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Difficulties in Maintaining Improved Handwashing Behavior, Karachi, Pakistan

Stephen P. LubyCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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Mubina AgboatwallaCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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Anna BowenCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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Eben KenahCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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Yushuf SharkerCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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Robert M. HoekstraCenters for Disease Control and Prevention, Atlanta, Georgia; Health Oriented Preventive Education, Karachi, Pakistan; International Centre for Diarrhoeal Disease, Bangladesh, Dhaka, Bangladesh; University of Washington University School of Public Health and Community Medicine, Seattle, Washington

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In an earlier study in Karachi, Pakistan, households that received free soap and handwashing promotion for 9 months reported 53% less diarrhea than controls. Eighteen months after the intervention ended, these households were enrolled in a follow-up study to assess sustainability of handwashing behavior. Upon re-enrollment, mothers in households originally assigned to the intervention were 1.5 times more likely to have a place with soap and water to wash hands (79% versus 53%, P = 0.001) and when asked to wash hands were 2.2 times more likely to rub their hands together at least three times (50% versus 23%, P = 0.002) compared with controls. In the ensuing 14 months, former intervention households reported a similar proportion of person-days with diarrhea (1.59% versus 1.88%, P = 0.66) as controls. Although intervention households showed better handwashing technique after 2 years without intervention, their soap purchases and diarrhea experience was not significantly different from controls.

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