Hand washing education in Quezalguaque, Nicaragua

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Hand washing education in Quezalguaque, Nicaragua

• APHA 136th Annual Conference,
• San Diego, CA October 29, 2008
• Denise Burke MPH, Courtney Cawthon MPH,
• Casey Rebholz MPH, Karen Sherk MPH
• (Presenting author)

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Presenter Disclosures

• Courtney Cawthon

The following personal financial relationships
with commercial interests relevant to this
presentation existed during the past 12 months
No relationships to disclose
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Learning Objective

• To understand the design, monitoring and
  evaluation of a community hygiene intervention

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Background

• Boston University Masters Practicum 2006
• Brookline Sister City Project
• Quezalguaque General Health Survey
• Demographics, health services access and
  utilization, common health issues

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Source http//www.mapsofworld.com/nicaragua
Source Mayors office, Quezalguaque, Nicaragua
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Setting

• Many households dont have electricity
• Wells are main source of water
• Sinks and latrines are often shared
• 55 had no school or not completed primary school
  
• Most live in close proximity to livestock

Photos courtesy of Christine Yennaco, BUSPH 08
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Disease Burden

• Worldwide
• A child dies every 30 seconds from diarrhea
• ARI is the cause of 30-50 of child visits
• 67 of child mortality
• In Nicaragua
• Diarrhea is a leading cause of mortality
• Quezalguaque Ministry of Health
• 54 of health center visits
• ARI the leading complaint in 2006-07

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Disease Transmission Model
Wagner and Lanois, 1958 PAHO
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Specific Aims

• Decrease frequency of diarrhea
• Decrease frequency of ARI
• Increase hand washing at 3 key times
• After defecation or using the latrine
• After changing /cleaning a child who has
  defecated
• Before preparing and serving food

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Formative Phase

• Qualitative evaluation
• (June 2-15, 2007)
• Key informant interviews
• Focus Groups
• Results
• Price is a barrier to purchasing hand soap
• Interest in home visits
• Prevention vs. Treatment

Photo courtesy of Brookline Sister City Project
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Source Mayors office, Quezalguaque, Nicaragua
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Intervention

• Charlas informal educational workshops
• Local project assistants
• Once a month in each intervention community
• Lesson plans by BUSPH grad student
• Health center support
• Free hand soap (CP, Central America)
• Home visits focused on
• education

Colgate-Palmolive Co.
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Enrollment and Data collection

• Enrollment (July 9-25, 2007)
• Children 5 years with a caregiver 18 years
• Photos, symptom diaries
• Baseline survey
• Direct observations

Photo courtesy of Christine Yennaco, BUSPH 08
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Monitoring
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Final Evaluation(January 2008)

• Repeat baseline survey
• Repeat direct observations

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Results

• 108 caregivers/149 children (94 retention)
• 97 female caregivers
• Average age
• Caregiver 28 years (range 18-59)
• Children 2.6 years
• Households
• 1.4 children
• 5.3 people
• 1.6 adults employed

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Results

• Disease prevention knowledge
• Hand washing behavior at key times
• Health outcomes

Photo courtesy of Christine Yennaco, BUSPH 08
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Disease Prevention Knowledge
Table 1. Comparison of Knowledge of Hand Washing
with Soap and Water to Prevent Disease, and
Importance of Key Activities for Hand Washing, at
follow-up
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Hand Washing Behavior
Table 2. Frequency of "Always" or "Almost Always"
Washing Hands with Soap and Water with Key
Activities, at follow-up
Among those with children wearing diapers, n51
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Health Outcomes
Table 3. Comparison of overall disease burden of
ARI and diarrhea at follow up
P-values only significant for diarrheal measures
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Discussion

• Heightened awareness of symptoms can lead to
  increased reporting
• Added emphasis of education materials on diarrhea
• Intervention techniques not closely evaluated
• Direct observations unsuccessful

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Limitations

• Communal sinks, location of sink and soap
• Self-report subject to bias
• Selection of study communities was not at random
• Demographic factors
• High unemployment rate
• Large families in close quarters
• Low educational attainment
• Persistent need for food

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Conclusions

• The intervention successfully increased knowledge
• To achieve more impact on health outcomes, need
  to address logistical barriers

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Thanks to our Funders

• APHA International Section Colgate-Palmolive

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Acknowledgements

• Advisors Dr. Jim Wolff and Sarah Johnson, for
  their constant encouragement and guidance.
• Boston University MPH Candidates Nicole Daley,
  Julie ODonnell, Christine Yennaco, Yuko
  Rodriguez, Dana Greeson and Ana Morales, who all
  contributed long hours and creative ideas to this
  project
• Special thanks to Colgate Palmolive-Central
  America, for their generous donation of hand
  soap.
• Most importantly, Brookline Sister City in
  Brookline, MA and Quezalguaque, Nicaragua, for
  letting us be a part of their wonderful work.

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Bibliography

• Arbizu M. Correspondence between Dr. Martha
  Arbizu, Director of Quezalguaque Health Center,
  and Sarah Johnson of the Brookline Sister City
  Project. Feb 2007.
• Burke D, Cawthon RC, Rebholz C, Sherk K.
  Quezalguaque General Health Survey 2006.
• Children in Cambodia Face High Mortality Rate.
  Department of Planning and Health Information,
  Ministry of Health, the Reproductive Health
  Association of Cambodia, and PRB. Population
  Reference Bureau. Accessed August 20, 2007.
  http//www.prb.org/Articles/2002/ChildreninCambodi
  aFaceHighMortalityRate.aspx
• Curtis V, Kanki B, Cousens S, Diallo I,
  Kpozehouen A, Sangare M, Nikiema M. Evidence of
  behaviour change following hygiene promotion
  programme in Burkina Faso. Bull World Health
  Organ. 2001 79(6)518-27
• Favin M. Promoting Hygiene Behavior Change with
  in C-IMCI The Peru and Nicaragua Experience.
  USAID Environmental Health Project Activity
  Report 143, October 2004.
• Gorter A, Sandiford P, Praw J, Morales P, Perez
  M, Alberts H. Hygiene behavior in rural Nicaragua
  in relation to diarrhea. International Journal of
  Epidemiology. 1998 271090-1100.
• Gungoren B, Latipov R, Regallet G, Musabaev E.
  Effect of hygiene promotion on the risk of
  reinfection rate of intestinal parasites in
  children in rural Uzbekistan. Trans R Soc Trop
  Med Hyg. 2007 Jun 101(6)564-569. Epub April 5,
  2007.
• Handwashing Handbook A guide for developing a
  hygiene promotion program to increase hand
  washing with soap. Global Public Private
  Partnership for Hand washing. World Bank 2005.
• Luby S, Agboatwalla M, Painter J, Altaf A,
  Billhimer W, Hoekstra R. Effect of Intensive Hand
  washing Promotion on Childhood Diarrhea in
  High-Risk Communities in Pakistan. JAMA 2004
  291(21)2547-54.
• MINSA, 10 most frequent causes of morbidity and
  mortality, Statistics from Ministry of Health of
  Quezalguaque, Nicaragua for the years 2005-2007.
• Shahid NS, Greenough WB III, Samadi AR, Hug MI,
  Rahman N. Hand washing with soap reduces
  diarrhoea and spread of bacterial pathogens in a
  Bangladesh village. J Diarrhoeal Dis Res. 1996
  Jun 14(2)85-89.
• Statisitics, At-a-glance Nicaragua. UNICEF, Info
  by country. http//www.unicef.org/infobycountry/ni
  caragua_statistics.html Accessed. 21 October 2008.

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Questions?
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Behavior Change Model