Volume 94, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



To better understand the risks of exposure for young children to fecal contamination in their environment, we systematically characterized and quantified behaviors of 154 children, 0–5 years old, in four high-density, low-income neighborhoods in Accra, Ghana. A repertoire of six different activities and five different compartments (categories of locations within the household) was developed, and about 500 hours of ordered structured observations of activities and locations of individual children were collected. These records were analyzed using a competing hazards model, estimating (Weibull) hazard rates for each state (activity/compartment combination), dependent on the present state and the preceding state. The estimated rates were used to simulate sequences of behavior and describe days in the life of a child in low-income, urban Africa. Children younger than 1 year spent most time playing or sleeping off the ground, older children frequently played on floors. Relatively little time was spent in drains or wet trash areas. Critical combinations of activities, like handwashing after defecation or before eating were estimated to occur rarely. These quantitative behavior estimates can inform future risk assessments that examine the relative roles of various fecal–oral exposure pathways in low-income urban settings.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE, Child Health Epidemiology Reference Group of WHO and UNICEF; , 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 21512161.[Crossref] [Google Scholar]
  2. Moe CL, Rheingans RD, , 2006. Global challenges in water, sanitation and health. J Water Health 4 (Suppl 1): 4157. [Google Scholar]
  3. Preston SH, Van de Walle E, , 1978. Urban French mortality in the nineteenth century. Population Studies 32: 275297.[Crossref] [Google Scholar]
  4. Eyler JM, , 1973. William Farr on the cholera: the sanitarian's disease theory and the statistician's method. J Hist Med Allied Sci 28: 79100.[Crossref] [Google Scholar]
  5. Aiello AE, Larson EL, , 2008. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2: 103110.[Crossref] [Google Scholar]
  6. Humphrey JH, , 2009. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 374: 10321035.[Crossref] [Google Scholar]
  7. Genser B, Strina A, Teles CA, Prado MS, Barreto ML, , 2006. Risk factors for childhood diarrhea incidence: dynamic analysis of a longitudinal study. Epidemiology 17: 658667.[Crossref] [Google Scholar]
  8. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM, , 2004. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA 291: 25472554.[Crossref] [Google Scholar]
  9. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, , 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 4252.[Crossref] [Google Scholar]
  10. Briscoe J, , 1984. Intervention studies and the definition of dominant transmission routes. Am J Epidemiol 120: 449455.[Crossref] [Google Scholar]
  11. Julian TR, Pickering AJ, , 2014. A pilot study on integrating videography and environmental microbial sampling to model fecal bacterial exposures in peri-urban Tanzania. PLoS One 10: e0136158e0136158.[Crossref] [Google Scholar]
  12. Sanipath Project Website. Available at: http://www.sanipath.org/. Accessed December 8, 2015.
  13. Peprah DI, Baker K, Moe C, Robb K, Wellington N, Yakubu H, Null C, , 2015. Public toilets and their customers in low-income, urban Accra, Ghana. Environ Urban 27: 589604.[Crossref] [Google Scholar]
  14. Csardi G, , 2014. igraph: An R Package for Network Analysis, Version 0.7.0. Available at: http://igraph.org. Accessed June 27, 2015. [Google Scholar]
  15. Prentice RL, Kalbfleisch JD, Peterson AV, Flournoy N, Farewell VT, Breslow NE, , 1978. The analysis of failure times in the presence of competing risks. Biometrics 34: 541554.[Crossref] [Google Scholar]
  16. Martinussen T, Scheike TH, , 2006. Dynamic Regresssion Models for Survival Data. Series: Statistics for Biology and Health. New York, NY: Springer. [Google Scholar]
  17. Adubofour K, , 2010. Sanitation Survey of Aboabo and Asawase. Technical Report, Department of Environmental Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. [Google Scholar]
  18. Fawzi M, Gomaa NF, Bakr WM, , 2009. Assessment of hand washing facilities, personal hygiene and the bacteriological quality of hand washes in some grocery and dairy shops in Alexandria, Egypt. J Egypt Public Health Assoc 84: 7193. [Google Scholar]
  19. Idowu OA, Rowland SA, , 2006. Oral fecal parasites and personal hygiene of food handlers in Abeokuta, Nigeria. Afr Health Sci 6: 160164. [Google Scholar]
  20. Whittington D, Lauria DT, Choe K, Hughes JA, Swarna V, Wright AM, , 1993. Household sanitation in Kumasi, Ghana: a description of current practices, attitudes, and perceptions. World Dev 21: 733748.[Crossref] [Google Scholar]
  21. Scott BE, Lawson DW, Curtis V, , 2007. Hard to handle: understanding mothers' handwashing behaviour in Ghana. Health Policy Plan 22: 216224.[Crossref] [Google Scholar]
  22. Ngure FM, Humphrey JH, Mbuya MNN, Majo F, Mutasa K, Govha M, Mazarura E, Chasekwa B, Prendergast AJ, Curtis V, Boor KJ, Stoltzfus RJ, , 2013. Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria. Am J Trop Med Hyg 89: 709716.[Crossref] [Google Scholar]
  23. Machdar E, van der Steen NP, Raschid-Sally L, Lens PNL, , 2013. Application of quantitative microbial risk assessment to analyze the public health risk from poor drinking water quality in a low income area in Accra, Ghana. Sci Total Environ 449C: 134142.[Crossref] [Google Scholar]
  24. USEPA, 2005. Exposure Factors Handbook. Technical Report. United States Environmental Protection Agency, Office of Research and Development, National Center for Environmental Assessment, Washington, DC. Available at: http://www.epa.gov/ncea/pdfs/efh/efh-complete.pdf. Accessed September 5, 2013. [Google Scholar]
  25. Ansari SA, Sattar SA, Springthorpe VS, Wells GA, Tostowaryk W, , 1988. Rotavirus survival on human hands and transfer of infectious virus to animate and nonporous inanimate surfaces. J Clin Microbiol 26: 15131518. [Google Scholar]
  26. Kaltenthaler EC, Elsworth AM, Schweiger MS, Mara DD, Braunholtz DA, , 1995. Faecal contamination on children's hands and environmental surfaces in primary schools in Leeds. Epidemiol Infect 115: 527534.[Crossref] [Google Scholar]
  27. Gibson LL, Rose JB, Haas CN, Gerba CP, Rusin PA, , 2002. Quantitative assessment of risk reduction from hand washing with antibacterial soaps. J Appl Microbiol Symposium 92 (Suppl): 136S143S.[Crossref] [Google Scholar]
  28. Black K, Shalat SL, Freeman NCG, Jimenez M, Donnelly KC, Calvin JA, , 2005. Children's mouthing and food-handling behavior in an agricultural community on the US/Mexico border. J Expo Anal Environ Epidemiol 15: 244251.[Crossref] [Google Scholar]
  29. AuYeung W, Canales RA, Leckie JO, , 2008. The fraction of total hand surface area involved in young children's outdoor hand-to-object contacts. Environ Res 108: 294299.[Crossref] [Google Scholar]
  30. Whitman RL, Przybyla-Kelly K, Shively DA, Nevers MB, Byappanahalli MN, , 2009. Hand-mouth transfer and potential for exposure to E. coli and F+ coliphage in beach sand, Chicago, Illinois. J Water Health 7: 623629.[Crossref] [Google Scholar]
  31. Ram PK, Jahid I, Halder AK, Nygren B, Islam MS, Granger SP, Molyneaux JW, Luby SP, , 2011. Variability in hand contamination based on serial measurements: implications for assessment of hand-cleansing behavior and disease risk. Am J Trop Med Hyg 84: 510516.[Crossref] [Google Scholar]
  32. Berry TD, Fournier AK, Porter BE, , 2012. Developing and testing a touch-path model for hand hygiene and pathogen risk design-behavior assessment of fast-food restaurant restrooms. Environ Behav 44: 451473.[Crossref] [Google Scholar]
  33. Genser B, Strina A, dos Santos LA, Teles CA, Prado MS, Cairncross S, Barreto ML, , 2008. Impact of a city-wide sanitation intervention in a large urban centre on social, environmental and behavioural determinants of childhood diarrhoea: analysis of two cohort studies. Int J Epidemiol 37: 831840.[Crossref] [Google Scholar]
  34. Pickering AJ, Julian TR, Mamuya S, Boehm AB, Davis J, , 2011. Bacterial hand contamination among Tanzanian mothers varies temporally and following household activities. Trop Med Int Health 16: 233239.[Crossref] [Google Scholar]
  35. Harvey SA, Olortegui MP, Leontsini E, Winch PJ, , 2009. “They'll change what they're doing if they know that you're watching”: measuring reactivity in health behavior because of an observer's presence—a case from the Peruvian Amazon. Field Methods 21: 325.[Crossref] [Google Scholar]
  36. Ram PK, Halder AK, Granger SP, Jones T, Hall P, Hitchcock D, Wright R, Nygren B, Islam MS, Molyneaux JW, Luby SP, , 2010. 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 83: 10701076.[Crossref] [Google Scholar]
  37. Ferguson AC, Canales RA, Beamer P, AuYeung W, Key M, Munninghoff A, Lee KTW, Robertson A, Leckie JO, , 2006. Video methods in the quantification of children's exposures. J Expo Sci Environ Epidemiol 16: 287298.[Crossref] [Google Scholar]
  38. Leszczyc PTLP, Timmermans H, , 2002. Unconditional and conditional competing risk models of activity duration and activity sequencing decisions: an empirical comparison. J Geogr Syst 4: 157170.[Crossref] [Google Scholar]

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Supplementary PDF

  • Received : 05 Jun 2015
  • Accepted : 18 Dec 2015
  • Published online : 06 Apr 2016

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