National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people.

INTRODUCTION: Infectious disease outbreaks have historically led to widespread disruptions in routine essential health services. Disruptions due to COVID-19 responses led to excess deaths, including among women and children. This review builds on earlier reviews of essential health services in national COVID-19 response and preparedness plans, focusing specifically on maternal, newborn, child, adolescent and ageing health (MNCAAH) in the context of renewed global emphasis on monitoring, recovering and strengthening these services. METHODS: Using Google searches, we identified publicly available COVID-19 response and preparedness plans authored by a national government body or Public Health Institute from any country, territory and/or area, published between January 2020 and December 2022. We assessed whether each plan considered maintenance of MNCAAH services with related activities, costing or monitoring plans, and whether these considerations were integrated into the national incident management system for COVID-19. RESULTS: We identified plans from 110 countries, representing 56% of our sample, in 10 languages. Most plans came from low-income and middle-income countries. Three quarters of dated documents were published between February and April 2020. 22% of plans referenced the impact of COVID-19 on MNCAAH, but only 13% included a planned activity for monitoring or mitigating this impact and less than 5% included relevant indicators, costing or integration of services in the incident management system. CONCLUSION: We propose that unless content specifically related to the services and needs of these populations is integrated, these services will suffer in a future disruptive event. The COVID-19 response demonstrated the need for an interdisciplinary response to address the unforeseen impacts that arose, yet plans continue to have a narrow focus and a generic approach which may be limiting.

Intervention design in public health: adaptive messaging in the Tanzanian National Sanitation Campaign.

Few case studies exist in the public health or design literatures showing how to create national scale messaging campaigns in low-income countries using design processes. In this paper, we describe how we used Behaviour Centred Design to develop Nyumba ni choo, the Tanzanian National Sanitation Campaign. The process involved multiple iterations of ideation and filtration by professional creatives, government staff, academics and sanitation specialists to create a branded mass communication campaign, which was refreshed annually. The campaign was based on the insight that Tanzania is modernizing rapidly, with people upgrading their homes, but leaving their outside toilets in a 'traditional' state. Built around the 'big idea' that a household is not fully modern without a good-quality, modern toilet, the campaign employed reality TV shows, live engagements and mass and digital media postings, all targeted at motivating both the government and general population to improve toilets. The campaign has made toilets a topic of national conversation and has led to a major uptick in the rate of toilet building. Efforts to improve public health-related behaviour can be enhanced by using systematic approaches that build on available evidence, understand behaviour in its common settings, employ psychological theory and engage creative expertise.

Seasonal variation in water use for hygiene in Oromia, Ethiopia, and its implications for trachoma control: An intensive observational study.

If facial hygiene practices vary seasonally this could have important implications for the design of interventions for trachoma control. This observational study was conducted to explore seasonal variation in hygiene behaviours in 9 households with at least one child aged 1-9 years-of-age in the West Arsi zone in rural Oromia, Ethiopia. Sixty-one household members were observed intensively over two days in the dry season (January), the rainy season (July) and during the harvest period (October) in 2018. Structured record forms were used to document household water availability and use. Daily water use per capita was very low in all seasons (3.1-4.2 litres). Around one third of water consumed in households in all seasons was associated with body washing. Soap was used during 44 of 677 (6%) of these observed occasions and half of all body washes (n = 340; 50%) included face washing. Overall, 95% of 58 individuals washed their faces at least once between 06:30h and 21:30h in the dry season (21% with soap), compared with 79% in the rainy season (2% with soap) (p = 0.013). Sixty-five percent of householders washed their faces during the harvest observation period (06:30h to 17:30h), none of whom used soap. Twenty-eight percent of 204 children aged 11 and under still had ocular or nasal discharge on their faces after washing. Seventy-three percent of those who washed their faces did so more than once in the dry season, compared with 33% in the rainy season (p<0.001). Face washing occurred throughout the day during the dry season, with a clear peak in the early morning and extra washes in the early evening. Face washing mainly took place in the early morning in the other two seasons. Genuine water scarcity in this area is likely to limit the impact of face washing interventions for trachoma control in the absence of water supply interventions. However, face washing was most common at the time of year when water is the hardest to come by, and seasonal differences in behaviour should be considered in any resulting intervention design.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review.

BACKGROUND: Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear. OBJECTIVES: To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change. METHODS: We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising. RESULTS: Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'. CONCLUSIONS: Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

Designing a Food Hygiene Intervention in Low-Income, Peri-Urban Context of Kisumu, Kenya: Application of the Trials of Improved Practices Methodology.

Food contamination during weaning and complementary feeding can result in high diarrheal incidence among infants. Caregiver practices are important determinants of exposure to foodborne pathogens, and can therefore play a role in reduction in infant food contamination. Through a qualitative approach, we used the Trials of Improved Practices methodology to design a food hygiene intervention in a low-income settlement of Kisumu city in Kenya. These settlements in Kisumu city host a large portion of the city's population and are faced with a high diarrheal disease burden. Caregivers were selected if they had a child aged 6-9 months, and together, we codesigned a combination of hardware and messaging components targeting handwashing with soap, hygienic feeding, reheating, and hygienic storage of infant food. Caregivers received up to six engagement visits with the research team. The visits were aimed at improving the designed hardware and messaging components. Results showed that feeding items were easily adopted by caregivers, whereas reheating of food was less observed. Households reportedly improved their food storage and handwashing practices. As a result, the hardware components were further refined and tested among the caregivers. Messaging components spurred the aspirations that caregivers had for their children and acted as reminders of practicing good food hygiene. The outcomes of the codesign process provided valuable insights on the knowledge of caregivers, a delivery approach for implementing the intervention, and further informed a subsequent trial that adopted the designed intervention to target early childhood exposure to enteric pathogens through contaminated food.

Detecting extra-ocular Chlamydia trachomatis in a trachoma-endemic community in Ethiopia: Identifying potential routes of transmission.

BACKGROUND: Trachoma elimination efforts are hampered by limited understanding of Chlamydia trachomatis (Ct) transmission routes. Here we aimed to detect Ct DNA at non-ocular sites and on eye-seeking flies. METHODS: A population-based household survey was conducted in Oromia Region, Ethiopia. Ocular and non-ocular (faces, hands, clothing, water containers and sleeping surfaces) swabs were collected from all individuals. Flies were caught from faces of children. Flies, ocular swabs and non-ocular swabs were tested for Ct by quantitative PCR. RESULTS: In total, 1220 individuals in 247 households were assessed. Active trachoma (trachomatous inflammation-follicular) and ocular Ct were detected in 10% and 2% of all-ages, and 21% and 3% of 1-9-year-olds, respectively. Ct was detected in 12% (95% CI:8-15%) of tested non-ocular swabs from ocular-positive households, but in none of the non-ocular swabs from ocular-negative households. Ct was detected on 24% (95% CI:18-32%) of flies from ocular-positive households and 3% (95% CI:1-6%) of flies from ocular-negative households. CONCLUSION: Ct DNA was detected on hands, faces and clothing of individuals living in ocular-positive households suggesting that this might be a route of transmission within Ct infected households. In addition, we detected Ct on flies from ocular-positive households and occasionally in ocular-negative households suggesting that flies might be a vector for transmission within and between Ct infected and uninfected households. These potential transmission routes may need to be simultaneously addressed to suppress transmission.

Comparison of Face Washing and Face Wiping Methods for Trachoma Control: A Pilot Study.

Eye-to-eye transmission of Chlamydia trachomatis, the causative agent of trachoma, may be plausibly interrupted if faces are kept free of ocular and nasal discharge. Between April and June 2018, 83 children aged 1-9 years with active trachoma were recruited from 62 households and allocated to a face cleaning protocol: face washing with water, face washing with water and soap, or face wiping. Faces were examined for the presence of ocular and nasal discharge, and swabs were taken from faces and hands to test for C. trachomatis at baseline, immediately post protocol, and after 1, 2, and 4 hours (washing protocols). Washing with soap was more effective at removing ocular discharge than either washing with water (89% and 27% of discharge removed, respectively, P = 0.003) or wiping with a hand (42%, P = 0.013). The reduction in prevalence of ocular discharge was sustained for at least four hours. The prevalence of C. trachomatis on face swabs was reduced by all washing protocols. The importance of soap should not be overlooked during facial cleanliness promotion.

Hygiene programming during outbreaks: a qualitative case study of the humanitarian response during the Ebola outbreak in Liberia.

BACKGROUND: Hygiene promotion is a cornerstone of humanitarian response during infectious disease outbreaks. Despite this, we know little about how humanitarian organisations design, deliver or monitor hygiene programmes, or about what works to change hygiene behaviours in outbreak settings. This study describes humanitarian perspectives on changing behaviours in crises, through a case study of hygiene promotion during the 2014-2016 Liberian Ebola outbreak. Our aim was to aid better understanding of decision making in high-stress situations where there is little precedent or evidence, and to prompt reflection within the sector around how to improve and support this. METHODS: We conducted in-depth, semi-structured interviews with fourteen purposively-sampled individuals (key informants) from international organisations involved in hygiene behaviour change during the outbreak. Through thematic analysis we identified the decisions that were made and processes that were followed to design, deliver and monitor interventions. We compared our findings with theory-driven processes used to design behaviour change interventions in non-outbreak situations. RESULTS: Humanitarians predominantly focussed on providing hygiene products (e.g. buckets, soap, gloves) and delivering messages through posters, radio and community meetings. They faced challenges in defining which hygiene behaviours to promote. Assessments focused on understanding infrastructural needs, but omitted systematic assessments of hygiene behaviours or their determinants. Humanitarians assumed that fear and disease awareness would be the most powerful motivators for behaviour change. They thought that behaviour change techniques used in non-emergency settings were too 'experimental', and were beyond the skillset of most humanitarian actors. Monitoring focussed on inputs and outputs rather than behavioural impact. CONCLUSIONS: The experiences of humanitarians allowed us to identify areas that could be strengthened when designing hygiene programmes in future outbreaks. Specifically, we identified a need for rapid research methods to explore behavioural determinants; increased skills training for frontline staff, and increased operational research to explore behaviour change strategies that are suited to outbreak situations.

Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya.

Complementary food hygiene is important to reduce infant exposures to enteric pathogens; however, interventions to improve food hygiene in low- and middle-income countries often ignore the larger context in which childcare occurs. In this study, we explore on observational and qualitative information regarding childcare in an informal community in Kenya. Our findings demonstrate that behaviors associated with food contamination, such as hand feeding and storing food for extended periods, are determined largely by the larger social and economic realities of primary caretakers. Data also show how caregiving within an informal settlement is highly dynamic and involves multiple individuals and locations throughout the day. Findings from this study will help inform the development and implementation of food hygiene interventions in informal urban communities.

The Safe Start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: a study protocol for a cluster randomized controlled trial.

BACKGROUND: Symptomatic and asymptomatic enteric infections in early childhood are associated with negative effects on childhood growth and development, especially in low and middle-income countries, and food may be an important transmission route. Although basic food hygiene practices might reduce exposure to faecal pathogens and resulting infections, there have been few rigorous interventions studies to assess this, and no studies in low income urban settings where risks are plausibly very high. The aim of this study is to evaluate the impact of a novel infant food hygiene intervention on infant enteric infections and diarrhoea in peri-urban settlements of Kisumu, Kenya. METHODS: This is a cluster randomized control trial with 50 clusters, representing the catchment areas of Community Health Volunteers (CHVs), randomly assigned to intervention or control, and a total of 750 infants recruited on a rolling basis at 22 weeks of age and then followed for 15 weeks. The intervention targeted four key caregiver behaviours related to food hygiene: 1) hand washing with soap before infant food preparation and feeding; 2) bringing all infant food to the boil before feeding, including when reheating or reserving; 3) storing all infant food in sealed containers; and, 4) using only specific utensils for infant feeding which are kept separate and clean. RESULTS: The primary outcome of interest is the prevalence of one or more of 23 pre-specified enteric infections, determined using quantitative real-time polymerase chain reaction for enteric pathogen gene targets. In addition, infant food samples were collected at 33 weeks, and faecal indicator bacteria (Enterococcus) isolated and enumerated to assess the impact of the intervention on infant food contamination. CONCLUSION: To our knowledge this is the first randomized controlled trial to assess the effect of an infant food hygiene intervention on enteric infections in a high burden, low income urban setting. Our trial responds to growing evidence that food may be a key pathway for early childhood enteric infection and disease and that basic food hygiene behaviours may be able to mitigate these risks. The Safe Start trial seeks to provide new evidence as to whether a locally appropriate infant food hygiene intervention delivered through the local health extension system can improve the health of young children. TRIAL REGISTRATION: The trial was registered at clinicaltrial.gov on March 16th 2018 before enrolment of any participants (https://clinicaltrials.gov/ct2/show/NCT03468114).

Theory-driven formative research to inform the design of a national sanitation campaign in Tanzania.

INTRODUCTION: There are gaps in global understanding about how to design and implement interventions to improve sanitation. This formative study provided insights for the subsequent redesign of a government-led national sanitation campaign targeting rural populations in Tanzania. METHODS: The Behaviour Centred Design approach was used to investigate the determinants of toilet building, improvement and use. Varied, novel, and interactive research tools were employed in fifty-five households in two regions of rural Tanzania. Results were analysed to articulate a Theory of Change, which then informed intervention design. RESULTS: Participants valued hard work, enterprise, and improving their lives over many years. They wanted better toilets but felt no urgency to act quickly. A common emotional motivator for improving toilets was to protect children from disease (Nurture) but this was insufficient to drive rapid change. Disgust with traditional toilets meant they were built at a distance from the house: an 'out of sight, out of mind' attitude. Other powerful motives included the desire to improve living conditions (Create), and to become a modern Tanzanian (Status), albeit without 'showing off'. Construction costs and water scarcity were the main stated barriers. Receiving information about realistic costs, support accessing materials, and visiting better latrines elsewhere were commonly reported reasons for improving latrines. CONCLUSIONS: The resulting Theory of Change recommended that the intervention should surprise people with a novel conversation about toilets, promote toilets as a means of conferring status, and introduce a perceived urgency to 'act now'. It should suggest that modest improvements would lead to a better life. Feelings of disgust and fear with poor quality toilets should be amplified, and barriers lessened through promoting transformational toilet improvements, and improving access to modern toilet products. This research provided considerable insight into sanitation behaviours in rural Tanzania, which informed creative intervention design.