intervention or of sampling method of data collection instruments,
Impact Achieved There was a greater reduction in diarrhoea incidence in the experimental areas than in the control areas (-66.2% vs. -34.4%) regardless of the age group, religion (Moslem and Buddhist), and maternal education. The greatest declines were among 1-24 month old and 25-60 month old Buddhist children (-93.1% and -92.4%) and 25-60 month old children with mothers who had the most education (-71.5%). Diarrhoea incidence was lowest among mothers who regularly practiced preventive behaviours and highest among those who never did so. The intervention was effective because it maintained and improved the effectiveness of already practiced preventive behaviours. Attendance at meetings had a positive significant effect on boiling of drinking water and hand washing with soap before eating (p<.01). Number of visits by VHV/VHCs was positively associated with method of disposal of diarrhoeal faeces (p<.01).
Luby.S.P., Agboatwalla, M., Feikin, D. R., Painter, J., Billhimer, W., Altaf, A. and Hoekstra, R. M. (2014) Effect of handwashing on child health: a randomised controlled trial. Lancet, 366, 225-233. Ref ID: 9340
Families in squatter settlements in Karachi, Pakistan
A randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea. Fieldworkers visited intervention households at least once a week to discuss the importance of handwashing and correct handwashing technique, and to promote regular handwashing habits. They encouraged participants to wet their hands, lather them completely with soap, rub them together for 45 s, and rinse the lather off completely. Hands were typically dried on participants' clothing. Fieldworkers encouraged all individuals in intervention households who were old enough to understand (generally those aged more than 30 months) to wash their hands after defaecation, after cleaning an infant who had defaecated, before preparing food, before eating, and before feeding infants. Fieldworkers also encouraged participants to bathe once a day with soap and water. Initially, .eldworkers provided 2-4 bars of soap per household, depending on size. Throughout the study, soap was regularly replaced during use. The Procter & Gamble company (Cincinnati, OH, USA) manufactured all the soap for the study. The antibacterial soap (Safeguard Bar Soap) contained 1•2% triclocarban as an antibacterial substance. The plain soap was identical to the antibacterial soap except that it did not contain triclocarban. Both types were provided as 90 g white bars without brand names or symbols. They looked and smelled the same and were packaged identically in generic white wrappers. Cases of 96 bars were identi.ed by serial numbers that were matched to households. Neither the .fieldworkers nor the families knew whether soaps were antibacterial or plain. Fieldworkers provided control families with a regular supply of children's books, notebooks, pens, and pencils to help with their children's education, but they gave no products that would be expected to affect rates of respiratory illness, diarrhoea, or impetigo. Fieldworkers neither encouraged nor discouraged handwashing in control households, and visited both control and intervention households with equal frequency.
Methods In adjoining squatter communities they randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1•2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat.
Findings Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap. The authors concluded that handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.
Notes: It is disappointing that the study contained no information on the quality of health promotion or any measure of actual handwashing practice (other than recording that the consumption of soap provided free by the programme increased by three times in the intervention community). As a demonstration of the impact of handwashing on disease, this is appears to be an excellent study - and an evaluation of the impact of health promotion the study is less useful and there is no discussion of the cost or sustainability of the approach used and the feasibility of scaling up. JH
Nanan, D., White, F., Azam, I., Afsar, H., & Hozhabri, S. 2013. Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan. Bulletin of the World Health Organization, vol. 81, pp. 160-165. Ref ID: 9066. Borderline for inclusion in database
Target Group/Country Rural villages in Northern Pakistan
Intervention Methodology The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2012, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour.
Evaluation Method A
case-control study was conducted during July-September 2012 to evaluate whether,
after selected confounders were controlled for, children aged <6 years with
diarrhoea were more or less likely to reside in villages that participated in
the project than in villages that did not participate.Cases were defined as
a child more than 4 months old with more than three loose watery stools per
day with the epidode of diarrhoea lasting less than two weeks. Controls were
children presenting at clinics with any complaint other than diarrhoea and without
a skin condition or work infestation. The child's parent or caretake was given
a structured questionnaire. 454 cases and 348 controls. Descriptive and logistic
regression analyses were performed. There was no baseline.
Children not living in WASEP villages had a 33% higher adjusted odds ratio for
having diarrhoea than children living in WASEP villages (adjusted odds ratio,
1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted
odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea
for every yearly increase in the mother's age (adjusted odds ratio, 0.974; P<0.044)
and a 1.4% decrease for every monthly increase in the child's age (adjusted
odds ratio, 0.986; P<0.001. A disappointing feature of this report is that
no information is provided of the actual intervention including hygiene education,water
supply and sanitation components. Note that the authors also stated that other
agencies were carrying out hygiene education in some of the villages.
Pinfold, J.V. (1990) Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. II. A hygiene intervention study in rural north-east Thailand. Epidemiology & Infection 105, 377-389. Ref ID : 3104
Target Group/Country Households in rural North East Thailand
Intervention Methodology Verbal health education on the need to wash hands was given to all sample while the intervention group also were provided with a water container with a tap to prevent hand contamination.
Evaluation Method Following bacteriological examination of water container and finger tip rinses of 60 persons, they were assigned to three groups of 30. On the second visit one group was a control, a second group received education and a third group received education and a water container with a tap. the main outcome indicator was Escherichia coli contamination of stored water. Two follow up visits were made.
Impact Achieved There was no significant improvement with education only compared to the control but the water of the group receiving education and tap was significantly less contaminated (P <0.001). This small scale study is mainly of interest because of the use of microbiological indicators for evaluation and the comparison of hygiene education with provision of a water container with a tap
Pinfold, J.V. and Horan, N.J. (1996) Measuring the effect of a hygiene behaviour intervention by indicators of behaviour and diarrhoeal disease. Transactions of the Royal Society of Tropical Medicine and Hygiene 90, 366-371. Ref ID : 7269
Pinfold, J. (1999) Analysis of different communication channels for promoting hygiene behaviour. Health Education Research: Theory and Practice 14, 629-639.Ref ID : 8592
Target Group/Country Rural North-east Thailand
Intervention Methodology A social marketing approach used a variety of media: stickers, posters, leaflets, comic books, songs, slide shows, T shirts and badges). Songs and dramas were broadcast on village loudspeakers. Schools were involved. One community received a higher cost intervention with more media and distribution of free soap. .
Evaluation Method Knowledge questionnaires, observations of dishwashing behaviour and fingertip microbiological assays to measure changes in hand washing behaviour were carried out before and after interventions for Control (n=166), low cost intervention (n=195) and high cost intervention (n=192). and observation (spot checks) of dirty dishes to indicate dish washing practice. Active surveillance was initiated for diearrhoeal disease after the intervention during the seasonal peak of summer diarrhoea.
Impact Achieved Fingertip contamination was reduced in the low cost intervention by 55%(p<0.001) and 65%(p<0,001) compared to 34% in controls. There was no apparent change in dishwashing behaviour by control group and significant improvements (p<0.05) in both intervention groups. There was 39% less diarrhoea in the intervention villages (p<0.05) than the control.
Shahid, N.S., Greenough, W.B.,3rd, Samadi, A.R., Huq, M.I., and Rahman, N. (1966) Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. Journal of Diarrhoeal Diseases R
Target Group/Country A periurban slum of Dhaka city
Intervention Methodology Half a bar of soap provided twice a week to intervention communities for handwashing and separate soap provided for washing clothes. Community health workers were trained and visited communities on a daily basis to reinforce handwashing education and record water/soap use.
Evaluation Method Base line and continuing surveillance of all family members in intervention (n=671) and control (n=671) communities every two days for a year to determine diarrhoea levels and take rectal swabs to establish aetiologies..
Impact Achieved There was a large (2.6 fold) reduction in diarrhoeal episodes in the intervention area during the observation period. Significant reduction in diarrhoeal incidences was observed in all age groups for all pathogens except for rotavirus.
Stanton, B.F. and Clemens, J.D. (1987) An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhoea in urban Bangladesh. II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhoea. American Journal of Epidemiology 125(2):292-301. Ref ID :6025
Stanton, B.F., Clemens, J.D., Khair, T., Khatun, K., and Jahan, D.A. (1987). An educational intervention for altering water-sanitation behaviours to reduce childhood diarrhoea in urban Bangladesh: formulation, preparation and delivery of educational intervention. Social Science & Medicine 24(3):275-283.Ref ID : 3095
Stanton, B.F., Clemens, J.D., and Khair, T. (1988) Educational intervention for altering water-sanitation behaviour to reduce childhood diarrhoea in urban Bangladesh: impact on nutritional status. American Journal of Clinical Nutrition 48(5):1166-1172. Ref ID : 3091
Target Group/Country Urban slum communities in Dhaka, Bangladesh
Intervention Methodology The intervention was carried out by trainers and community health volunteers consisted of small group discussions for women and children, larger demonstrations to mixed audiences and community wide planning and action meetings which included husbands. Sessions were carried out intensively for 8 weeks with a follow-up programme afterwards and methods included games, stories posters and flexi-flans. The intervention targeted 3 three water-sanitation behaviours handwashing before preparing food, disposal of children’s faeces, disposal of garbage and faeces.
Evaluation Method Fifty-one communities, each comprising 38 families with children <6 yrs , were randomized either to receive (n = 937 families/25 communities) or not to receive (n = 986/26) the intervention. All families were visited every two weeks over five month period to determine diarrhoea histories and an observational visit was made to 102 intervention and 115 control families. A baseline survey of heights and weights of children was carried out and repeated at three months intervals.
Impact Achieved After intervention more mothers washed their hands before preparing food in the intervention areas (39779, 49% p<0.05) than in control areas (25/75, 33%). There was no decrease in other targeted behaviours. During the six months after the intervention, the rate of diarrhoea (per 100 person-weeks) in children under six years of age was 4.3 in the intervention communities and 5.8 in the control communities (26% protective efficacy; p < 0.0001). A corresponding improvement in handwashing practices before preparing food was noted, although no improvement was observed for defecation and waste disposal practices. There was no significant difference in nutritional status between the intervention and control communities.
Wilson, J.M. and Chandler, G.N. (1993) Sustained improvements in hygiene behaviour amongst village women in Lombok, Indonesia. Transactions of the Royal Society of Tropical Medicine and Hygiene 87(6):615-616. Ref ID : 809 Borderline for inclusion in database
Target Group/Country Mothers in Lombok, Indonesia
Intervention Methodology At two weekly intervals over a 4 month period two community organizers spent 2 to 3 days in the village worked with 65 mothers of children under 11. Soap and a plastic soap box were given out. Informal discussion encouraged women to wash their hands and their children's hands after defaecation and before preparing food. When they noticed children's faeces on the ground they encouraged mothers to put them away.
Evaluation Method Follow-up of 57 mothers 2 years later. A blinded survey was carried out in that questions on illness experiences were carried out by an interviewer who was not told the real purpose of the study. Controls are mentioned but no data is presented.
Impact Achieved Two years after the intervention, 79% of mothers were still using hand soap, despite the fact that they now had to buy it themselves. The diarrhoea incidence rate had declined from 3 to 0.33 episodes/100 children/week immediately after the intervention and by the end of the 2 years had increased to 1. This small scale study is of interest in showing continuation of use of soap however its value is limited by the lack of a clearly defined control and supporting data/statistical analysis of the information on diarrhoea incidence.
14.5 School-based activities
Bilqis, A.H., Ali, N., Zeitlyn, S., Yahya, F.S.M., and Shaheed, N.M. (1994). Promoting sanitation in Bangladesh. World Health Forum 15(4):358-362. Ref ID : 760. (Borderline for inclusion in database)
Target Group/Country Communities in Banaripara Thana of Barisal District (170,000 population) in rural Bangladesh
Intervention Methodology A one day orientation meeting for local organizations was followed up by 'courtyard meetings' in communities and with financial incentives for schools to use pupils to motivate families to build latrines. Attempts were made to involve the local high schools, religious schools, religious leaders and other local leaders in sanitation activities. In November 1990 the District Commissioner of Barisal District announced that the school which achieved the highest sanitation coverage in its catchment are would be rewarded with a contribution towards its development fund. This encouraged the local schools to arrange meetings with their pupils and other people to promote sanitation and demonstrate the construction of latrines. teachers asked their pupils to build sanitary latrines for their homes. they also formed groups of eighth grade pupils and went into their local communities to promote the programme. These activities went on until the end of 1991 and three schools won awards)
Evaluation Method Survey of random sample of 210 households from 30 villages. No controls or baseline.
Impact Achieved 153 (73%) of families reported owning latrines, 18% said they had latrines before programme. Almost all (91%) of those who had built latrines during the programme reported that they had received communications about latrines from school pupils. Surprisingly, when the project team visited three schools (It is not clear from the paper whether they were the award-winning schools or three other schools) the state of latrines was very poor and publicity materials - leaflets, charts and posters were locked in the headmaster's office!
Hope, R., Carter, C.A., and Rai, I.M. (1988) Utilizing education infrastructure for primary health care. Trop.Doct. 18(1):37-39. Ref ID : 1273 Borderline for inclusion in database
Target Group/Country Secondary schools serving 30,000 people living in scattered communities over the steep foothills of the Himalaya in East Nepal
Intervention Methodology Training of 400 secondary school students the knowledge and skills necessary for building domestic pit latrines in their villages. The schools built demonstration latrines in village markets and used home made posters and leaflets to persuade villagers to build latrines at their homes. At the end of the pilot phase of the project certificates were given to all families having a pit latrine and a cash prize was awarded to the family with the highest score on the evaluation questionnaire.
At the end of the 4 week building period there were 150 completed domestic pit latrines and 45 pits or partially complete latrines. Only 50% of latrines had functioning covers over holes. When asked why they were building latrines, families without secondary school students often answered "everybody is building them, so we must too". It seemed that people could understand the convenience of privacy in an area where there was no jungle cover, but did not appreciate the hygiene reasons for using pit latrines. This study showed the value of personal example in communities and is of interest in demonstrating that a school-based intervention can reach the community. A limitation is the lack of any raw data.
Evaluation Method Monitored the construction of new latrines within the pilot area (no baseline or controls). At each complete latrine a member of the family *not a secondary school pupil) was interviewed using an evaluation questionnaire (provided in the report),
Impact Achieved At the end of the 4 week building period there were 150 completed domestic pit latrines and 45 pits or partially complete latrines. Only 50% of latrines had functioning covers over holes. When asked why they were building latrines, families without secondary school students often answered "everybody is building them, so we must too". It seemed that people could understand the convenience of privacy in an area where there was no jungle cover, but did not appreciate the hygiene reasons for using pit latrines. This study showed the value of personal example in communities and is of interest in demonstrating that a school-based intervention can reach the community. A limitation is the lack of any raw data.
Mwasha, E. (1996) Schoolchildren help solve sanitation problems in Tanzania. Waterlines 14(3):21..Ref ID : 7387 Borderline for inclusion in database
Mwasha,E.S. (1994) The HESAWA school health and sanitation package, Mwanza, Tanzania: Zonal HESAWA Coordination Office.Ref ID: 8745
Target Group/Country Rural districts in Tanzania around lake Victoria
Intervention Methodology 'The Health through Sanitation and Water' project (HESAWA) in 1993 around uses a problem-based learning methodology. Its approach consists of screening schoolchildren for the presence of intestinal worms, checking their levels of haemoglobin and evaluation of their nutrition status.
Evaluation Method Prior to the screening exercise, between 20 and 30 senior pupils visit each home in the village, in pairs, to collect basic information on the current state of latrines, refuse pits and drying racks. After the screening has been completed and the results have been compiled by the health team and the teachers, the village chairman invites parents to a meeting at which they are given a written report on their children's health and the parents are involved in discussing the problems, causes and solutions
Impact Achieved As example of impact in Bwanga village, three months after the project began there were seven demonstration latrines in different schools, 305 new household latrines had been built, the number of households with refuse pits had increased from 22 to 63% and dish racks had risen by 33% to 77%. An evaluation by AMREF found that HESAWA schools had performed better than control villages in the construction of latrines, dish racks and refuse pits
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