Effect of Intensive Handwashing Promotion on Childhood Diarrhea in High-Risk Communities in Pakistan: A Randomized Controlled Trial
Abstract
CONTEXT: Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies lacked sufficient power to assess the impact of household handwashing on diarrhea in infants. OBJECTIVE: To evaluate the effect of promoting household handwashing with soap among children at the highest risk of death from diarrhea. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Field workers visited participating households at least weekly from April 15, 2002, to April 5, 2003. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years. INTERVENTIONS: Weekly visits in 25 neighborhoods to promote handwashing with soap after defecation and before preparing food, eating, and feeding a child. Within intervention neighborhoods, 300 households (1523 children) received a regular supply of antibacterial soap and 300 households (1640 children) received plain soap. Eleven neighborhoods (306 households and 1528 children) comprised the control group. MAIN OUTCOME MEASURE: Incidence density of diarrhea among children, defined as the number of diarrheal episodes per 100 person-weeks of observation. RESULTS: Children younger than 15 years living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea (95% confidence interval [CI], -65% to -41%) compared with children living in control neighborhoods. Infants living in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea (95% CI, -61% to -16%) vs infants living in control neighborhoods. Severely malnourished children (weight for age z score, <-3.0) younger than 5 years living in households that received handwashing promotion and plain soap had 42% fewer days with diarrhea (95% CI, -69% to -16%) vs severely malnourished children in the control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap. CONCLUSION: In a setting in which diarrhea is a leading cause of child death, improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from diarrhea.
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“As Luby et al. (2004) suggested, many health threats can be addressed partly through ensuring adequate handwashing facilities, limiting the spread of pathogens.”
BackgroundWolfe, M. K., Kaur, M., Yates, T., Woodin, M. A., & Lantagne, D. (2018) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.17-0897 · Cited by 82 · see citing works
Parker, A. A., STEPHENSON, R., Riley, P. L., OMBEKI, S., KOMOLLEH, C., SIBLEY, L., & Quick, R. E. (2006) · Epidemiology and Infection · doi:10.1017/s0950268806005954 · Cited by 80 · see citing works
Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene
Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., Perencevich, E. N., Polgreen, P. M., Schweizer, M. L., Trexler, P. A., et al. (2014) · Infection Control and Hospital Epidemiology · doi:10.1086/651677 · Cited by 81 · see citing works
Rosen, L., Manor, O., Engelhard, D., Brody, D. L., Rosen, B., Peleg, H., Meir, M., & Zucker, D. M. (2005) · Preventive Medicine · doi:10.1016/j.ypmed.2005.09.012 · Cited by 80 · see citing works
Agüero, J. M., & Beleche, T. (2017) · Journal of Health Economics · doi:10.1016/j.jhealeco.2017.03.008 · Cited by 80 · see citing works
“Moreover, intensive small-scale interventions show significant reductions in diarrhea (e.g., Ejemot-Nwadiaro et al., 2008; Luby et al., 2004; Luby et al., 2005),3 but scaling up similar inter- 2 For example, Koplik (1902) summarizes the research of the previous decade and recommends the…”
McDonald, E., Bailie, R. S., Brewster, D., & Morris, P. S. (2008) · BMC Public Health · doi:10.1186/1471-2458-8-153 · Cited by 79 · see citing works
“Eleven studies were considered not eligible for inclusion and the reasons for this include: three were cross sectional studies [56-58]; one an ethnographic study [ 59 ]; two studies did not include the use of a control group [60,61]; two papers were reviews [62,63]; one paper only provided information on study design…”
ResultGera, T., Shah, D., & Sachdev, H. S. (2018) · Indian Pediatrics · doi:10.1007/s13312-018-1279-3 · Cited by 77 · see citing works
“Of these 107 references were excluded and 62 publications (41 studies) were included in the final analyses [10-71].”
BackgroundThe World Health Organization ‘5 Moments of Hand Hygiene’
Chou, D. T. S., Achan, P., & Ramachandran, M. (2012) · Journal of Bone and Joint Surgery - British Volume · doi:10.1302/0301-620x.94b4.27772 · Cited by 76 · see citing works
Hard to handle: understanding mothers' handwashing behaviour in Ghana
Scott, B. E., Lawson, D. W., & Curtis, V. (2007) · Health Policy and Planning · doi:10.1093/heapol/czm014 · Cited by 71 · see citing works
“can reduce rates of diarrhoea among the under fives by 42–47% (Curtis and Cairncross 2003; Luby et al. 2004) and rates of respiratory infections by 16% (Rabie and Curtis 2006).”
BackgroundInfluentialPaiva, R. F. D. P. D. S., & de Souza, M. F. D. P. (2018) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00017316 · Cited by 71 · see citing works
A Nationwide Survey on the Hand Washing Behavior and Awareness
Jeong, J. S., Choi, J. K., Jeong, I. S., Paek, K. R., In, H.-K., & Park, K. D. (2007) · Journal of Preventive Medicine and Public Health · doi:10.3961/jpmph.2007.40.3.197 · Cited by 69 · see citing works
“Ë ¥& Ì@jkÍÎj°±` SARS, +Ï ÐÑp, P4, ÒÓÔ, C, ÁiK ÕD Ö8H×;?IDØo¢1⁄44g> ÙS'eÚÛ¢Æ [5], &Ì;^_ Ã< ;Ü1⁄44ÝÞfg¥ßà <áÞ, C 40-50% >ÂP âh㣰a°Ê£ [6-9].”
Ethics in Public Health Research
Curtis, V. A., Garbrah-Aidoo, N., & Scott, B. (2007) · American Journal of Public Health · doi:10.2105/ajph.2006.090589 · Cited by 67 · see citing works
Herd Protection from Drinking Water, Sanitation, and Hygiene Interventions
Fuller, J. A., & Eisenberg, J. N. S. (2016) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.15-0677 · Cited by 67 · see citing works
Rough Guide to Impact Evaluation of Environmental and Development ProgramsPreprint
Pattanayak, S. K. (2009) · RePEc: Research Papers in Economics · Cited by 67 · see citing works
Amin, N., Pickering, A. J., Ram, P. K., UNICOMB, L. E., Najnin, N., Homaira, N., Ashraf, S., Abedin, J., Islam, M. S., & Luby, S. P. (2014) · American Journal of Tropical Medicine and Hygiene · doi:10.4269/ajtmh.13-0475 · Cited by 66 · see citing works
“5) 9 (2) Both hands 121 (94) 114 (89) 65 (97) 300 (71) Handwashing agent used within the last 1 hour (multiple responses allowed) After defecation Any soap and water (soap, soapy water, or detergent) 27 (96) 19 (83) 13 (100) 59 (92) Water only 1 (4) 3 (13) 0 4 (6) Other 0 1 (4) 0 1 (2) After toileting Any soap and wat…”
Preventing dengue through mobile phones: Evidence from a field experiment in Peru
Dammert, A. C., Galdo, J. C., & Galdo, V. (2014) · Journal of Health Economics · doi:10.1016/j.jhealeco.2014.02.002 · Cited by 64 · see citing works
Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene
Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., Perencevich, E. N., Polgreen, P. M., Schweizer, M. L., Trexler, P. A., et al. (2014) · Infection Control and Hospital Epidemiology · doi:10.1017/s0899823x00193900 · Cited by 62 · see citing works
Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam
Xuan, L. T. T., & Hoat, L. N. (2013) · Global Health Action · doi:10.3402/gha.v6i0.18869 · Cited by 62 · see citing works
Waddington, H. S., Masset, E., Bick, S., & Cairncross, S. (2023) · PLoS Medicine · doi:10.1371/journal.pmed.1004215 · Cited by 69 · see citing works
New treatments compared to established treatments in randomized trials
Djulbegović, B., Kumar, A., Glasziou, P., Perera, R., Reljic, T., Stanton, L., Raftery, J. P., Johansen, M., Tanna, G. L. D., Miladinović, B., et al. (2012) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.mr000024.pub3 · Cited by 60 · see citing works
Schiavo, R., Leung, M. M., & Brown, M. (2014) · Pathogens and Global Health · doi:10.1179/2047773214y.0000000127 · Cited by 59 · see citing works
Lobo, M., Augusto, J. B., Antunes, F., Ceita, J., Xiao, L., Codices, V., & Matos, O. (2014) · PLoS ONE · doi:10.1371/journal.pone.0097708 · Cited by 58 · see citing works
Buekens, P. M. (2004) · JAMA · doi:10.1001/jama.291.21.2639 · Cited by 57 · see citing works
A glossary of culture in epidemiology
Hruschka, D. J., & Hadley, C. (2008) · Journal of Epidemiology & Community Health · doi:10.1136/jech.2008.076729 · Cited by 56 · see citing works
Examining the relationship between socio-economic status, WASH practices and wasting
Raihan, M. J., Farzana, F. D., Sultana, S., Haque, M. A., Rahman, A. S., Waid, J. L., McCormick, B., Choudhury, N., & Ahmed, T. (2017) · PLoS ONE · doi:10.1371/journal.pone.0172134 · Cited by 55 · see citing works
Urban infrastructure in Latin America and the Caribbean: public policy priorities
Jaitman, L. (2015) · Latin American Economic Review · doi:10.1007/s40503-015-0027-5 · Cited by 58 · see citing works
Gungoren, B., Latipov, R., Régallet, G., & Musabaev, E. I. (2007) · Transactions of the Royal Society of Tropical Medicine and Hygiene · doi:10.1016/j.trstmh.2007.02.011 · Cited by 51 · see citing works
“There is a lack of evidence showing how improved hygiene can help to reverse such grim figures and contribute to the well-being of children because it is more difficult to measure the effectiveness of hygiene promotion programs than water and sanitation interventions (Almedom et al., 1997; Carneiro et al., 2002; Curti…”
BackgroundKlasen, S., Lechtenfeld, T., Meier, K., & Rieckmann, J. (2012) · Journal of Development Effectiveness · doi:10.1080/19439342.2012.720995 · Cited by 51 · see citing works
“More explicitly, in a randomised control trial from urban Pakistan Luby et al. (2004) find that hand washing substantially reduces diarrhoea among children.”
BackgroundHuang, D. B., & Zhou, J. (2007) · Journal of Medical Microbiology · doi:10.1099/jmm.0.46867-0 · Cited by 51 · see citing works
“Many intensive handwashing promotion studies have been conducted among children, persons in the developing world and health care workers (Haggerty et al., 1994; Luby et al., 2004; Shahid et al., 1996).”
BackgroundAtolanı, O., Baker, M. T., Adeyemı, O. S., Ismaeel, R. O., Hamid, A. A., Ameen, M., Oguntoye, S. O., & USMAN, L. A. (2020) · EXCLI journal · doi:10.17179/excli2020-1386 · Cited by 50 · see citing works
“…alcohols such as either ethanol, isopropyl alcohol, propan-1-ol or propan-2-ol; and additives such as colorants, stabilizers, fragrance and sometimes preservatives which may include formaldehyde, parabens among other chemicals (Luby et al., 2004, 2005; Kramer et al., 2007; Napolitani et al., 2020).”
Clean hands reduce the burden of disease
Pittet, D. (2005) · The Lancet · doi:10.1016/s0140-6736(05)66886-9 · Cited by 51 · see citing works
Ram, P. K., DiVita, M. A., Khatun-e-Jannat, K., Islam, M., Krytus, K., Cercone, E., Sohel, B. M., Ahmed, M., Rahman, A. M. Q., Rahman, M., et al. (2015) · PLoS ONE · doi:10.1371/journal.pone.0125200 · Cited by 49 · see citing works
“In a year-long trial of handwashing promotion in Karachi, Pakistan, diarrhea rates were 50% lower in the intervention group over the course of a year of surveillance but did not differ at all during the first two months following the introduction of the intervention, suggesting that the behavior had not changed early…”
BackgroundBacterial and fungal isolation from face masks under the COVID-19 pandemic
Park, A.-M., Khadka, S., Sato, F., Omura, S., Fujita, M., Hashiwaki, K., & Tsunoda, I. (2022) · Scientific Reports · doi:10.1038/s41598-022-15409-x · Cited by 49 · see citing works
MacLeod, C., Braun, L., Caruso, B. A., Chase, C., Chidziwisano, K., Chipungu, J., Dreibelbis, R., Ejemot-Nwadiaro, R. I., Gordon, B. A., Mills, J. E., et al. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-068887 · Cited by 54 · see citing works
Ellis, M. W., Schlett, C. D., Millar, E. V., Wilkins, K. J., Crawford, K. B., Morrison-Rodriguez, S. M., Pacha, L. A., Gorwitz, R. J., Lanier, J. B., & Tribble, D. R. (2014) · Clinical Infectious Diseases · doi:10.1093/cid/ciu166 · Cited by 47 · see citing works
Acute Gastroenteritis in Children
Bhutta, Z. A. (2011) · Elsevier eBooks · doi:10.1016/b978-1-4377-0755-7.00332-8 · Cited by 47 · see citing works
Opryszko, M. C., Majeed, S. W., Hansen, P. M., Myers, J. A., Baba, D. J., Thompson, R. E., & Burnham, G. M. (2010) · Journal of Water and Health · doi:10.2166/wh.2010.121 · Cited by 45 · see citing works
“…shown to be effective in reducing diarrhoea in studies elsewhere (Esrey et al. 1991; Mintz et al. 1995; Quick et al. 1999; 2006; Curtis & Cairncross 2003; Luby et al. 2004; Fewtrell et al. 2005; Clasen et al. 2006), but there is little evidence regarding their level of effectiveness in Afghanistan.”
BackgroundChan, E. Y. Y., Tong, K. H. Y., Dubois, C., Mcdonnell, K., Kim, J. H., Hung, K. K. C., & Kwok, K. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182312268 · Cited by 51 · see citing works
“The use of the more economical regular soap is now favored in most handwashing campaigns as similar reduction in diarrheal incidence has been observed with the use of regular soap and antibacterial soap [68,72].”
BackgroundResultPang, J., Chua, J., & Hsu, L. Y. (2015) · BMC Public Health · doi:10.1186/s12889-015-1910-3 · Cited by 43 · see citing works
“In addition, an annual hand and food hygiene campaign, which had been shown to be effective in reducing diarrhoea disease even in mostly rural areas [13, 14, 42].”
BackgroundWali, N., Chen, W. L., Rawal, L. B., Amanullah, A. S. M., & Renzaho, A. M. N. (2018) · Archives of Public Health · doi:10.1186/s13690-018-0305-1 · Cited by 43 · see citing works
Bhutta, Z. A. (2006) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/01.mpg.0000255846.77034.ed · Cited by 42 · see citing works
Field trial of a low cost method to evaluate hand cleanliness
Luby, S. P., Agboatwalla, M., Billhimer, W. L., & Hoekstra, R. M. (2007) · Tropical Medicine & International Health · doi:10.1111/j.1365-3156.2007.01847.x · Cited by 41 · see citing works
“…trial households randomized to soap and handwashing promotion received three times as much soap as control households reported purchasing (Luby et al. 2004), yet we measured no difference in the proportion of mothers’ hands that were contaminated in households that received soap compared…”
BackgroundResultInfluential
- Authors
- Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. L., & Hoekstra, R. M.
- Affiliations
- Centers for Disease Control and Prevention (US)
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2004-06-02
- Volume
- 291
- Issue
- 21
- Pages
- 2547
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2165965969
- Cited by
- 309
- References
- 23
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 13 · 2023: 10 · 2022: 13 · 2021: 16 · 2020: 6 · 2019: 12 · 2018: 9 · 2017: 13 · 2016: 16 · 2015: 21 · 2014: 28 · 2013: 11 · 2012: 17
- FWCI
- 13.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Life Sciences › Agricultural and Biological Sciences › Food Science › Food Safety and Hygiene
- Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
- Keywords
- handwashing with soap, childhood diarrhea, infants, severe malnutrition, antibacterial soap, urban slums, low-income communities, diarrhea prevention, child mortality
- MeSH terms
- Adolescent, Adult, Child, Child, Preschool, Diarrhea, Infantile, Family, Female, Hand Disinfection, Humans, Hygiene, Infant, Male, Pakistan, Poverty, Risk Factors, Soaps
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