Aiello AE , Larson EL , 2002. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2: 103–110.
Ejere HO , Alhassan MB , Rabiu M , 2015. Face washing promotion for preventing active trachoma. Cochrane Database Syst Rev 2015: CD003659.
Freeman MC et al., 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.
Prüss-Ustün A et al., 2014. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894–905.
Curtis V , 2003. Talking dirty: how to save a million lives. Int J Environ Health Res 13 (Suppl 1): S73–S79.
Delea MG , Snyder JS , Belew M , Caruso BA , Garn JV , Sclar GD , Woreta M , Zewudie K , Gebremariam A , Freeman MC , 2019. Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol. BMC Public Health 19: 801.
Tidwell JB , Fergus C , Gopalakrishnan A , Sheth E , Sidibe M , Wohlgemuth L , Jain A , Woods G , 2019. Integrating face washing into a school-based, handwashing behavior change program to prevent trachoma in Turkana, Kenya. Am J Trop Med Hyg 101: 767–773.
Brauer M , Zhao JT , Bennitt FB , Stanaway JD , 2020. Global access to handwashing: implications for COVID-19 control in low-income countries. Environ Health Perspect 128: 57005.
Freeman MC et al., 2014. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 19: 906–916.
Roche R , Bain R , Cumming O , 2017. A long way to go – estimates of combined water, sanitation and hygiene coverage for 25 sub-Saharan African countries. PLoS One 12: e0171783.
Aiemjoy K et al., 2016. “If an eye is washed properly, it means it would see clearly”: a mixed methods study of face washing knowledge, attitudes, and behaviors in rural Ethiopia. PLoS Negl Trop Dis 10: e0005099.
Luby SP , Agboatwalla M , Bowen A , Kenah E , Sharker Y , Hoekstra RM , 2009. Difficulties in maintaining improved handwashing behavior, Karachi, Pakistan. Am J Trop Med Hyg 81: 140–145.
Najnin N et al., 2019. Impact of a large-scale handwashing intervention on reported respiratory illness: findings from a cluster-randomized controlled trial. Am J Trop Med Hyg 100: 742–749.
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.
White S , Thorseth AH , Dreibelbis R , Curtis V , 2020. The determinants of handwashing behaviour in domestic settings: an integrative systematic review. Int J Hyg Environ Health 227: 113512.
Contzen N , Meili IH , Mosler H-J , 2015. Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med 124: 103–114.
Curtis V , Cousens S , Mertens T , Traore E , Kanki B , Diallo I , 1993. Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility. Bull World Health Organ 71: 23–32.
Luby SP , Halder AK , 2008. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med Int Health 13: 835–844.
Manun’Ebo M , Cousens S , Haggerty P , Kalengaie M , Ashworth A , Kirkwood B , 1997. Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaïre. Trop Med Int Health 2: 1015–1021.
Halder AK , Tronchet C , Akhter S , Bhuiya A , Johnston R , Luby SP , 2010. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.
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.
Biran A , Rabie T , Schmidt W , Juvekar S , Hirve S , Curtis V , 2008. Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop Med Int Health 13: 278–285.
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: 7–16.
Delea MG , Snyder JS , Woreta M , Zewudie K , Solomon AW , Freeman MC , 2020. Development and reliability of a quantitative personal hygiene assessment tool. Int J Hyg Environ Health 227: 113521.
Freeman MC et al., 2022. The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: a cluster-randomized trial. PLOS Glob Public Health 2: e0000056.
Ethiopia Demographic and Health Survey 2016, 2016. Available at: https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf. Accessed January 28, 2021.
Contzen N , Mosler H-J , 2015. Identifying the psychological determinants of handwashing: results from two cross-sectional questionnaire studies in Haiti and Ethiopia. Am J Infect Control 43: 826–832.
Friedrich MND , Binkert ME , Mosler H-J , 2017. Contextual and psychosocial determinants of effective handwashing technique: recommendations for interventions from a case study in Harare, Zimbabwe. Am J Trop Med Hyg 96: 430–436.
George CM et al., 2017. Psychosocial factors mediating the effect of the CHoBI7 intervention on handwashing with soap: a randomized controlled trial. Health Educ Behav 44: 613–625.
Open Data Kit , 2018.Open Data Kit. Available at: https://opendatakit.org/. Accessed September 13, 2022.
Parvez SM et al., 2019. Microbiological contamination of young children’s hands in rural Bangladesh: associations with child age and observed hand cleanliness as proxy. PLoS One 14: e0222355.
Young SL , Boateng GO , Jamaluddine Z , Miller JD , Frongillo EA , Neilands TB , Collins SM , Wutich A , Jepson WE , Stoler J ; HWISE Research Coordination Network , 2019. The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries. BMJ Glob Health 4: e001750.
UNICEF & WHO , 2018. Core Questions on Water, Sanitation, and Hygiene for Household Surveys: 2018 Update. Available at: https://washdata.org/sites/default/files/documents/reports/2019-03/JMP-2018-core-questions-for-household-surveys.pdf. Accessed April 21, 2021.
Flay B , Petraitis J , 1994. The theory of triadic influence: a new theory of health behavior with implications for preventive interventions. Adv Med Sociol 4: 19–44.
Mosler H-J , 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431–449.
Michie S , van Stralen MM , West R , 2011. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 42.
Abdi H , Williams LJ , 2010. Principal component analysis: principal component analysis. WIREs Comp Stat 2: 433–459.
Rutstein SO , Johnson K , 2004. The DHS Wealth Index DHS Comparative Reports No. 6. Gaithersburg, MD: Demographic and Health Surveys Program, USAID.
Donneau AF , Mauer M , Coens C , Bottomley A , Albert A , 2014. Longitudinal quality of life data: a comparison of continuous and ordinal approaches. Qual Life Res 23: 2873–2881.
McCullagh P , 1980. Regression models for ordinal data. J R Stat Soc B 42: 109–127.
R Core Team , 2020. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.
Nounkeu C , Kamgno J , Dharod J , 2019. Assessment of the relationship between water insecurity, hygiene practices, and incidence of diarrhea among children from rural households of the Menoua Division, West Cameroon. J Public Health Africa 10: 951.
Polack S , Kuper H , Solomon AW , Massae PA , Abuelo C , Cameron E , Valdmanis V , Mahande M , Foster A , Mabey D , 2006. The relationship between prevalence of active trachoma, water availability and its use in a Tanzanian village. Trans R Soc Trop Med Hyg 100: 1075–1083.
Seimetz E , Boyayo A-M , Mosler H-J , 2016. The influence of contextual and psychosocial factors on handwashing. Am J Trop Med Hyg 94: 1407–1417.
Stoler J , Jepson WE , Wutich A , 2020. Beyond handwashing: water insecurity undermines COVID-19 response in developing areas. J Glob Health 10: 010355.
Contzen N , De Pasquale S , Mosler H-J , 2015. Over-reporting in handwashing self-reports: potential explanatory factors and alternative measurements. PLoS One 10: e0136445.
Hutton G , Chase C , 2016. The knowledge base for achieving the sustainable development goal targets on water supply, sanitation and hygiene. Int J Environ Res Public Health 13: 536.
O’Boyle CA , Henly SJ , Larson E , 2001. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 29: 352–360.
De Wandel D , Maes L , Labeau S , Vereecken C , Blot S , 2010. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 19: 230–239.
Chen X , Munoz B , Wolle MA , Woods G , Odonkor M , Naufal F , Mkocha H , West SK , 2021. Environmental factors and hygiene behaviors associated with facial cleanliness and trachoma in Kongwa, Tanzania. PLoS Negl Trop Dis 15: e0009902.
Sanders AM et al., 2021. Evaluation of facial cleanliness and environmental improvement activities: lessons learned from Malawi, Tanzania, and Uganda. PLoS Negl Trop Dis 15: e0009962.
Armstrong RA , 2014. When to use the Bonferroni correction. Ophthalmic Physiol Opt 34: 502–508.
Perneger TV , 1998. What’s wrong with Bonferroni adjustments. BMJ 316: 1236–1238.
Rothman KJ , 1990. No adjustments are needed for multiple comparisons. Epidemiology 1: 43–46.
Past two years | Past Year | Past 30 Days | |
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Abstract Views | 294 | 294 | 39 |
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Many water, sanitation, and hygiene (WASH) interventions target improvements in personal hygiene behaviors. Yet measuring personal hygiene behaviors is a challenge due to a lack of reliable, valid, objective, and simple-to-use approaches. The purpose of this study was to examine differences between two types of hygiene outcome measures and their ability to detect relationships between WASH-related behavioral factors and behaviors. We compared hygiene outcomes generated by the Quantitative Personal Hygiene Assessment Tool (qPHAT), which yields objective measures of cleanliness on an 11-point scale, and those generated by conventional, dichotomous indicators of cleanliness. We used cross-sectional data on hygiene outcomes related to facial and hand cleanliness collected during the Andilaye Trial, an impact evaluation of a community-based WASH intervention implemented in Amhara, Ethiopia. We fit multivariable models to examine associations between measures of children’s facial and hand cleanliness, via both qPHAT and dichotomous indicators, and 1) household WASH conditions, 2) psychosocial factors, and 3) reported personal hygiene practices. The qPHAT-generated outcomes were able to detect relationships between intermediate behavioral factors and hygiene outcomes that dichotomous indicators were not, including associations with water insecurity and various psychosocial factors. qPHAT-generated outcomes were negatively associated with reported face washing practices, suggesting a bias in reported behaviors. Our study highlights the limitations of reported practices and dichotomous hygiene indicators and indicates that using more quantitative hygiene outcome measures, such as those generated by qPHAT, may reveal important intermediate factors that influence hygiene behavior and support improved monitoring and evaluation of interventions.
Financial support: This work was supported by the
Disclosure: Inputs from the World Bank Group and 3ie influenced some aspects of the study design. The funders have otherwise played no role in the design of the study; collection, analysis, or interpretation of the data; or writing of the manuscript. The Andilaye Trial and its sub-studies received ethical approval from Emory University's Institutional Review Board (IRB00076141) and the Amhara Regional Health Bureau Research Ethics Review Committee (HRTT0135909). Fieldworkers provided study participants details regarding the study prior to requesting consent to participate, and took steps to ensure confidentiality.
Authors’ addresses: Rebecca S. Kann, Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, and Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, E-mail: rkann@uw.edu. Jedidiah S. Snyder, Matthew C. Freeman, and Maryann G. Delea, Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, E-mails: jedidiah.snyder@emory.edu, matthew.freeman@emory.edu, and mdelea@emory.edu. Mulat Woreta and Kassahun Zewudie, Emory Ethiopia, Bahir Dar, Ethiopia, E-mails: mulatworeta@ymail.com and lekassahun4@gmail.com.
Aiello AE , Larson EL , 2002. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2: 103–110.
Ejere HO , Alhassan MB , Rabiu M , 2015. Face washing promotion for preventing active trachoma. Cochrane Database Syst Rev 2015: CD003659.
Freeman MC et al., 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.
Prüss-Ustün A et al., 2014. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Trop Med Int Health 19: 894–905.
Curtis V , 2003. Talking dirty: how to save a million lives. Int J Environ Health Res 13 (Suppl 1): S73–S79.
Delea MG , Snyder JS , Belew M , Caruso BA , Garn JV , Sclar GD , Woreta M , Zewudie K , Gebremariam A , Freeman MC , 2019. Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol. BMC Public Health 19: 801.
Tidwell JB , Fergus C , Gopalakrishnan A , Sheth E , Sidibe M , Wohlgemuth L , Jain A , Woods G , 2019. Integrating face washing into a school-based, handwashing behavior change program to prevent trachoma in Turkana, Kenya. Am J Trop Med Hyg 101: 767–773.
Brauer M , Zhao JT , Bennitt FB , Stanaway JD , 2020. Global access to handwashing: implications for COVID-19 control in low-income countries. Environ Health Perspect 128: 57005.
Freeman MC et al., 2014. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health 19: 906–916.
Roche R , Bain R , Cumming O , 2017. A long way to go – estimates of combined water, sanitation and hygiene coverage for 25 sub-Saharan African countries. PLoS One 12: e0171783.
Aiemjoy K et al., 2016. “If an eye is washed properly, it means it would see clearly”: a mixed methods study of face washing knowledge, attitudes, and behaviors in rural Ethiopia. PLoS Negl Trop Dis 10: e0005099.
Luby SP , Agboatwalla M , Bowen A , Kenah E , Sharker Y , Hoekstra RM , 2009. Difficulties in maintaining improved handwashing behavior, Karachi, Pakistan. Am J Trop Med Hyg 81: 140–145.
Najnin N et al., 2019. Impact of a large-scale handwashing intervention on reported respiratory illness: findings from a cluster-randomized controlled trial. Am J Trop Med Hyg 100: 742–749.
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.
White S , Thorseth AH , Dreibelbis R , Curtis V , 2020. The determinants of handwashing behaviour in domestic settings: an integrative systematic review. Int J Hyg Environ Health 227: 113512.
Contzen N , Meili IH , Mosler H-J , 2015. Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med 124: 103–114.
Curtis V , Cousens S , Mertens T , Traore E , Kanki B , Diallo I , 1993. Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility. Bull World Health Organ 71: 23–32.
Luby SP , Halder AK , 2008. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med Int Health 13: 835–844.
Manun’Ebo M , Cousens S , Haggerty P , Kalengaie M , Ashworth A , Kirkwood B , 1997. Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaïre. Trop Med Int Health 2: 1015–1021.
Halder AK , Tronchet C , Akhter S , Bhuiya A , Johnston R , Luby SP , 2010. Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh. BMC Public Health 10: 545.
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.
Biran A , Rabie T , Schmidt W , Juvekar S , Hirve S , Curtis V , 2008. Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop Med Int Health 13: 278–285.
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: 7–16.
Delea MG , Snyder JS , Woreta M , Zewudie K , Solomon AW , Freeman MC , 2020. Development and reliability of a quantitative personal hygiene assessment tool. Int J Hyg Environ Health 227: 113521.
Freeman MC et al., 2022. The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: a cluster-randomized trial. PLOS Glob Public Health 2: e0000056.
Ethiopia Demographic and Health Survey 2016, 2016. Available at: https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf. Accessed January 28, 2021.
Contzen N , Mosler H-J , 2015. Identifying the psychological determinants of handwashing: results from two cross-sectional questionnaire studies in Haiti and Ethiopia. Am J Infect Control 43: 826–832.
Friedrich MND , Binkert ME , Mosler H-J , 2017. Contextual and psychosocial determinants of effective handwashing technique: recommendations for interventions from a case study in Harare, Zimbabwe. Am J Trop Med Hyg 96: 430–436.
George CM et al., 2017. Psychosocial factors mediating the effect of the CHoBI7 intervention on handwashing with soap: a randomized controlled trial. Health Educ Behav 44: 613–625.
Open Data Kit , 2018.Open Data Kit. Available at: https://opendatakit.org/. Accessed September 13, 2022.
Parvez SM et al., 2019. Microbiological contamination of young children’s hands in rural Bangladesh: associations with child age and observed hand cleanliness as proxy. PLoS One 14: e0222355.
Young SL , Boateng GO , Jamaluddine Z , Miller JD , Frongillo EA , Neilands TB , Collins SM , Wutich A , Jepson WE , Stoler J ; HWISE Research Coordination Network , 2019. The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries. BMJ Glob Health 4: e001750.
UNICEF & WHO , 2018. Core Questions on Water, Sanitation, and Hygiene for Household Surveys: 2018 Update. Available at: https://washdata.org/sites/default/files/documents/reports/2019-03/JMP-2018-core-questions-for-household-surveys.pdf. Accessed April 21, 2021.
Flay B , Petraitis J , 1994. The theory of triadic influence: a new theory of health behavior with implications for preventive interventions. Adv Med Sociol 4: 19–44.
Mosler H-J , 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431–449.
Michie S , van Stralen MM , West R , 2011. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 42.
Abdi H , Williams LJ , 2010. Principal component analysis: principal component analysis. WIREs Comp Stat 2: 433–459.
Rutstein SO , Johnson K , 2004. The DHS Wealth Index DHS Comparative Reports No. 6. Gaithersburg, MD: Demographic and Health Surveys Program, USAID.
Donneau AF , Mauer M , Coens C , Bottomley A , Albert A , 2014. Longitudinal quality of life data: a comparison of continuous and ordinal approaches. Qual Life Res 23: 2873–2881.
McCullagh P , 1980. Regression models for ordinal data. J R Stat Soc B 42: 109–127.
R Core Team , 2020. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.
Nounkeu C , Kamgno J , Dharod J , 2019. Assessment of the relationship between water insecurity, hygiene practices, and incidence of diarrhea among children from rural households of the Menoua Division, West Cameroon. J Public Health Africa 10: 951.
Polack S , Kuper H , Solomon AW , Massae PA , Abuelo C , Cameron E , Valdmanis V , Mahande M , Foster A , Mabey D , 2006. The relationship between prevalence of active trachoma, water availability and its use in a Tanzanian village. Trans R Soc Trop Med Hyg 100: 1075–1083.
Seimetz E , Boyayo A-M , Mosler H-J , 2016. The influence of contextual and psychosocial factors on handwashing. Am J Trop Med Hyg 94: 1407–1417.
Stoler J , Jepson WE , Wutich A , 2020. Beyond handwashing: water insecurity undermines COVID-19 response in developing areas. J Glob Health 10: 010355.
Contzen N , De Pasquale S , Mosler H-J , 2015. Over-reporting in handwashing self-reports: potential explanatory factors and alternative measurements. PLoS One 10: e0136445.
Hutton G , Chase C , 2016. The knowledge base for achieving the sustainable development goal targets on water supply, sanitation and hygiene. Int J Environ Res Public Health 13: 536.
O’Boyle CA , Henly SJ , Larson E , 2001. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 29: 352–360.
De Wandel D , Maes L , Labeau S , Vereecken C , Blot S , 2010. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 19: 230–239.
Chen X , Munoz B , Wolle MA , Woods G , Odonkor M , Naufal F , Mkocha H , West SK , 2021. Environmental factors and hygiene behaviors associated with facial cleanliness and trachoma in Kongwa, Tanzania. PLoS Negl Trop Dis 15: e0009902.
Sanders AM et al., 2021. Evaluation of facial cleanliness and environmental improvement activities: lessons learned from Malawi, Tanzania, and Uganda. PLoS Negl Trop Dis 15: e0009962.
Armstrong RA , 2014. When to use the Bonferroni correction. Ophthalmic Physiol Opt 34: 502–508.
Perneger TV , 1998. What’s wrong with Bonferroni adjustments. BMJ 316: 1236–1238.
Rothman KJ , 1990. No adjustments are needed for multiple comparisons. Epidemiology 1: 43–46.
Past two years | Past Year | Past 30 Days | |
---|---|---|---|
Abstract Views | 294 | 294 | 39 |
Full Text Views | 289 | 289 | 25 |
PDF Downloads | 81 | 81 | 0 |