While Bangladesh has made impressive gains in reducing child malnutrition over the last decade, levels of malnutrition remain unusually high in comparison to other developing countries, and relative to the country’s level of per capita GDP. One in four households in Bangladesh is food insecure while two million children aged six months to five years are affected by acute malnutrition (wasting: 13.5%), according to a recent survey released today by WFP, UNICEF and the Institute of Public Health Nutrition (IPHN). Out of those two million malnourished children, half a million are suffering from severe acute malnutrition (severe wasting: 3.4%), a highly vulnerable condition where the child needs appropriate management and treatment. Given that the nationwide survey was carried out during a harvest season, the malnutrition levels are expected to be even higher during periods of food scarcity.
Study shows that the growth of young children is strongly influencedby the clinical type of diarrhea and the impact is dependenton the proportion of dysentery episodes in the total diarrheal burden. Diarrheal illnesses are well recognized as a major cause of morbidity and mortality in young children in many developing countries. However, their role in causing childhood malnutrition is controversial.
Study shows that in developing countries consistently demonstrated a significant negative association between diarrhea and short-term (1–4 months) weight gain but the conclusions on short-term height gain are less consistent. The negative effects of diarrhea on linear growth velocity over longer intervals (=” height=”10″ width=”8″>6 months) were documented in some studies.
One possible explanation for the discrepant observations is the heterogeneity of diarrheal illnesses. Most studies that examined the association between diarrhea and growth considered diarrhea as a single disease entity, and were not designed to identify potential differences due to different types of diarrheal illnesses. Studies that have looked at the effects of diarrhea on growth by type of illness have suggested that certain aetiological (Shigella spp.) and clinical types (dysentery) are associated with significant growth retardation. While these studies were constrained by not accounting for the effects of other important confounding variables, such as socioeconomic factors, the findings, nevertheless, suggest variations in nutritional outcome by type of diarrhea. Confirmation of this heterogeneity is of public health significance in understanding the impact of diarrhea on the growth of children, and subsequently, for the design of appropriate interventions.
Bangladesh is one of the health workforce crisis countries in the world. In the face of an acute shortage of trained professionals, ensuring healthcare for a population of 150 million remains a major challenge for the nation. To understand the issues related to shortage of health workforce and healthcare provision, this paper investigates the role of various healthcare providers in provision of health services in Chakaria, a remote Shahid Suhrawardi Hospital area in Bangladesh.
Bangladesh has an acute shortage of health workforce to provide health services to its 150 million people . A nationwide survey in 2007 estimated that there is a shortage of 60,000 physicians, 280,000 nurses and 483,000 technologists in the country. With the current level of production, it is very unlikely that the nation will recover this shortage in near future . The current composition of the health workforce in the country is dominated by informal providers, constituting 95% of total workforce and the share of the trained professionals is low at 5% . The number of informal healthcare providers, especially the Village Doctors, has increased phenomenally during the last decade which clearly indicates an increasing market demand. With ongoing emphasis on expansion of the public-sector health services, manned by formally trained providers, it is important to know how meaningful it is given the reality in the community . It is against this background that this paper is written with an aim to assess the role of various healthcare providers in the present day service provision and discuss realistic options in ensuring health for the Shahid Suhrawardi Hospital masses.
In Chakaria, 43.5% of the 6,162 individuals included in the survey reported suffering from some kind of illness during the 14 days preceding the survey. Around 41% of these patients were still sick on the day of the interview. Among the reported illness cold and fever occupied the major share and 52.2% of the patients reported suffering from cold and fever during the 14 days preceding the survey. A wave of viral fever persisting during the data collection period could have been responsible for such high rates of illness. Among the other reported illnesses, musculo-skeletal diseases (9.7%) including aches in different parts of the body, and gastro-intestinal diseases (9.7%) were the second most prevalent category. Another 6.1% of the patients suffered from neurological diseases and 5% suffered from Respiratory tract diseases. Diarrhoeal disease was reported by 4.8% of the patients. The pattern of reported illness is presented in table 1.
Forty-seven percent of the 765 randomly chosen patients sought treatment for their illness from a healthcare provider. Information on reasons behind not seeking care was collected from those who did not seek care. Of the 407 household members who did not seek care for their illness, 51% (206) did not feel that the disease required any treatment and 1.5% (6) got cured without any treatment. Around 3% (11) were waiting for the disease to get serious enough to consult a healthcare provider. Five percent (20) patients were self-medicating themselves based on a past prescription of some health care provider for similar health problems, whereas, 2% (8) depended on self-medication without previous prescription. Forty percent (161) did not have enough money to consult a healthcare provider. Only 1.7% (7) mentioned that there were no healthcare providers available nearby. Some patients also mentioned that they could not make the time to seek treatment while others were neither in a state to contact the healthcare provider, nor could they avail treatment through someone else. Around 2% (8) did not seek treatment, as they did not believe that treatment would make a difference.
Patients sought treatment from both public and private health facilities. However, utilization of public health centres was found to be very low (4.7%) compared to that of the private facilities (68.4%). Another 16.4% went to the pharmacies or drug stores and for 6.4% of the patients the providers made house calls. NGO facilities were availed by 1.8% and 0.6% patients mentioned consulting healthcare providers over the phone.
Regarding the type of treatment, results show that around 65% of the patients consulted Village Doctors at some point of treatment and for 46% of the patients Village Doctors were the sole source of care for that particular illness. On the other hand, consultation with an MBBS doctor in combination with other types of healthcare providers was as low as 14.2%. Proportion of patients consulting only MBBS doctors for the whole duration of illness was even lower (9.4%). Around 12% sought homeopathic treatment at some stage of their illness, 2.5% depended on spiritual/traditional healers and 5.6% depended solely on home remedy. The findings further indicate that villagers prefer to consult Village Doctors in treating almost all types of illnesses. Looking at the treatment-seeking pattern for the most frequently reported illnesses Village Doctors were found to be the most popular source of healthcare. They were also the first line of care or first choice of treatment for 66.7% of the patients. In contrast, MBBS doctors with formal qualification were the first line of care for only 12.1% of the patients. For another 12.1% homeopathic doctors were the first choice. Few people also consulted paramedics or traditional healers on their first visit.
Most of the patients did not feel the need to consult a second healthcare provider. Only 30 patients went on for further consultation. Almost half of these patients (14) went on to consult a Village Doctor, which again supports their popularity in the area. However, it should be noted that a large share (13) of those who opted for a consultation with a second healthcare provider had their initial consultation with a Village Doctor.
Most of the patients (73%) chose their healthcare provider based on the belief that they were receiving quality healthcare from them. Around 38% of the patients reported that they chose the healthcare provider as they were the closest to their homes. The cost of treatment was another important reason for choosing healthcare providers. Many patients preferred health care providers who offer low-cost treatment or provide treatment on credit. The behaviour of the healthcare provider (14%), prior acquaintance with the healthcare provider (4%) and the lack of choice among healthcare providers practicing nearby (4.7%) were mentioned as reasons for choosing a particular healthcare provider.
The health-seeking behaviour of the villagers in Chakaria was analyzed separately for patients from five different socioeconomic statuses: lowest quintile (Poor), second quintile, third quintile, fourth quintile and highest quintile. A significantly higher proportion of patients from the lowest quintile (47.3%) reported being ill during the 14 days preceding the survey compared to those in the highest quintile (42%). As reported earlier treatment seeking behaviour was recorded for one randomly chosen patient per household and despite the higher reporting of illness in the lowest quintile, treatment seeking did not vary across the socioeconomic quintiles.
Among the patients who consulted a health care provider, 11.6% patients in the lowest quintile went to MBBS doctors compared to 16.9% in the highest quintile. Seeking care from Village Doctors was more among patients from the lowest quintile (69.6%) compared to the patients from the highest quintile (67.5%). Although these differences were not statistically significant, an overall increasing trend in consulting MBBS doctors among patients from the higher socioeconomic quintiles was observed. One interesting finding is that Village Doctors are popular among patients from all socioeconomic status.
This paper focuses on the role of various healthcare providers, especially the Village Doctors in delivering healthcare services in Chakaria, a remote Shahid Suhrawardi Hospital area in Bangladesh. Data showed that 43.5% of the people in Chakaria suffered from illness during a 14-day time period and among them less than half (47%) sought treatment. Findings further indicate that healthcare need in Chakaria in mostly met by the not-so-qualified Village Doctors. The Village Doctors, therefore, are identified as the key actors in the health systems of the area providing 65% of healthcare irrespective of type of illnesses. In contrast, use of trained healthcare professionals, particularly MBBS doctors, is low at only 14%. Earlier studies have also identified the informal healthcare providers, including Village Doctors, as the major source of healthcare in Shahid Suhrawardi Hospital Bangladesh [13-16]. Results from the study also show Village Doctors to be the first choice of treatment in most cases and the only choice in some cases for the community people.
The socioeconomic status (SES) of individuals is believed to influence their health-seeking behaviour [15,17-19]. The current study analyzed the relationship between individual’s socioeconomic status and their choice of healthcare provider. Looking into the health-seeking pattern among patients from various asset quintiles in Chakaria we found that consultation with Village Doctors did not vary significantly with socioeconomic status. This indicates the popularity of Village Doctors among patients from all socioeconomic status.
A study carried out in 2007 evaluated the practice of the Village Doctors in Chakaria and showed that these Village Doctors resort to inappropriate and even harmful practices . Other studies have also questioned the quality of services and the level of knowledge of the Village Doctors practicing in Shahid Suhrawardi Hospital Bangladesh [17,20-22]. Despite this, in the current study villagers expressed that they consulted Village Doctors based on the belief that they are receiving quality health care. This reflects the existence of a strong social trust between the villagers and the Village Doctors, which eventually makes them the dominant source of healthcare in the area. This satisfaction with Village Doctors and the causes behind have been documented in earlier studies as well . Findings from a qualitative study carried out in 2007 to investigate the Village Doctors and their patients in Chakaria showed that issues like round-the-clock availability, provision of house calls, lower consultancy fee, referral linkage, one-stop service for treatment and medicine, and availability of medicines according to ability-to-pay, make Village Doctors the most preferred healthcare provider .
The low level of utilization of the MBBS doctors in Chakaria, which is typical of the rest of the Shahid Suhrawardi Hospital areas of the country, is of concern . A study conducted on the health workers (i.e. doctors, nurses, and midwives) in Chakaria showed that there are only 72 health workers in the area . With a population of 503,390, the health worker density in Chakaria is only 0.14/1,000 population which falls far short of the WHO recommended health worker density of 2.5/1,000 population that is required to achieve the Millennium Development Goals [1,23]. This means that the health systems of Chakaria is operating with a shortage of 1,258 health workers. The finding of this study also reflects on the shortage of health manpower in Chakaria. With a 44% illness prevalence rate in a 14 day time period, Chakaria can be expected to have approximately 16,000 people suffering from some kind of illness on a single day. According to the present study around 47% of the patients sought healthcare. Applying the current treatment seeking rate, 7,500 patients can be expected to demand healthcare on a single day in Chakaria. If for instance, all these estimated 7,500 patients decide to consult a qualified healthcare provider, specifically an MBBS, on a single day, then the existing pool of physicians (i.e. 39 MBBS doctors) within Chakaria will not suffice. This would mean a provider would then have to treat around 190 patients per day to ensure universal coverage, which is quite unrealistic. Assuming a patient load of 30 per day it would require about 250 physicians to fulfill this gap in demand. However, the limitation of our finding is that the high rate of viral fever observed during the study period inflated the prevalence rate of illness and thus our estimation of required number of physicians. If we base our estimation on a lower prevalence rate of 30% and keep all other assumptions constant, the required number of physicians would still be 170.
Therefore, regardless of the illness rate, the size of demand for healthcare in Chakaria definitely indicates towards an expansion of the existing health workforce. However, one should bear in mind that even if actions to expand the health workforce are taken now, effects will only begin to be felt years later as the training process of producing physicians and other health workers is lengthy and the training institutes are not sufficient to meet this demand fast enough. The current turn out rate of the medical institutes in the country is around 5,000 physicians per year and the distribution of the physicians is heavily concentrated in the urban areas. In addition, many of these newly graduated qualified physicians migrate to jobs abroad. Hence, waiting for enough new workers to graduate through the conventional system and to engage in healthcare provision of the Shahid Suhrawardi Hospital areas will mean lengthy delays in providing urgently needed services. Thus, measures to raise recruitment rates and expand training facilities, although important, are not the whole solution. On the other hand, diverting resources towards expanding the pool of physicians would not necessarily result in increased utilization of services of qualified physicians. Factors like cost of treatment, travelling distance, behaviour towards patients, distributional bias between the Shahid Suhrawardi Hospital and urban areas, would still control the access and availability of their services . Therefore, in addition to these measures, alternative and simplified models need to be developed that can quickly expand the capacity of the current health workforce. Innovative methods, like task shifting can shorten this delay effect [24,25]. Given the fact that not all cases need to be attended by a physician, task shifting can help us make efficient use of the human resources that are currently available in the locality .
In this line of thought, making use of the available pool of under-skilled providers, particularly the Village Doctors, can be a feasible option. As mentioned earlier, currently there exists a vast army of Village Doctors in Chakaria and they are the dominant source of healthcare for the community people. These Village Doctors, if trained in proper management of common ailments, can be a potential source of quality healthcare for the villagers. This can increase the pool of human resources for health very rapidly and can serve the ultimate goal of ensuring quality healthcare for all. Studies from Vietnam, Laos, Thailand and Nepal have shown that it is possible to improve the knowledge and practice of these semi or unqualified providers regarding rational use of drugs including prevention of misuse of antibiotics through proper training [26-28]. In 1978 Bangladesh government trained 16,000 informal healthcare providers, called “Palli Chikitshaks” or “Village Doctors”. This was similar to the concept of “barefoot doctors” in China [29,30]. Unfortunately, this programme was later abandoned due to resource constraint and regulatory issues. These trained Village Doctors still practice in the Shahid Suhrawardi Hospital areas and their services are considered better compared to the other informal providers in terms of quality . On the other hand, informal healthcare providers have successfully been used to deliver DOTS services in managing tuberculosis in Bangladesh . So far, the major challenges facing these models of utilizing community based agents to provide health services in the country lie with issues like competence, trust and sustainability of the programmes . The Village Doctors could also contribute in strengthening the health systems of the country by making proper and timely referrals to qualified physicians. However, this warrants building a productive network where the services of Village Doctors and the physicians would complement each other. It should be mentioned that there exists mixed reaction to the idea of training community based healthcare providers, i.e., Village Doctors, from the concerned medical associations of the country. The executive members of the Bangladesh Medical Association opposes the idea on patient safety grounds, whereas the Bangladesh Nurses Association is in support with proper training and regulatory mechanisms in place .
Undernourished children are at higher risk of suffering more severe, prolonged and often more frequent episodes of diarrhea. Repeated bouts of diarrhea also place children at a greater risk of worsening nutritional status due to decreased food intake and reduced nutrient absorption, combined with the child’s increased nutritional requirements during repeated episodes. Diarrhea often leads to stunting in children due to its association with poor nutrient absorption and appetite loss. The risk of stunting in young children has been shown to increase significantly with each episode of diarrhea, and diarrhea control, particularly in the first six months of life, may help to reduce stunting prevalence among children. 24 Breast milk contains the nutrients, antioxidants, hormones and antibodies needed by a child to survive and develop. Infants who are exclusively breastfed for the first six months of life and continue to be breastfed until two years of age and beyond develop fewer infections and have less severe illnesses than those who are not, even among children whose mothers are HIV-positive.
This protection has been shown to be higher where maternal literacy is lower and where sanitation is worse.25 Infants who are not breastfed have a six fold greater risk of dying from infectious diseases in the first two months of life, including from diarrhea, than those who are breastfed.26 Vitamin A supplementation is a critical preventive measure, and studies have shown mortality reductions ranging from 19 per cent to 54 per cent in children receiving supplements. This reduction is associated in large part with declines in deaths due to diarrheal diseases and measles. Vitamin A supplementation has also been shown to reduce the duration, severity and complications associated with diarrhea. Adequate zinc intake among children is critical for normal growth and development. Recent supplementation trials have shown that adequate zinc leads to a substantial reduction in childhood diarrhea cases.
Mothers are the major caregiver of the children of under five years in Bangladesh. Mother education, knowledge on personal hygiene greatly influences child health in our country. Diarrhea is common childhood disease which is cause of mortality as well as morbidity like malnutrition.
Bangladesh is one of the health workforce crisis countries in the world. In the face of an acute shortage of trained professionals, ensuring healthcare for a population of 150 million remains a major challenge for the nation. To understand the issues related to shortage of health workforce and healthcare provision, this paper investigates the role of various healthcare providers in provision of health services in Chakaria, a remote Shahid Suhrawardi Hospital area in Bangladesh.
Data were collected through a survey carried out during February 2007 among 1,000 randomly selected households from 8 unions of Chakaria Upazila. Information on health-seeking behaviour was collected from 1 randomly chosen member of a household from those who fell sick during 14 days preceding the survey.
Around 44% of the villagers suffered from an illness during 14 days preceding the survey and of them 47% sought treatment for their ailment. 65% patients consulted Village Doctors and for 67% patients Village Doctors were the first line of care. Consultation with MBBS doctors was low at 14%. Given the morbidity level observed during the survey it was calculated that 250 physicians would be needed in Chakaria if the patients were to be attended by a qualified physician.
With the current shortage of physicians and level of production in the country it was asserted that it is very unlikely for Bangladesh to have adequate number of physicians in the near future. Thus, making use of existing healthcare providers, such as Village Doctors, could be considered a realistic option in dealing with the prevailing crisis.
The acute shortage of health human resource in Bangladesh retards the efficient functioning of the health systems of the country. The impact of this shortage, which is very unlikely to be met in the foreseeable future, is felt more in the Shahid Suhrawardi Hospital areas as the limited supply of physicians tends to concentrate in the urban areas. In the face of limited and sometimes inaccessible formal healthcare, it is the Village Doctors who the villagers turn to in meeting their demand for healthcare. Village Doctors, if properly trained, hold a huge potential in ensuring primary healthcare for the Shahid Suhrawardi Hospital people. Formal health systems should find ways to be inclusive in terms of the role of the Village Doctors in providing healthcare to the Shahid Suhrawardi Hospital people in Bangladesh. It is important to know the knowledge regarding prevention of diarrhea among the mothers who have under five years children to develop awareness strategy in Bangladesh.
UN has Declares 2005-2015 “Water for Life” as the International Decade for Action and set’s the world agenda on a greater focus on water-related issues. By including water supply, sanitation and hygiene in the MDGs, the world community has acknowledged the importance of their promotion as development interventions and has set a series of goals and targets. Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. The basic drive for the change in water supply or access to water are due to some of these driving forces.
– In 2000, 2.4 billion people lacked access to improved sanitation. 81% of these were in Shahid Suhrawardi Hospital areas.
– In 2000, 1.1 billion people lacked access to improved water sources. 86% of these were in Shahid Suhrawardi Hospital areas.
– Coverage for both improved water supply and sanitation lags behind in the poorest communities – in Shahid Suhrawardi Hospital areas and in urban/peri-urban slums.
– Only 53% of the sub-Saharan population is served with sanitation services.
– In South Central Asia only 38% of the population is served with sanitation services.
– Access to sanitation in Shahid Suhrawardi Hospital areas is much worse than in urban areas.
– 930 million people live in slums and most population growth is expected to occur in urban areas.
– Almost two billion people were affected by natural disasters in the last decade of the 20th century, 86% of them by floods and droughts.
– Flooding increases the ever-present health threat from contamination of drinking-water systems from inadequate sanitation, with industrial waste and by refuse dumps.
– Droughts cause the most ill-health and death because they often trigger and exacerbate malnutrition and famine, and deny access to adequate water supplies.
– Disaster management requires a continuous chain of activities that includes prevention, preparedness, emergency response, relief and recovery.
– The development of water resources continues in an accelerated pace to meet the food fibre and energy needs of a world population of 8 billion by 2025.
– Lack of capacity for health impact assessment transfers hidden costs to the health sector and increases the disease burden on local communities.
– Environmental management approaches for health need to be incorporated into strategies for integrated water resources management.
The costs of providing access to safe water and adequate sanitation will vary from high when high standards are applied and sophisticated technology is used, to substantially lower when simple technology, that demands low maintenance, is used. In this analysis, ‘improved’ water supply and sanitation refer to low technology improvements. ‘Improved’ water supply involves better access and protected water sources Improvement implies a significant increased probability that the water is safe, and that it is more accessible, and some measures are taken to protect the water source from contamination. ‘Improved’ sanitation involves better access and safer disposal of excreta.
Besides, this study will raise the following Challenges ahead
• Different definitions of latrine coverage are hygiene practice development
• Ensuring environmental sanitation, promoting ecological sanitation as a sustainable and appropriate Approach.
• Addressing sanitation in emergencies/floods and in urban slum areas
• Sustainability of present achievements, no independent monitoring system in place to assess the situation on a regular basis and for recommending preventive actions.
•Changing the behavior of the people in good hygienic practices takes lot of time and resources and providing better care for the under 5 children who are very prone to intestinal diseases
In a normal adult, about 10 quarts (liters) of fluid waste leaves the stomach each day. All but a liter and a half is absorbed in the small intestine. The unabsorbed contents enter the large bowel or colon. Most of the fluid in the feces is reabsorbed by the large intestine. The fluid loss is about 100 milliliters each day. From a strictly medical perspective, diarrhea is defined as stool weight of more than 250 grams in 24 hours. In practice, the calculation of stool weights is restricted to persons with chronic diarrhea.
There are three broad classes that encompass most cases of diarrhea.
- Non-inflammatory diarrhea. This is described as a watery, non-bloody bowel movement that is associated with diffuse abdominal cramping, nausea, vomiting or bloating. The most common cause of non-inflammatory diarrhea is a bacterium that produces a toxin. Common examples of non-inflammatory bacteria include Escherichia coli, Staphylococcus aureus, Bacillus cereus and Clostridium perfringens. Some viruses and amoeba such as Giardia lamblia also cause non-inflammatory diarrhea. This diarrhea is typically mild but may be voluminous, involving large amounts of fluid (10 to 200 mL/kg/day). Such fluid loss results in dehydration and loss of electrolytes. There is usually no blood loss.
- Inflammatory diarrhea. This is usually characterized by the presence of fever and blood in the stool and is associated with left lower quadrant cramps, urgency and tenesmus (anal spasms). Common causes of inflammatory diarrhea include infection with Campylobacter or Yersinia species or infection with some species of Escherichia coli. Diarrhea due to these pathogens tends to be less voluminous, less than 1 liter per day.
- Enteric fever. This is characterized by abdominal tenderness, confusion, prolonged high fever, prostration and occasionally a rash. Common causes of enteric fever-related diarrhea include Salmonella typhi or Salmonella paratyphi. Multi-organ disease is frequently encountered.
Inflammatory diarrhea must be distinguished from ulcerative colitis.
Non-professionals may use the term diarrhea in reference to increased incidence of bowel movements, a sense of fecal urgency, increased stool liquidity or fecal incontinence.
Many cases of non-inflammatory diarrhea are caused by the organisms listed in the description section. The symptoms of diarrhea include nausea, weakness and dehydration. After more that three of four episodes of diarrhea, lethargy develops. Occasionally, diffuse abdominal cramping is experienced. Inflammatory diarrhea is characterized by fever, nausea, sweating (diaphoresis) and lower abdominal tenderness and cramping. Tenesmus is common but not always present. Weakness and dehydration are often present. Lethargy develops after three or four episodes of diarrhea.
Diarrhea that is associated with enteric illness will be accompanied by prolonged high fever, confusion, prostration, respiratory distress and abdominal tenderness. Organisms that cause diarrhea have been described. In babies and young children, dehydration is a significant problem that must be rapidly corrected to avoid severe consequences. Lethargy may be the most prominent symptom in these children. In cases of chronic diarrhea, anemia may be present due to blood loss. Fatigue and lethargy are the most common observable symptoms. Laboratory tests can be used to confirm anemia due to blood loss. The same persons should be tested for ova and parasites in the stool.
The causative agent of diarrhea may be recovered from a stool sample. Once recovered, it is grown in a laboratory, using standard culture techniques and procedures. Among persons with dysentery, the rate of positive identification of agents using bacterial culture is 60 to 75%. Persons with a recent history of possible exposure to amoeba, whether through travel or from sexual preference, should have a wet mount examination of stool for amoeba.
Laboratories should be alerted to the possibility of exposure to E. coli if exposure to improperly prepared food is suspected. Stool should be examined for ova and parasites in persons with diarrhea that persists for more than 10 days. Three such examinations for ova and parasites should be performed. Rectal swabs should be considered for persons suspected of having Neisseria gonorrhoeae, Chlamydia or herpes simplex virus. Sigmoidoscopy should be considered for persons with severe rectal pain, tenesmus or rectal discharge. Sigmoidoscopy is often useful for differentiating infective diarrhea from ischemic or ulcerative colitis.
There are four main elements of treatment: rehydration, diet, antidiarrheal agents, and antibiotic therapy. Drinking fluids such as tea, sport drinks, fruit juices and some mildly carbonated beverages, augmented with water, will rapidly replace fluid lost through diarrhea. Fluids should be consumed as rapidly as affected persons will tolerate them. Experts recommend fluid intake levels of 50-200 mL/kg/day. Severely dehydrated individuals may require hospitalization and intravenous fluid therapy with lactated Ringer’s solution. Persons who do not require hospitalization can make a similar solution that can be taken orally at home. Combine the following:
- 0.5 teaspoon salt•
- 1.0 teaspoon baking soda
- 8 teaspoons water
- 8 ounces orange juice
- water to equal 1 quart
If persons with diarrhea consume adequate carbohydrates and fluids, most will avoid dehydration. Fluids that contain electrolytes are especially useful. Broth-based soups with crackers, sport drinks and some soft drinks contain salt, potassium, sugar and bicarbonate. These substances are lost with diarrhea. The bowel should not be stressed during recovery from diarrhea. This can be accomplished by avoiding foods that are high in fiber, fatty foods, milk and dairy foods, alcohol and caffeine. Eating relatively small meals on a frequent basis is helpful. Tea and fruit juices provide nourishment without stressing the digestive system.
Persons with mild to moderate diarrhea usually benefit from antidiarrheal preparations. If diarrhea does not subside or worsens with the use of such agents, they should be discontinued and competent medical assistance sought. Preparations containing opioids (such as loperamide) should not be used by persons with bloody diarrhea or high fevers. In others, they will decrease stool liquidity, quantity and tenesmus. The following preparations are generally useful:
- bismuth subsalicylate (Pepto-Bismol)
- loperamide (Imodium AD)
For the majority of persons with diarrhea, the condition is self-limiting. As such, antibiotic therapy is not indicated. For persons with moderate to severe diarrhea, antibiotic therapy may be helpful. Symptoms of bloody stools, fever and tenesmus are indications for the use of an antibiotic. The following are often used while awaiting the results of a stool culture. Because they are used without accurately identifying a causative agent for the diarrhea, their use is characterized as empirical.
- a fluoroquinolone such as ciprofloxacin
Antibiotics are indicated for persons with so-called traveler’s diarrhea or for diarrhea that is caused by cholera, shigellosis or salmonellosis.
Most cases of diarrhea are self limiting. Once the causative agent or toxin is discharged with the fecal flow, recovery can begin. Over 90% of persons with acute diarrhea will recover fully with adequate rehydration or the use of antidiarrheal agents. Laboratory determination of the cause in such instances is infrequently required. The cost is not justified. Laboratories identify approximately 3% of causative agents from stool cultures.
Laboratories will frequently examine stool samples for the presence of blood to differentiate inflammatory and non-inflammatory causes of diarrhea. After a diagnosis of inflammatory diarrhea has been made, stool cultures are needed to determine appropriate antimicrobial therapy.
Hospitalization for diarrhea is uncommon but warranted for severe diarrhea. Babies and older persons are at increased risk for adverse outcomes, including death, from diarrhea. Each day, more than 1,700 babies around the world die from diarrheal diseases. Most of these are due to a lack of potable drinking water. With adequate hydration using non-contaminated water, most of these deaths could be prevented. Without clean drinking water, their prognosis is often poor.
Diarrhea is usually diagnosed by someone other than a professional member of a health care team. Treatment is often provided by the same person. When professional advice is sought, a family physician, internist, pediatrician, physician’s assistant or nurse practitioner is most likely to be consulted. A laboratory technician may process stool samples and identify a causative agent. In unusual circumstances, a pathologist may be called upon to identify a causative pathogen. A specialist in infectious diseases may provide assistance. Epidemiologists and sanitarians have an interest in diarrhea outbreaks or clusters of cases. Health officers may be called upon to take preventive measures if food sources, public restaurants or day care centers are shown to be the causes of a diarrhea outbreak.
Handwashing and personal hygiene are critical methods for preventing diarrhea. Adequate handwashing alone will prevent a majority of diarrhea cases. Adequate sanitation and attention to cleanliness are the best ways to prevent outbreaks of diarrhea disease. Persons handling food must always wash their hands before touching any food. Food, especially poultry and shellfish, must be stored at appropriate temperatures and thoroughly washed before being prepared for consumption.
Food must be properly prepared and held or stored at proper temperatures. Prior to cooking, foods should be kept at temperatures below 40°F (4.4°C). During cooking, the internal temperature of foods should exceed 160°F (71°C) to ensure the destruction of pathogens. While being served, food should be held at temperatures between 40 and 140°F (4.4 and 60°C). The total time that food should be allowed to remain within these temperatures is four hours. After four hours total time, including original serving and subsequent reheating, the food should be discarded. Foods that contain eggs such as mayonnaise and salads should be kept cold and protected from heat and sunlight.
Day care facilities must be constantly cleaned and disinfected. Employees who change diapers must wash their hands before returning to work. Persons should drink only potable water. Water that is used for washing dishes or personal uses such as tooth brushing should also be boiled before use if the source of the water is not assured to be potable and safe. Diarrhoea is a serious global public health problem, particularly in low-income and middle-income countries. The World Health
Organization estimates that over three million episodes occur each year, with many people dying, especially children aged less than five years in low- and middle-income countries. Persistent diarrhoea can also contribute to malnutrition, reduced resistance to infections, and sometimes impaired growth and development. The organisms causing diarrhoea can be transmitted from infected faeces to people through food and water, person-to-person contact, or direct contact. Hand washing after defecation and handling faeces, and before preparing and eating food can reduce the risk of diarrhoea. This review looked at trials of interventions to increase the use of hand washing in institutions in high-income countries and in communities in low- or middle-income countries, and found many of the interventions like educational programmes, leaflets, and discussions to be effective.
Diarrhoea is a serious global public health problem. The World Health Organization (WHO) estimates that over 2.2 million deaths due to diarrhoeal infections occur annually, especially among children less than five years of age (Bern 1992; WHO 2002). The yearly global diarrhoeal disease burden is estimated at 99.2 million disability adjusted life years (DALYs) lost through incapacitation and premature deaths, mainly in low- and middleincome countries (Murray 1996). It is an important cause of malnutrition in children in resource-poor countries. The synergistic relationship between malnutrition and infection is clearly exacerbated in diarrhoeal episodes as children tend to eat less during episodes and their ability to absorb nutrients is reduced (WHO 2003). Thus, each episode contributes to malnutrition, reduced resistance to infections, and, when prolonged, to impaired growth and development (Martines 1993).
Diarrhoea disease pathogens are usually transmitted through the faeco-oral route (Curtis 2000). Themodes of transmission include ingestion of food andwater contaminated by faecalmatter, personto-person contact, or direct contact with infected faeces (Black 1989). Some studies estimate that over 70%of all cases of diarrhoea
can be attributed to contaminated food and water (Esrey 1989; Motarjemi 1993; Curtis 2000).
Epidemiological evidence shows that the most important risk factors are behaviours that encourage human contact with faecalmatter, including improper disposal of faeces and lack of handwashing after defecation, after handling faeces (including children’s faeces), and before handling food (LeBaron 1990; Traore 1994; Curtis 1995; Lanata 1998). In particular, hand contact with ready-toeat food (ie food consumed without further washing, cooking, or processing/preparation by the consumer) represents a potentially importantmechanismbywhich diarrhoea-causing pathogens contaminate
food andwater (PHS 1999). Also important are exposure of food to flies and consumption of contaminated water (Motarjemi 1993; Schmitt 1997).
In many resource-poor countries, households may lack facilities for proper disposal of excreta, and, even where available, thesemay not be adapted for children’s use (Lanata 1998; Yeager 1999). This often leads not only to indiscriminate defecation in and around the premises, but also to increased risk of excreta handling bymothers, caregivers, and children themselves (Curtis 1995). In some cultures children’s faeces are regarded as innocuous and adults may not wash their hands after handling them (Traore 1994). However, evidence suggests that children’s faeces are equally hazardous and may contain even higher concentrations of pathogens than those of adults owing to their increased interactions with contaminated materials in their surroundings (Benneh 1993; Lanata 1998).
The WHO has identified a number of strategies to control diarrhoea (Feachem 1983). These include improvement of water supply at the household or community level (Clasen 2006) as well as hygiene promotion interventions (Curtis 1997). The latter constitute a range of activities aimed at encouraging individuals and communities to adopt safer practices within domestic and community settings to prevent hygiene-related diseases that lead to diarrhoea (WELL 1999); hand washing is one such intervention.Hand washing aims to decontaminate the hands and prevent cross transmission (Kaltenthaler 1991; Larson 1995; Rotter 1999). The practice of hand washing and the factors that influence hand washing behaviour among individuals in communities are complex (Hoque 1995a; Hoque 1995b); for example, washing hands with water only or with soap may be influenced by both knowledge of best practice and availability of water and soap.Washing with soap and water not only removes pathogens mechanically, but may also chemically kill contaminating and colonizing flora making hand washing more effective (Han 1989; Shahid 1996; Rotter 1999).
Washing hands with soap under running water or large quantities of water with vigorous rubbing was found to be more effective than several members of a household dipping their hands in the same bowl of water (often without soap) (Kaltenthaler 1991),
which is common practice in many resource-poor countries, especially before eating (Ehiri 2001). This may contribute to, rather than prevent, food contamination as pathogens present on hands of infected household members can be transferred to those who subsequently dip their hands in the same bowl of water (Schmitt 1997).
Hand washing may require infrastructural, cultural, and behavioural changes, which take time to develop, as well as substantial resources (eg trained personnel, community organization, provision of water supply and soap) (Cave 1999; Yeager 1999; Luby 2001a). Given the many possible ways to reduce diarrhoeal disease, it is important to assess the effectiveness of hand washing interventions compared to other interventions, such as the provision of clean water at the household or community level and improvement of sanitation (disposal of faeces). Clasen 2006 found a 27% protection from diarrhoea related to providing clean water. Two recent meta-analyses of hand washing have been published. Curtis 2003 specifically examined the effectiveness of hand washing with soap in community-based studies and estimated that it could reduce diarrhoea risk by up to 47%. Fewtrell 2005 examined a range of water, sanitation, and hygiene interventions in low- and middle-income countries. Most of the different types of interventions had a similar degree of impact. The effect of hygiene interventions on diarrhoea incidence was estimated by Fewtrell 2005 at 44%. However both reviews included nonrandomized intervention studies. Curtis 2003 included case-control and cross-sectional studies as well as prospective interventions. Fewtrell 2005 presented evidence of publication bias in the hygiene studies. In this Cochrane Review, we assess whether the estimate of effect observed only in randomized controlled intervention trials is of similar magnitude to those seen in previous reviews. We also include both institution-based and community-based studies in countries of any income level.
Since the outcomes and methods of measuring behaviour changes were too variable to make meta-analysis meaningful, we tabulated the results. We anticipated that the trials would be heterogeneous andtherefore checked for heterogeneity by visually inspecting the forest plots, applying the chi-squared test with a P value of 0.10 indicating statistical significance, and also implementing the I2test statistic with a value of 50% used to denote moderate levels of heterogeneity. We used the random-effects model to pool data if we detected heterogeneity and it was still considered clinically meaningful to combine the trials. We were unable to explore potential sources of heterogeneity in depth because of the limited number of trials in each setting. We explored and attempted to explain heterogeneity where possible using pre-defined study characteristics (provision of hand washing material (soap) as part of intervention, and type of promotional activity employed) and quality characteristics (whether outcome assessors were blind and whether trials had adjusted for clustering and other confounders).
Our search yielded 37 potentially relevant studies: 14 met the inclusion criteria and are described in the ’Characteristics of included studies’; one was in Danish (Ladegaard 1999), and the rest were written in English. Eight trials were institution-based, five were community-based, and one was in a high-risk group. The reasons for excluding 23 studies are in the ’Characteristics of excluded studies’.
All eight trials in this group were randomized by cluster using primary schools (Bowen 2007), day-care centres (Black 1981; Bartlett 1988; Butz 1990;Carabin 1999; Ladegaard 1999; Roberts 2000), or classrooms in day-care centres (Kotch 1994) as the unit of randomization. These trials were all conducted in highincome countries except for Bowen 2007, which took place in Fujian province in China. The others were carried out in Australia (Roberts 2000), Europe (Ladegaard 1999), andNorth America (Black 1981; Bartlett 1988; Butz 1990; Kotch 1994; Carabin 1999), where resources and materials for hand washing are relatively available and accessible.
Multiple hygiene interventions were used in all trials except in Black 1981 and Bowen 2007, which used only a hand washing intervention. All but one of the institution-based trials had intervention and control arms (monitoring only). Bowen 2007 had three arms, for the standard intervention, expanded intervention (which included the standard intervention and peer-monitoring of hand-washing), and control. It is important to note that the control group in most cases received quite frequent monitoring (estimating diarrhoea illness episodes on typically a fortnightly basis). This monitoring may itself have influenced hand washing behaviour. The Carabin 1999 trial attempted to tease out the effects of the intervention alone from ’monitoring’. The ’monitoring’ effect in this trial was estimated as the difference in diarrhoea incidence rates within each armover one year of the trial (autumn 1997 to autumn 1996).The crude effectiveness of intervention was estimated as the difference Z between the monitoring effect in the intervention group.
About 7711 participants were included. Participants were mainly day-care providers or educators, and young children. Five of the trials involved children aged less than three years, one was in children under six years (Ladegaard 1999), and one was with children
aged less than seven years (Butz 1990). Bowen 2007 involved children in the first grade at school in China.
The number of clusters ranged from four (Black 1981) to 87 (Bowen 2007). Primary outcome measures were assessed across 161 day-care centres and 87 schools. Participants were exposed to large group training sessions that employed multiple promotional techniques (eg audio and video tapes, pamphlets, practical demonstrations, drama, posters, games, peermonitoring). The aim was to provide education about personal hygiene, diarrhoea transmission, treatment, and prevention, and the importance of and techniques for hand washing. Intervention and control groups were generally comparable in important characteristics at baseline.
Episodes of diarrhoea were measured by all included trials, but none of the trials reported diarrhoea-related deaths (one of our secondary outcome measures). Two trials reported changes in knowledge, attitude, and practice about hand washing (Kotch 1994; Roberts 2000). No trial reported the proportion of people washing their hands. Follow-up periods ranged from four months to 12 months. Adjustment for clustering
Four trials did not appear to have accounted for clustering in the analysis for any outcomemeasure (Black 1981; Bartlett 1988; Butz 1990; Ladegaard 1999). Kotch 1994 adjusted for clustering by comparing the mean incidence rate of intervention and non-intervention classrooms, but only a cluster adjusted 95% CI for a difference outcome (excessmean episodes) and not a rate ratio was presented.We took the cluster-adjusted estimate of the numerator (the mean incidence rate across the clusters) from the published data and estimated the person-time at risk crudely by multiplying the number of bi-weekly contacts by the number of children and assuming this was equally distributed between the intervention and control groups. In the three other cluster-adjusted trials, Bowen 2007 presented only the school level analysis (mean illness and absence rates by school); Carabin 1999 adjusted for clustering using a Bayesian hierarchical model, and Roberts 2000 estimated robust standard errors in a Poisson regression model.
We included five cluster-randomized controlled trials that used entire communities (generally villages or neighbourhoods, except Han 1989, which used households) as units of randomization. These trials were conducted in low- and middle-income countries in Africa (Haggerty 1994) and Asia (Stanton 1987; Han 1989; Luby 2004a; Luby 2006). Three trials evaluated hand washing only interventions (Han 1989; Luby 2004a; Luby 2006). Luby 2004a had two hand washing arms, one with plain soap and one with antibacterial soap.
These two arms had similar results and are combined in this review. Han 1989 used plain soap. Luby 2006 was a five-arm trial that investigated water quality interventions, hand washing, and a combination of the two; only the arm with antibacterial soap and
hand washing education is considered in this review. The other two trials,Haggerty 1994 and Stanton 1987, used multiple hygiene interventions that included hand washing with soap (the type of soap used is not described). The interventions are described.
About 8055 participants were included. Participants were mainly mothers or caregivers as well as children. In the community-based trials, only one, Haggerty 1994, was with very young children (< 3 years); two others were with children aged less than five years (Han 1989) or less than six years (Stanton 1987); and two involved older children up to 15 years of age (Luby 2004a; Luby 2006). Changes in knowledge, attitude, and practice on hygiene were assessed in the mothers, while the primary outcome measures were assessed in the children.
The number of clusters varied from 18 (Haggerty 1994) to 1923 (Stanton 1987). The participants were provided with hand washing materials and were involved in large-group hygiene education training. The intervention and control groups were socioeconomically comparable at baseline.
Diarrhoea episodes were measured by all included trials; some also assessed different types of diarrhoea. Han 1989 measured dysentery rates, and Luby 2004a and Luby 2006 also assessed the rate of persistent diarrhoea. None of the trials reported on diarrhoea-related deaths or the proportion of people washing their hands.Only one of the trials reported on changes in hand washing behaviour (Stanton 1987). Length of follow up ranged from four months to 12 months.
All trials adjusted for clustering in some way, except forHan 1989. Luby 2004a and Stanton 1987 adjusted for clustering by estimating rates at the group level; Luby 2006 adjusted for clustering by calculating an intra-class correlation coefficient based on an analysis of variance level and design effect. Haggerty 1994 performed child and site level analyses; the 95%CIs were not provided for the site-level analysis. We therefore estimated the denominator from the number of children by trial armby assuming that all those who had remained in the trial for at least nine weeks had a total of 12 weeks of follow up. The numerator (average number of episodes per child) was provided at the cluster level.
We identified only one trial that individually randomized 148 adultswithAIDS fromone human immunodeficiency virus (HIV) clinic in the USA to receive intensive hand washing promotion delivered by specialist nurses (Huang 2007). The intervention included hygiene education, hand washing demonstrations by nurses and participants, and weekly telephone calls to reinforce hand washing messages. Themajor outcomes reported were mean episodes of diarrhoea in each group and number of hand washing episodes per day.
Three of the eight trials used an adequate method to generate the allocation sequence (Carabin 1999; Roberts 2000; Bowen 2007); themethod was unclear in the others. Themethod used to conceal allocation was unclear in all trials. Three trials reported blinding of the outcome assessors (Bartlett 1988, Kotch 1994, and Roberts 2000); the rest were open trials. It was difficult to assess the number of randomized participants included in the analysis as this was reported at different levels (cluster, child, person time-at-risk).
However, all trials were able to account for the number of randomized clusters included in the analysis. Five trials reported adequate comparability between the intervention and control groupswith respect to diarrhoea incidence and sociodemographic characteristics (including mean total enrolment, percentage of drop outs, sex, age, and race composition of children enrolled, diapering, and toilet facilities) at baseline (Black
1981; Bartlett 1988; Butz 1990; Ladegaard 1999; Bowen 2007).
Investigators in Bowen 2007 were forced to over or under-sample certain regions to obtain more ’control’ schools, after the original control schools were sent intervention packs by mistake and thus excluded. This trial reported small differences in household
sanitation and piped water at baseline, but no differences between schools in number of students, class size, or hygiene infrastructure. Comparability at baseline was unclear in the other trials. All trials reported collecting data at the same point in time for both the
intervention and control groups.
Luby 2004a, Luby 2006, and Stanton 1987 reported adequate methods for generating allocation sequence. Only Luby 2004a reported adequate allocation concealment; it was unclear in the other trials. All were open trials, except for Haggerty 1994, which reported blinding of the outcome assessor. Inclusion of all randomized participants in the analysis was unclear as it was reported at different levels of analysis (cluster, household, child).
Four trials reported baseline similarity of diarrhoea morbidity and socioeconomic characteristics (including population/household size, socioeconomic status, hand washing and sanitary facilities, and sources of water supply) between the intervention and control groups (Stanton 1987; Han 1989; Luby 2004a; Luby 2006). There were some differences at baseline in Haggerty 1994 (controls had diarrhoea episodes of longer duration than the intervention group). All the trials reported collecting data at the same period for intervention and control groups, and they all accounted for clustering in the analysis, except for Han 1989.
Huang 2007 did not clearly report the method of randomization or allocation concealment and did not use blinding. All 148 randomized participants were followed for the trial’s one-year duration.
Participants were similar at the start of the trial in terms of age, sex, ethnicity, hand washing episodes per day, CD4 count, HIV load, and prophylaxis for opportunistic infections. The results were presented as a continuous outcome only (mean and standard deviation of number of diarrhoea episodes in each arm over the year). This should be viewed with caution as it is likely that the distribution of diarrhoea episodes may be highly skewed (the mean of 1.24 and standard deviation of 0.9 episodes in the intervention arm imply a non-normal distribution of diarrhoea episodes). If so, the mean may not be the most appropriate measure of the ’average number’ of episodes per participant.
The incidence of diarrhoea was assessed in 7711 children aged less than seven years in 161 day-care centres and 87 schools in the eight trials. We separated the trials into those with crude rate ratios (Black 1981; Bartlett 1988; Butz 1990; Kotch 1994; Ladegaard 1999) and those that adjusted for clustering and confounders (Carabin 1999; Roberts 2000; Bowen 2007). Both groups had similar risk reductions, and, overall, there was a 29% reduction in the incidence of diarrhoea in the intervention group (IRR 0.71,
95% CI 0.60 to 0.84; 7 trials, Analysis 01.01).
All trials showed a benefit fromthe intervention, except for Bowen 2007,which showed no difference between each armand forwhich it was not possible to calculate a rate ratio (the median episodes of diarrhoea were 0 per 100 student-weeks in the control group, standard intervention group, and expanded intervention). Roberts 2000 showed greater risk reduction than other trials, possibly due to amore specificmethod of handwashing (an approximate “count to 10” to wash and “count to 10” to rinse).
All participants weremonitored, at least fortnightly, to collect data on diarrhoea episodes. This monitoring itself may have helped to improve compliance with hand washing. Only Carabin 1999 attempted to investigate this effect by assessing rates in both groups compared to the pre-intervention period. They found that monitoring alone appeared to reduce the incidence of diarrhoea (IRR 0.73, 95% CI 0.54 to 0.97; Table 04), and that the intervention effect did not appear to have any benefits over and above this
monitoring effect when adjusted for age and gender (IRR 0.77, 95% CI 0.51 to 1.18; Table 04) or adjusted for age, gender, season, and baseline incidence rate in each cluster (IRR 1.10, 95% CI 0.81 to 1.50; Table 04). However, monitoring was particularly frequent (daily) in this trial. In the Bowen 2007 trial among first grade students in schools in China, monitoring may have been less intensive as in-class monitoring was carried out on only one day a week by teachers; reasons for absenteeism were noted when recorded. As the trial was school-based, no illness information was collected during weekends or school holidays. This design reduced the burden of data collection of teachers, but it may also have reduced the ability of the trial to detect differences in the incidence of diarrhoea between each arm of the trial.
No trial reports clearly stated whether allocation was concealed, and we were therefore unable to assess whether this aspect of trial quality may be influencing results. Only blinding of the outcome assessors was possible in the trials, and, amongst those trials with adjusted rate ratios, the one trial in which the assessors were blinded, Roberts 2000, appeared to show greater effect than the one in which they were not, Carabin 1999 (Analysis 01.01.02).
However, a sensitivity analysis among the studies estimating crude rate ratios showed that the three unblinded trials −Black 1981, Butz 1990, and Ladegaard 1999− appeared to find a greater benefit from the intervention (IRR 0.65, 95% CI 0.53 to 0.80) than the two trials that used blinding (IRR 0.86, 95% CI 0.76 to 0.97) (Analysis 01.02). However, two of the open trials randomized a small number of clusters; Black 1981 used two clusters per arm and Ladegaard 1999 used eight clusters, and this may have influenced
the intervention method applied. Black 1981 also focused exclusively on hand washing, while the other trials promoted multiple hygiene interventions.
Two trials reported behavioural changes (Kotch 1994; Roberts 2000). As described in Table 05, Kotch 1994 reported that hand washing behaviour based on ’event sampling scores’ improved in the intervention classrooms compared with control classrooms.
Roberts 2000 reported that the intervention improved compliance with infection control procedures in three day-care centres. This was associated with a lower illness incidence in children greater than or equal to two years (RR 0.34, 95% CI 0.17 to 0.65),
reflecting a two-third reduction in diarrhoeal episodes.
Overall, the intervention reduced the incidence of diarrhoea by 31% (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials, Analysis 02.01). Three trials assessed the effect of intervention on the incidence rate of different categories of diarrhoea (Han 1989; Luby 2004a; Luby 2006), and although they reported reductions in the risk of diarrhoea with the interventions (Han 1989 reported on dysentery, and Luby 2004a and Luby 2006 reported on persistent diarrhoea), none of the results were statistically significant.
The included trials demonstrated distinct benefits from the promotion of hand washing for reducing the incidence of diarrhoea in different settings. However, the methodological quality of the included trials limits a clear interpretation of the evidence presented. Of the 14 trials, only six reported using an adequate method to generate the allocation sequence (Stanton 1987; Carabin 1999; Roberts 2000; Luby 2004a; Luby 2006; Bowen 2007).
Themethodwas unclear in the other trials, and, thus, selection bias may have been introduced. Only one trial, Luby 2004a, clearly reported adequately concealed allocation; this is difficult to achieve in trials of this nature since cross-contamination is recognized as a problem (Hayes 2000). Blinding can also be difficult to achieve in these trials, and only four trials attempted blinding of outcome assessors (Bartlett 1988; Haggerty 1994; Kotch 1994; Roberts 2000). The inclusion of all randomized participants in the analysis was reported at different levels of analysis (eg cluster, child,
household, person-time at risk), which made it difficult to assess.
Also, people tended to enter and leave naturally over the course of a study since most trials were conducted in communities and institutions, and not closed populations. However, all the institutional-based trials reported adequate inclusion of all the randomized clusters, while inmost of the community-based trials this was not explicitly reported. One trial reported differences at baseline between the intervention and control groups (Haggerty 1994), while three trials did not report on this clearly (Kotch 1994; Carabin 1999; Roberts 2000). Thismight be a problemif therewere few clusters. All the included trials reported collecting data over the same period in both trial arms.
There was wide variation in the benefits of hand washing promotion on the incidence of diarrhoea reported by individual trials. This heterogeneity is not surprising as the trials differed greatly in terms of setting, population, and hand washing intervention. However, the pooled estimates from the included trials show a 29%risk reduction for the institution-based trials and 31%for the community-based trials. There was also an important reduction in mean episodes (1.68 fewer episodes in the intervention group)
in a high-risk population (AIDS patients), but this is based on one trial with 148 participants and requires confirmation. In most trials, the interventions were based on hygiene promotion (providing education about diarrhoea transmission and treatment, and hand washing behaviours).
Most trials did not appear to have used any explicit ’behavioural change’ model, though two trials applied ’participatory learning processes’ (Bartlett 1988; Ladegaard 1999). It is not clear whether interventions based on any such models would be more or less effective. Hygiene education may have a ’herd effect’ in clusterrandomized trials (hand washing by some community members will benefit others indirectly by reducing the number of pathogens in the local environment) and may have other benefits beyond reductions in diarrhoea such as saving mother’s time (looking after sick children). Generally, the included trials did not assess such outcome measures, and nor did this review.
Many trials promoted a whole range of hygiene interventions in addition to hand washing. There did not appear to be any greater risk reduction for those promoting several hygiene interventions compared with those promoting hand washing only, though this is difficult to assess with only a limited number of trials. The contribution of the different hygiene education components in achieving the benefits is also unclear.
It is possible that bias was introduced by the intensive monitoring of outcomes in both intervention and control groups in these trials. Carabin 1999 attempted to explore this by assessing the effects of the intervention itself from that of monitoring. The effect of monitoring on diarrhoeal episodes was significant, but the intervention itself had no statistically significant effect. Monitoring of hand washing may therefore be more important than other facets of the intervention on compliance and effectiveness. This is
known as theHawthorne effect (Feachem1983) whereby themere fact of being under observation leads to improvement in a trial outcome (in this case, increased frequency of hand washing and reduction of diarrhoea). Carabin 1999 used particularly frequent
monitoring (daily); less frequent monitoring may have reduced the importance of this effect.
Provision of hand washing materials by the investigators may increase hand washing effectiveness (although there were too few trials to make strong conclusions) as these trials showed slightly greater risk reductions in diarrhoea episodes than ones that did
not. Although this review shows that hand washing can be effective, most of the trials should be regarded as ’efficacy’ trials in the sense that they include intense follow up and monitoring (all contacted intervention communities at least fortnightly, some more often to ascertain diarrhoea episodes and reinforce the hygiene promotion messages);many also provided handwashingmaterials and replenished supplies regularly. One large-scale trial from Burkina Faso that is not included in this review suggested that changes in hand washing behaviour could be maintained in the longer term (three years) in a large community (a city of approximately 300,000 residents) (Curtis 2001) and may be cost-effective (Borghi 2002), but this trial did not assess trends in hospitalization for diarrhoea and requires replicating in other communities. Bowen 2007, included in this review, was larger and had less intensive monitoring (carried out by teachers), but it was not able to detect any difference between either of the intervention and control groups in terms of diarrhoea episodes (there was a median of 0 episodes per 100. student-weeks in all groups). However, Bowen 2007 did find a statistically significant reduction in overall illness (mostly accounted for by differences in rates of upper respiratory tract infections) of 35% and 71% in the standard and expanded intervention groups respectively, and reductions in absenteeism of 44% and 42% respectively, compared with controls. This highlights the difficulties in the design of effectiveness studies with more limited monitoring but with sufficient power and sensitivity to detect differences in diarrhoea episodes. Most trials in this review were relatively small with short-term follow up, and it is unclear if their level of effectiveness would be maintained if they were scaled up to larger regions with less intensive monitoring over a longer time period.
All institution- and community-based trials in this review were conducted in children aged less than 15 years, and mostly in children aged less than seven years. Therefore results cannot be generalized to all ages. In future studies, comparison of effects in young (less than three years) and older children may inform decisions of whom to target and optimal message delivery mode suitable for the two settings (institutions in high-income settings; communities in low- and middle-income countries). Older children are able to make their own decisions about hand washing, while toddlers will always be dependent on adults to help them.
The approximate 30%reduction in diarrhoea morbidity observed in our review suggests less benefit than was reported by previous reviews of hand washing and hygiene interventions (Curtis 2003; Fewtrell 2004; Fewtrell 2005),which estimated reductions of 47% and 44%respectively.However it is higher than the estimated 27% diarrhoea reduction of providing clean water (Clasen 2006). In this review, we included only randomized controlled trials where specific hand washing interventions were tested with or without additional hygiene promotion. We excluded observational, casecontrol, and controlled before-and-after studies, some of which were included in previous reviews. Unlike one previous review (Curtis 2003), we also avoided double-counting of studies since this may overestimate the intervention effect, tends to breakdown the assumption of study independence, and narrows the 95%CIs. Also, we combined incidence rate ratios for diarrhoea as a primary outcome and attempted to extract or estimate these fromthe paper if they were not reported. Guevara 2004 supports the use of rate ratios in meta-analyses of studies of this nature as it improves
the clinical interpretability of findings. Some trials reported odds ratios, but thesemay overestimate the risk reduction for a common outcome such as diarrhoea episodes if they are combined with rate ratios in a meta-analysis, as in one previous review (Curtis 2003).
Thus the stringent inclusion criteria for this Cochrane Review and the methods of analysis may be responsible for the lower magnitude of effect observed than in the earliermeta-analyses. Nonetheless this review provides strong evidence that hand washing interventions reduce diarrhoeal morbidity by about 30%.
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