Volume 101, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Trachoma is the leading infectious cause of blindness, and facial cleanliness is associated with reduced odds of trachomatous inflammation and infection, but there is little evidence of how to drive this behavior change at scale. We report the results of a program integrating face washing into a school-based handwashing promotion program in Turkana County, Kenya. Children aged 5–15 years participated in an intervention delivered to schools in two phases, along with a third phase receiving the intervention after the evaluation, which served as a control. The primary outcome was the number of face washing events that took place when handwashing occurred, which was measured by a 3-hour structured observation at all 67 schools, and a total of 3,871 handwashing events were observed. Differences in observed in face washing behavior between each phase and the control schools were calculated using log-binomial regression with clustering at the school level, whereas survey responses on knowledge of trachoma transmission and prevention were compared using χ tests adjusted for clustering at the school level. Face washing during handwashing events was higher in schools after 12 months (59.3%) and 20 months (44.2%) than in control schools (18.7%, < 0.001). Trachoma knowledge was higher in schools evaluated after 12 months (80%) and 20 months (70%) than in control schools (42%, < 0.001), and knowledge of some of key preventive behaviors was higher in intervention schools. Integrating face washing messages into school-based handwashing promotion programs increased face washing, which may help to prevent trachoma when combined with other interventions.

[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.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. World Health Organization, 2017. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report on elimination of trachoma, 2014–2016. Wkly Epidemiol Rec 92: 359368. [Google Scholar]
  2. World Health Organization, 2018. Trachoma Fact Sheet. Geneva, Switzerland: WHO. [Google Scholar]
  3. Pascolini D, Mariotti SP, , 2012. Global estimates of visual impairment: 2010. Br J Ophthalmol 96: 614618. [Google Scholar]
  4. World Health Organization, 2003. Report of the 2nd Global Scientific Meeting on Trachoma. Geneva, Switzerland. WHO. [Google Scholar]
  5. Mariotti SP, Pascolini D, Rose-Nussbaumer J, , 2009. Trachoma: global magnitude of a preventable cause of blindness. Br J Ophthalmol 93: 563568. [Google Scholar]
  6. World Health Organization, 2018. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report on elimination of trachoma, 2017. Wkly Epidemiol Rec 93: 371380. [Google Scholar]
  7. Burton M, Habtamu E, Ho D, Gower EW, , 2015. Interventions for trachoma trichiasis. Cochrane Database Syst Rev 2015: CD004008. [Google Scholar]
  8. Evans JR, Solomon AW, , 2011. Antibiotics for trachoma. Cochrane Database Syst Rev 3: CD001860. [Google Scholar]
  9. Rabiu M, Alhassan MB, Ejere HO, Evans JR, , 2012. Environmental sanitary interventions for preventing active trachoma. Cochrane Database Syst Rev 2: CD004003. [Google Scholar]
  10. Ejere HO, Alhassan MB, Rabiu M, , 2015. Face washing promotion for preventing active trachoma. Cochrane Database Syst Rev 2: CD003659. [Google Scholar]
  11. Ngondi J, Gebre T, Shargie EB, Adamu L, Teferi T, Zerihun M, Ayele B, King JD, Cromwell EA, Emerson PM, , 2010. Estimation of effects of community intervention with antibiotics, facial cleanliness, and environmental improvement (A, F, E) in five districts of Ethiopia hyperendemic for trachoma. Br J Ophthalmol 94: 278281. [Google Scholar]
  12. Ngondi J, Matthews F, Reacher M, Baba S, Brayne C, Emerson P, , 2008. Associations between active trachoma and community intervention with antibiotics, facial cleanliness, and environmental improvement (A, F, E). PLoS Negl Trop Dis 2: e229. [Google Scholar]
  13. Rog M, Swenor B, Cajas-Monson LC, McHiwe W, Kiboko S, Mkocha H, West S, , 2011. A cross-sectional survey of water and clean faces in trachoma endemic communities in Tanzania. BMC Public Health 11: 495. [Google Scholar]
  14. Dodson S, Heggen A, Solomon AW, Sarah V, Woods G, Wohlgemuth L, , 2018. Behavioural change interventions for sustained trachoma elimination. Bull World Health Organ 96: 723725. [Google Scholar]
  15. Delea MG, Solomon H, Solomon AW, Freeman MC, , 2018. Interventions to maximize facial cleanliness and achieve environmental improvement for trachoma elimination: a review of the grey literature. PLoS Negl Trop Dis 12: e0006178. [Google Scholar]
  16. Ferrer RA, Klein WM, , 2015. Risk perceptions and health behavior. Curr Opin Psychol 5: 8589. [Google Scholar]
  17. Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, Amnie AG, Beckwith C, Cairncross S, Callejas R, Colford JM, Jr., 2013. Integration of water, sanitation, and hygiene for the prevention and control of neglected tropical diseases: a rationale for inter-sectoral collaboration. PLoS Negl Trop Dis 7: e2439. [Google Scholar]
  18. Waite RC, Woods G, Velleman Y, Freeman MC, , 2017. Collaborating to develop joint water, sanitation and hygiene (WASH) and neglected tropical disease (NTD) sector monitoring: an expert consultation. Int Health 9: 215225. [Google Scholar]
  19. World Health Organization, 2015. Water Sanitation & Hygiene for Accelerating and Sustaining Progress on Neglected Tropical Diseases: a Global Strategy 2015–2020. Geneva, Switzerland: WHO. [Google Scholar]
  20. Boisson S, Engels D, Gordon BA, Medlicott KO, Neira MP, Montresor A, Solomon AW, Velleman Y, , 2016. Water, sanitation and hygiene for accelerating and sustaining progress on neglected tropical diseases: a new Global Strategy 2015–20. Int Health 8: i19i21. [Google Scholar]
  21. Townsend J, Greenland K, Curtis V, , 2017. Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China. Trop Med Int Health 22: 7481. [Google Scholar]
  22. Nicholson JA, Naeeni M, Hoptroff M, Matheson JR, Roberts AJ, Taylor D, Sidibe M, Weir AJ, Damle SG, Wright RL, , 2014. An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Trop Med Int Health 19: 284292. [Google Scholar]
  23. McGuinness SL, Fiona Barker S, O’Toole J, Cheng AC, Forbes AB, Sinclair M, Leder K, , 2018. Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low‐and middle‐income countries: a systematic review. Trop Med Int Health 23: 816833. [Google Scholar]
  24. Wolf J, Hunter PR, Freeman MC, Cumming O, Clasen T, Bartram J, Higgins JP, Johnston R, Medlicott K, Boisson S, , 2018. Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta‐analysis and meta‐regression. Trop Med Int Health 23: 508525. [Google Scholar]
  25. Stocks ME, Ogden S, Haddad D, Addiss DG, McGuire C, Freeman MC, , 2014. Effect of water, sanitation, and hygiene on the prevention of trachoma: a systematic review and meta-analysis. PLoS Med 11: e1001605. [Google Scholar]
  26. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB, , 2011. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med 8: e1001052. [Google Scholar]
  27. Sightsavers, 2019. Super School of Five. Available at: https://www.sightsavers.org/programmes/super-school-of-5/. Accessed February 1, 2019. [Google Scholar]
  28. Unilever PLC, 2015. Lifebuoy Way of Life: Towards Universal Handwashing with Soap, Social Mission Report. Available at: https://www.unilever.com/Images/lifebuoy-way-of-life-2015_tcm244-418692_en.pdf. Accessed February 1, 2019. [Google Scholar]
  29. Kenya Ministry of Health, 2016. The 2nd Kenya National Strategic Plan for Control of Neglected Tropical Diseases 2016–2020. Available at: http://espen.afro.who.int/system/files/content/resources/KENYA_NTD_Master_Plan_2016_2020.pdf. [Google Scholar]
  30. Ngugi E, Kipruto S, Samoei P, , 2013. Exploring Kenya’s Inequality: Pulling Apart or Pooling Together. Nairobi, Kenya: Kenya National Bureau of Statistics and Society for International Development. [Google Scholar]
  31. World Health Organization, 2018. Design Parameters for Population-Based Trachoma Prevalence Surveys. (WHO/HTM/NTD/PCT/2018.07). Geneva, Switzerland: WHO. [Google Scholar]
  32. Curtis VA, Danquah LO, Aunger RV, , 2009. Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res 24: 655673. [Google Scholar]
  33. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V, , 2014. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2: 145154. [Google Scholar]
  34. Donner A, , 1989. Statistical Methods in Ophthalmology: An Adjusted Chi-Square Approach. Biometrics 45: 605611. [Google Scholar]
  35. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ, , 2015. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ 350: h391. [Google Scholar]
  36. Ram PK, 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. [Google Scholar]
  37. West SK, Ansah D, Munoz B, Funga N, Mkocha H, , 2017. The “F” in SAFE: reliability of assessing clean faces for trachoma control in the field. PLoS Negl Trop Dis 11: e0006019. [Google Scholar]
  38. King JD, Ngondi J, Kasten J, Diallo MO, Zhu H, Cromwell EA, Emerson PM, , 2011. Randomised trial of face-washing to develop a standard definition of a clean face for monitoring trachoma control programmes. Trans R Soc Trop Med Hyg 105: 716. [Google Scholar]
  39. Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R, , 2018. Comparing the behavioural impact of a nudge‐based handwashing intervention to high‐intensity hygiene education: a cluster‐randomised trial in rural Bangladesh. Trop Med Int Health 23: 1025. [Google Scholar]

Data & Media loading...

  • Received : 13 May 2019
  • Accepted : 20 May 2019
  • Published online : 05 Aug 2019

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error