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New cases of coronavirus disease 2019 (COVID-19) are continually being recorded worldwide, despite global efforts in implementing non-pharmaceutical interventions and establishing vaccination programs. This trend highlights the need to identify the factors associated with the continued spread of COVID-19. The World Health Organization recommends hand washing as a cost-effective intervention for preventing COVID-19, indicating that water, sanitation, and hygiene (WaSH) are central to the prevention of the disease. However, low- and middle-income countries lack adequate access to WaSH, which increases the risk of contracting COVID-19. The aim of this study was to identify the WaSH factors associated with the incidence of COVID-19 and quantitatively estimate the effects of improvements in WaSH on reducing the incidence of COVID-19 during the peak of the pandemic. Lasso regression and extreme gradient boosting models were used to identify the WaSH factors. Distinct estimation models were developed to assess the effect of WaSH in rural regions under two assumptions: increasing regional basic sanitation coverage up to 25 % and 50%. The reduction in the incidence of COVID-19 during the peak of the pandemic was calculated for each rural region. The results of the analyses indicated that basic sanitation is important for reducing the incidence of COVID-19 in rural regions compared to urban regions in the Philippines. In addition, the results suggested that increasing basic sanitation coverage could reduce the incidence of COVID-19 by 2-66 %, alleviating the burden on healthcare facilities. This study indicates that improved basic sanitation infrastructure are needed in rural Philippines. The results of this study emphasise the significance of WaSH as an indicator of COVID-19 incidence, highlighting the need for its enhancement to enable the achievement of sustainable disease prevention and pandemic preparedness goals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Despite a downward trend, Ethiopia still faces significant challenges with high rates of stunting and acute malnutrition in children. To tackle these issues, the Feed the Future Ethiopia Growth Through Nutrition Activity, a USAID-funded project aligned with Ethiopia's National Nutrition Program, was executed from 2016 to 2023. This initiative aimed to enhance nutrition for women and young children across six regions through multisectoral interventions. Annual surveys conducted in 2017, 2018, and 2020 evaluated the impact of livelihood support and Water, Sanitation, and Hygiene (WASH)-focused social behavior change communication (SBCC) on vulnerable households with children under two. The results showed significant improvements in child nutrition. Dietary diversity among children increased from 12% to 34% (p<0.001), and the percentage of children receiving a minimal acceptable diet rose from 12% to 30.7% (p<0.001). Women's dietary diversity also improved markedly, from 2% to 16% (p<0.001). Handwashing practices saw improvements, with the proportion of households having handwashing facilities rising from 14% to 31% (p<0.001), and the adherence to critical handwashing moments increased from 16% to 23%. However, challenges in water treatment and latrine use persisted, with less than 25% improvement. The findings suggest that integrating livelihood support with SBCC interventions can positively enhance nutritional outcomes. Continued focus on these strategies is recommended to further support vulnerable households., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Purpose: The purpose of this study was to examine the association between hygiene and sexual practices and the incidence of urinary tract infection (UTI) among Jordanian pregnant women., Methods: The cross-sectional data were collected using self- administered survey from October 2018 to January 2019 in central Jordan. A total of 200 pregnant women completed the survey. All of them were married and aged between 18 and 45 years (M = 27.45; SD = 6.06). The measures used were demographics, social, hygiene and sexual practices., Results: A significant association was found between the incidence of UTI and the educational level of husbands (p = 0.05), history of UTI in previous pregnancies (p = 0.02) and being in the second trimester of pregnancy (p = 0.02). Their sexual and hygiene practices also were significantly associated with the incidence of UTI., Conclusion: History of UTI in previous pregnancies, hygiene and sexual practices are associated with increased incidence of UTI among Jordanian pregnant women. Appropriate strategies and techniques to promote health and preventive behaviors for pregnant women with UTI should be provided to improve the quality of life among pregnant women and reduces economic burdens on health care system., (© 2024. The Author(s).)

Background: Over 1.7 billion instances of diarrheal illness in children are reported worldwide yearly. Diarrhea was a major cause of death in children, accounting for 9% of all global under-five child deaths in 2021. The objective of this study was to identify the association between hygiene practices and childhood diarrhea among under-five children in Myanmar., Method: This cross-sectional study was conducted in 16 townships from 8 states and regions of Myanmar. 1207 children between the ages of 6 and 59 months were recruited by multistage random sampling. Data were collected with a preformed questionnaire after participants provided consent. Multiple logistic regressions were administered to determine the factors associated with childhood diarrhea., Result: This study found that 86 (7.13%) under-five children experienced diarrhea disease. This study identified that children receiving limited hygiene services were 2.85 times (AOR = 2.85, 95% CI: 1.31 to 6.21; p value 0.01) and children without hygiene services were 2.63 times (AOR = 2.63, 95% CI: 1.42 to 4.89; p value 0.01) more likely to have diarrhea disease than those with basic hygiene services. Other factors associated with diarrhea included: fathers who washed their hands less than four steps (AOR = 2.20, 95% CI: 1.29 to 3.74; p value 0.01), families taking more than 15 min to collect water (AOR = 1.77, 95% CI: 1.06 to 2.97; p value 0.03), families sharing toilet usage (AOR = 2.00, 95% CI: 1.15 to 3.48; p value 0.01), mother's inadequate and problematic hygiene promotion health literacy (AOR = 2.20, 95% CI: 1.24 to 3.90; p value 0.01), houses made of bamboo or lacking floors (AOR = 2.31, 95% CI: 1.38 to 3.89; p value 0.01), families with three or more children (AOR = 1.68, 95% CI: 1.01 to 2.79; p value 0.05) and breastmilk being the primary food after 6 months of age (AOR = 2.07, 95% CI: 1.09 to 3.93; p value 0.03)., Conclusions: Ensuring access to basic hygiene services, getting water at home 24 h per day, seven days per week, using private toilets, promoting hygiene health literacy, improving house flooring, family planning and introducing a variety of foods after age 6 months could significantly prevent diarrhea among under-five children in Myanmar. This study underscores the critical role of handwashing facilities in reducing the diarrhea incidence in children., (© 2024. The Author(s).)

Background: Menstrual hygiene management is a critical aspect of adolescent health. However, access to adequate menstrual hygiene products and sanitation facilities is severely restricted during times of war. There is a dearth of information about the menstrual hygiene needs of adolescent girls during humanitarian crises. This study investigated the menstrual hygiene management needs of the internally displaced adolescent girls in the war-torn region of Tigray, Ethiopia., Methods: A qualitative study was conducted in three centers for internally displaced people in Mekelle, Tigray Region. Four focus-group discussions and six in-depth interviews were conducted using the local language among 39 adolescent girls aged 13-19 years. The collected data were recorded, transcribed, translated, and analyzed using the ATLAS.ti-7.5.18 software through a qualitative thematic analysis approach., Results: Six primary themes were identified: 1) shortage of menstrual pads; 2) poor accommodation of latrine facilities; 3) silence around menstruation; 4) exchange of menstrual pads for life-saving commodities, 5) lack of privacy; 6) menstruation is a "curse" for adolescent girls living in displaced people's camps. The study highlights the significant challenges faced by internally displaced adolescent girls in managing their menstrual hygiene while living in camps for internally displaced people. Lack of access to adequate menstrual hygiene management supplies often leads them to use rags or worn-out clothing instead of menstrual pads., Conclusion: Access to adequate menstrual hygiene products and sanitation facilities is severely limited among displaced adolescent girls in Tigray. The findings emphasize the urgent need to address menstrual hygiene issues during emergencies. Supplying essential items such as sanitary pads, soap, water, sanitation infrastructure, and improved information on menstrual hygiene management should be prioritized., Competing Interests: LLW serves as a non-compensated member of the board of directors of the charity, Dignity Period. The other authors have no competing interests to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Betsu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Despite the implementation of non-pharmaceutical interventions, the threat of coronavirus disease 2019 (COVID-19) remains significant on a global scale. Identifying external factors contributing to its spread is crucial, especially given the World Health Organization's recommendation emphasizing access to water, sanitation, and hygiene as essential in curbing COVID-19. There is a notable discrepancy in access to sanitation facilities, particularly evident in low- and middle-income countries. However, there is a lack of quantitative assessments regarding these factors. This study examines various environmental, socioeconomic, water, sanitation, and hygiene factors and their associations with COVID-19 incidence. All regions in the Philippines were categorized into clusters based on socioeconomic factors. A conceptual structural equation model (SEM) was developed using domain knowledge. The best-fitting SEM for each cluster was determined, and associations between factors and COVID-19 incidence were estimated. The correlation analysis revealed that rainfall, minimum temperature, and relative humidity were positively correlated with weekly COVID-19 incidence in urban regions. Maximum temperature, mean temperature, wind speed, and wind direction were negatively correlated with weekly COVID-19 incidence in rural regions, with time lags of 0, 3, and 7 weeks. In urban regions (Cluster 1), factors such as urbanization rate (1.00), area (-0.93), and population (0.54) were found to be associated with weekly COVID-19 incidence. Conversely, in rural regions (Cluster 2), factors including area (0.17), basic sanitation (0.84), and wind direction (0.83) showed associations with weekly COVID-19 incidence. These factors were causally associated with a latent variable reflecting the hidden confounders associated with COVID-19 incidence. It is important to note that sanitation factors were associated only in rural regions. Improving access to sanitation facilities in rural regions of the Philippines is imperative to effectively mitigate disease transmission in future pandemics. Identification of the causal effect of unobserved confounders with COVID-19 incidence is recommended for future research., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Safe drinking water, sanitation, and hygiene (WASH) are crucial to human health. Reducing inequalities and ensuring universal access to WASH are essential to achieving the agenda of sustainable development. We aimed to measure access to WASH among ethnic minority populations in Bangladesh and understand the situation and factors affecting WASH practices among them. Additionally, we reviewed policy related to WASH to highlight the inequality faced by ethnic minority populations., Methodology: We utilized data from the multiple indicator cluster survey-2019. We used the chi-square test for bivariate analysis and multilevel mixed-effect logistic regression analyses to identify the effect of ethnicity on WASH in Bangladesh after controlling selected covariates. Furthermore, we systematically reviewed Bangladesh's WASH-related policies and programs., Findings: While 98.5% of Bengalis had access to basic drinking water services, the percentage is 60.6% for the ethnic minority population. For improved sanitation facilities not shared with others, the difference between Bengali and ethnic populations was 22.3% (64.6% vs. 42.3%). On the other hand, 75% of the Bengali population had a handwashing facility with water and soap, and 50% of the ethnic population had them. Ethnicity appeared to be a statistically significant predictor of every component of WASH. Compared to Bengali, the ethnic population had 87%, 45%, 31%, and 45% less access to water (aOR = 0.13, p ≤ 0.001), sanitation (aOR = 0.55, p ≤ 0.001), and handwashing (aOR = 0.69, p ≤ 0.05), and WASH facilities aOR = 0.55, p ≤ 0.001), respectively. Among the policies of Bangladesh, only one identified action for WASH rights of ethnic minorities., Conclusion: The government should identify the issues of WASH among ethnic minorities and represent them adequately in policies to achieve the aim of 'leaving none behind' of sustainable development goals., (© 2024. The Author(s).)

Despite some progress, universal access to safe water, sanitation and hygiene (WASH) by 2030-a remit of Sustainable Development Goal 6-remains a distant prospect in many countries. Policy-makers and implementers of the WASH sector are challenged to track a new path. This research aimed to identify core orienting themes of the sector, as legacies of past processes, which can provide insights for its future. We reviewed global policy, science and programmatic documents and carried out 19 expert interviews to track the evolution of the global WASH sector over seven decades. We situated this evolution in relation to wider trends in global health and development over the same time period.With transnational flows of concern, expertise and resources from high-income to lower-income countries, the WASH sector evolved over decades of international institutionalisation of health and development with (1) a focus on technologies (technicalisation), (2) a search for generalised solutions (universalisation), (3) attempts to make recipients responsible for environmental health (responsibilisation) and (4) the shaping of programmes around quantifiable outcomes (metricisation). The emergent commitment of the WASH sector to these core themes reflects a pragmatic response in health and development to depoliticise poverty and social inequalities in order to enable action. This leads to questions about what potential solutions have been obscured, a recognition which might be understood as 'uncomfortable knowledge'-the knowns that have had to be unknown, which resonate with concerns about deep inequalities, shrinking budgets and the gap between what could and has been achieved., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We aimed to investigate whether early-life hygiene-related factors influenced the risk of inflammatory bowel disease (IBD) in a Scandinavian population and test the association's consistency across cohorts., Methods: This study followed 117 493 participants in the All Babies in Southeast Sweden study and the Norwegian Mother, Father, and Child Cohort Study. IBD diagnoses were defined by national registers. Comprehensive data on hygiene-related exposures, such as having pets, rural living, daycare attendance, and siblings, were retrieved from questionnaires administered from pregnancy until child's age of 36 months. A multivariable Cox regression model yielded adjusted hazard ratios (aHRs) for IBD accounting for socioeconomic status and perinatal factors. Cohort-specific estimates were pooled using a random-effects model., Results: In over 2 024 299 person-years of follow-up 451 participants developed IBD. In pooled estimates children attending daycare up to 36 months of life vs not attending daycare were less likely to develop Crohn's disease (aHR, 0.60; 95% confidence interval [CI], 0.37- 0.98). Children having 1 or more siblings had a modestly increased risk of IBD (aHR, 1.17; 95% CI, 0.96-1.42; aHR for each sibling, 1.12; 95% CI, 1.01-1.24). The other hygiene factors were not significantly linked to later IBD. In the Norwegian Mother, Father, and Child Cohort Study cohort, bed sharing was associated with an increased risk of IBD, most notably for ulcerative colitis (aHR, 1.67; 95% CI, 1.01-2.78)., Conclusions: In this birth cohort study from 2 high-income Scandinavian countries, some early-life hygiene-related exposures were associated with IBD risk. The generalizability of these results to countries of other socioeconomic level is unknown., (© 2023 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

This study investigates the hygiene status, behavioral practices, and handling of cutting boards for meat and vegetable processing in selected open markets in Benin City. Utilizing a structured questionnaire and laboratory analysis for Escherichia coli and Aeromonas, the research found prevalent Escherichia coli in all samples, with varying concentrations of Aeromonas, more pronounced in vegetable processing areas. Analysis of the questionnaire revealed that 30% of traders leave cutting boards uncovered, 88% clean them before use (52% with water and detergent), and 12% dust boards before use. Furthermore, 80% of meat sellers store leftover meat in refrigerators, while 68% of vegetable sellers store leftovers in the open market. The findings underscore the importance of proper hygienic practices in handling cutting boards to mitigate food contamination risks, urging awareness among traders regarding effective cleaning and storage procedures.

Menstruation is a natural cyclic occurrence experienced by reproductive age females in a good health which deemed a proper management, otherwise, it ends with various health complications and impaired quality of life. The aim of this study was to investigate the menstrual hygiene management practice and its determinant factors among reproductive age females living in the IDPs camps of Shire town, Northern Ethiopia. A cross-sectional study was conducted among 633 reproductive age females in Shire town from May to June 2022. Data were entered, cleaned, and analyzed using SPSS version 23. Descriptive analysis and binary and multivariable logistic regression were conducted to obtain the descriptive findings and to investigate the strength of the association respectively. P-value < 0.05 was considered statistically significant. The prevalence of good menstrual hygiene management practice among the reproductive age females was 41.9% (95% CI, 38-45.8%). Menstrual hygiene management practice was significantly (p < 0.05) associated with access to sanitary materials, educational level, availability of continuous water supply and sex-separated latrines. The results of this study demonstrated that more than a half of the reproductive age females did not have good menstrual hygiene management practices. Consequently, it is recommended to work collaboratively to enhance the menstrual hygiene practice, especially in IDPs camps., (© 2024. The Author(s).)

The predominant use of disposable, non-organic menstrual products has significant environmental impacts due to waste and resource depletion. Concerns over the environmental, economic, and health implications of menstrual hygiene management (MHM) have highlighted the need to explore sustainable options like reusable sanitary pads (RSPs). Despite their benefits, the adoption of RSPs is limited by a lack of awareness, availability, cost, and research. This study emphasizes the need for the development of an instrument that can capture the effectiveness, safety, and user satisfaction of RSPs, addressing a significant gap in the literature. Using a convenient sampling method, data were collected through a structured offline survey and the sample comprised 446 South Asian women of reproductive age. The instrument included 15 items designed to measure factors such as comfort, hygiene, convenience, and environmental consciousness. The instrument's reliability and validity are thoroughly assessed using reliability and factor analysis to ensure its effectiveness in capturing the multifaceted dimensions of MHM product choices. The study revealed that the overwhelming majority of women would prefer the option of RSPs that are comfortable, accessible, and easy to use and dispose of. The findings aim to provide a validated tool for manufacturers, policymakers, and researchers to evaluate reusable pads, promoting their broader acceptance and adoption of a sustainable and equitable approach to menstrual hygiene., (© 2024. The Author(s).)

Introduction: High-quality evidence is crucial for guiding effective humanitarian responses, yet conducting rigorous research, particularly randomised controlled trials, in humanitarian crises remains challenging. The TISA ("traitement intégré de la sous-nutrition aiguë") trial aimed to evaluate the impact of a Water, Sanitation and Hygiene (WASH) intervention on the standard national treatment of uncomplicated Severe Acute Malnutrition (SAM) in children aged 6-59 months. Implemented in two northern Senegalese regions from December 22, 2021, to February 20, 2023, the trial faced numerous challenges, which this paper explores along with the lessons learned., Methods: The study utilised trial documentation, including field reports, meeting minutes, training plans, operational monitoring data and funding proposals, to retrace the trial timeline, identify challenges and outline implemented solutions. Contributions from all TISA key staff-current and former, field-based and headquarters-were essential for collecting and interpreting information. Challenges were categorised as internal (within the TISA consortium) or external (broader contextual issues)., Results: The TISA trial, executed by a consortium of academic, operational, and community stakeholders, enrolled over 2000 children with uncomplicated SAM across 86 treatment posts in a 28,000 km 2 area. The control group received standard outpatient SAM care, while the intervention group also received a WASH kit and hygiene promotion. Initially planned to start in April 2019 for 12 months, the trial faced a 30-month delay and was extended to 27 months due to challenges like the COVID-19 pandemic, national strikes, health system integration issues and weather-related disruptions. Internal challenges included logistics, staffing, data management, funding and aligning diverse stakeholder priorities., Discussion and Conclusion: Despite these obstacles, the trial concluded successfully, underscoring the importance of tailored monitoring, open communication, transparency and community involvement. Producing high-quality evidence in humanitarian contexts demands extensive preparation and strong coordination among local and international researchers, practitioners, communities, decision-makers and funders from the study's inception., Trial Registration: Clinicaltrials.gov NCT04667767 ., (© 2024. The Author(s).)

The 2023 World Menstrual Hygiene Day (WMHD) celebration at the University of Health and Allied Sciences (UHAS) sought to create awareness about menstruation. Toward normalizing menstruation, the 3-day event brought together key stakeholders and engaged community members on various topics relating to menstruation. Among the stakeholders were basic school teachers (13), school children (155), in a 2:1 female vs. male ratio within the ages of 10-17 years, School Health and Education Program Coordinators (2), Health Officers (4), Academicians (15), University students (35), Media representatives (3), and Civil society representatives (130). Particular among these discussions were the biology of menstruation, nutrition related facts during menstruation, sociocultural, and mental health issues surrounding menstruation. These discussions were intended to incite more conversations about menstruation, and contribute toward the agenda 2030 goal of making menstruation a normal fact of life. The paper describes activities conducted to improve menstrual health, reduce period poverty, and involve men in breaking the stigma around menstruation. This contributes to creating supportive environments for menstruating individuals. Meanwhile, the lessons from the activities to celebrate WMHD in Ghana are relevant for other communities to consider replicating with consideration for contextual differences., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Gbogbo, Wuresah, Addo, Klomegah, Gbogbo, Axame, Klutse, Makam, Dowou, Nelson, Boateng, Mantey, Kugbey, Doku, Hennegan, Baiden, Aziato and Binka.)

Background: School-based water, sanitation and hygiene (WASH) may improve the health and attendance of schoolchildren, particularly post-menarcheal girls, but existing evidence is mixed. We examined the impact of an urban school-based WASH programme (Project WISE) on child health and attendance., Methods: The WISE cluster-randomised trial, conducted in 60 public primary schools in Addis Ababa, Ethiopia over one academic year, enrolled 2-4 randomly selected classes per school (~ 100 pupils) from grades 2 to 8 (aged 7-16) in an 'open cohort'. Schools were assigned 1:1 by stratified randomisation to receive the intervention during the 2021/2022 or the 2022/2023 academic year (waitlist control). The intervention included improvements to drinking water storage, filtration and access, handwashing stations and behaviour change promotion. Planned sanitation improvements were not realised. At four unannounced classroom visits post-intervention (March-June 2022), enumerators recorded primary outcomes of roll-call absence, and pupil-reported respiratory illness and diarrhoea in the past 7 days among pupils present. Analysis was by intention-to-treat., Results: Of 83 eligible schools, 60 were randomly selected and assigned. In total, 6229 eligible pupils were enrolled (median per school 101.5; IQR 94-112), 5987 enrolled at study initiation (23rd November-22nd December 2021) and the remaining 242 during follow-up. Data were available on roll-call absence for 6166 pupils (99.0%), and pupil-reported illness for 6145 pupils (98.6%). We observed a 16% relative reduction in odds of pupil-reported respiratory illness in the past 7 days during follow-up in intervention vs. control schools (aOR 0.84; 95% CI 0.71-1.00; p = 0.046). There was no evidence of effect on pupil-reported diarrhoea in the past 7 days (aOR 1.15; 95% CI 0.84-1.59; p = 0.39) nor roll-call absence (aOR 1.07; 95% 0.83-1.38; p = 0.59). There was a small increase in menstrual care self-efficacy (aMD 3.32 on 0-100 scale; 95% CI 0.05-6.59), and no evidence of effects on other secondary outcomes., Conclusions: This large-scale intervention to improve school WASH conditions city-wide had a borderline impact on pupil-reported respiratory illness but no effect on diarrhoeal disease nor pupil absence. Future research should establish relationships between WASH-related illness, absence and other educational outcomes., Trial Registration: ClinicalTrials.gov, number NCT05024890., (© 2024. The Author(s).)

Bovine digital dermatitis remains a widespread endemic disease of dairy cattle worldwide. Footbathing is commonly used as a control measure and has significant economic and environmental impacts. Few studies document footbathing practices on dairy farms or evaluate their suitability for achieving foot disinfection. This study describes footbathing practices on 32 farms observed in the United Kingdom, Ireland, and the Netherlands. We measured solution depth throughout footbathing and observed levels below 7 cm on 9 out of 32 farms, which leads to inadequate foot coverage. Solution depth was associated with the number of cow passages and decreased by 1.2 cm for every 100 cow passages. We also describe levels of OM content (g/L) throughout footbathing as a proxy for footbath hygiene. Our data indicates that almost half of footbaths (15/32) became contaminated above the 20 g/L threshold to which veterinary biocides are tested for efficacy, and that OM content is associated with the number of cow passages per liter of footbathing solution provided. A multivariable mixed model predicted that 1 L of footbathing solution per cow should be sufficient to prevent excess contamination. As a further measure of hygiene, we tested a subset of footbath samples to quantify the amount of DNA present from the Treponema species which are considered instrumental in the etiology of digital dermatitis. We did not detect Treponema DNA in footbath samples, which suggested they are unlikely to act as infection reservoirs for this disease. Multivariable mixed models including farm identity as a random effect demonstrated that for both change in solution depth and OM content the effect of farm-level factors was large. Because of the magnitude of this farm effect, applying model predictions will not translate to adequate solution depth and hygiene on all farms. Our data highlights the importance of footbath auditing on individual farms., (The Authors. Published by Elsevier Inc. on behalf of the American Dairy Science Association®. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).)

Despite global recognition, WHO reports reveal significant gaps, with one in four healthcare facilities lacking basic water services, affecting over 1.8 billion people, and 21% lacking sanitation services, impacting 1.5 billion people, especially prevalent in low- and middle-income countries. This study aimed to critically evaluate the current state of water, sanitation and hygiene (WASH) facilities across a diverse range of healthcare settings. This review included various databases such as PubMed, MEDLINE, EMBASE, CINAHL, Scopus and grey literature; eligible studies employing various designs were scrutinized for WASH infrastructure and practices. Methodological quality was rigorously evaluated using the QuADS checklist. Data analysis, performed with R software, involved deriving pooled estimates of WASH intervention effects. Sensitivity analyses were conducted, employing statistical methods such as funnel plots to ensure robustness and mitigate biases. Of the 13,250 articles screened, 18 were included in this review. Meta-analyses revealed significant effect sizes for WASH interventions across domains - water (67.38%), sanitation (53.93%), waste management (40.82%), environment (56.58%), hygiene (66.83%), and management (42.30%). Widespread disparities in WASH persist across healthcare facilities, with rural areas facing notable deficits. Challenges in water quality, sanitation and waste management demand comprehensive, multi-sectoral approaches for improvement., (Copyright © 2024 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: The lack of menstrual hygiene management (MHM) information and facilities in schools is a major contributor to adolescent girls' school absenteeism in low- and middle-income countries like Bangladesh., Objectives: This paper examines the changes over time in school MHM facilities, knowledge and perceptions among adolescent girls, in relation to school absenteeism between 2014 and 2018 in Bangladesh., Methods: We examined changes in MHM and school absenteeism among schoolgirls using nationally representative data from the Bangladesh National Hygiene Baseline Survey 2014 and National Hygiene Survey 2018. Given the repetitive nature of our data and its clustering within participants, our method included performing descriptive analysis, bivariate analysis, and multivariate Generalised Estimating Equation (GEE) modelling to analyse these changes., Results: Results showed that adolescent girls' menstruation-related absenteeism decreased between 2014 and 2018. Percentage of adolescents who missed school decreased from 25% to 14% (PD: -11; CI: -16 to -6.1), while the average number of missed days reduced from 2.8 to 2.5 (PD: -0.33; CI: -0.57 to -0.10). In the GEE model, we found that living in rural areas (coef: -5.6; CI: -10.06 to -1.14), parental restrictions on going outside (coef: 4.47; CI: 0.75 to 8.2), education levels of girls (coef: -9.48; CI: -14.17 to -4.79), girl's belief that menstruation affects school performance (coef: 23.32; CI: 19.71 to 26.93), and using old cloths (coef: -4.2; CI: -7.6 to -0.79) were significantly associated with higher absenteeism. However, participant's age, type of school, knowledge of menstruation before menarche, receiving information regarding MHM, separate place for changing absorbents, and separate latrine and urine facility were not significantly associated with the changes in absenteeism over time., Conclusion: This paper emphasised the associations between changes in school absenteeism, parental restrictions on students, students' education levels, and menstruation-related misperceptions. Ongoing research, policy reviews, and targeted interventions to improve MHM perceptions among girls are required to provide long-term benefits for adolescent girls in Bangladesh.

Background: Menstruation is a normal biological process experienced by more than 300 million women globally every day. Women require clean menstrual absorbents that can be changed as often as needed in a private and safe place with proper hygiene and disposal facilities. These needs must be met consistently throughout the duration of the menstrual cycle. Access to menstrual needs is crucial for women's health, wellbeing, and dignity. This study assessed the prevalence and factors associated with unmet need for menstrual hygiene management (MHM) in Ethiopia, Kenya, Uganda, Burkina Faso, Ghana, and Niger., Methods: We used data from the Performance Monitoring for Action (PMA) 2020 surveys. We defined the unmet need for MHM as the "lackof resources, facilities and supplies for MHM." Sample characteristics were summarised using frequencies and percentages, while prevalence was summarised using proportions and their respective confidence intervals (CI). Factors associated with unmet need for MHM were assessed using multilevel logistic regression models., Results: The study included 18,048 women of reproductive age from the six countries. The prevalence of unmet need for MHM was highest in Burkina Faso (74.8%), followed by Ethiopia (69.9%), Uganda (65.2%), Niger (57.8%), Kenya (53.5%), and lowest in Ghana (34.2%). Unmet need for MHM was consistently higher among uneducated and multiparous women, those who reused MHM materials, practiced open defecation, and lived in rural areas across all six countries. The odds of unmet need for MHM were higher among younger women under 35 years, unmarried women, those with lower education levels, and those from poorer households. Similarly, the reuse of MHM materials, use of shared or non-improved toilet facilities, and open defecation increased the odds of unmet need for MHM. In contrast, the presence of handwashing facilities reduced the odds of unmet need for MHM., Conclusion: More than half of the women in five of the six countries have an unmet need for MHM, with significantly higher odds among younger women, those with low wealth status, the unmarried, and those with inadequate access to sanitary facilities. This study highlights the state of period poverty in Sub-Saharan Africa. Efforts to end period poverty should consider MHM needs as an integrated whole, as addressing each need in isolation is insufficient., (© 2024. The Author(s).)

Background: Inadequate menstrual hygiene management can result in physical, social, psychological, and educational challenges for schoolgirls. To address these issues, researchers have conducted intervention studies, but the impact on school attendance has varied. This review has systematically collected and evaluated evidence about the effects of menstrual hygiene interventions on schoolgirls., Method: A systematic search of the literature was done and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA statement). Both peer-reviewed journals and gray literature were searched using PubMed and Google Scholar. The search included individual, or cluster randomized controlled trials, and quasi-experimental studies, and covered the period from the date of indexing until January 3, 2023., Result: A review of sixteen trial studies showed that menstrual hygiene interventions have a positive effect on schoolgirls' school attendance, performance, and dropout rates, as well as on their menstrual knowledge, attitudes, practices, and emotional well-being. There was a low to medium risk of bias in most of the studies. Additionally, the literature overlooked the impact of interventions that involve parental and male engagement, interventions correcting community misperceptions about menstruation, and the impact of infrastructure improvements on water, sanitation, and hygiene., Conclusion: Interventions aimed at improving menstrual hygiene management can enhance schoolgirls' educational outcomes, and can improve their menstrual knowledge, attitudes, and practices by helping them manage their periods more effectively. Most interventions have focused on the provision of menstrual products and menstrual education but have neglected improvements in the physical environment at home and school and the social norms surrounding menstruation. Trial studies should take a holistic approach that considers the total socio-cultural environment in which menstrual hygiene management takes place, thus enabling stakeholders and policymakers to develop sustainable, long-term solutions to these problems., Competing Interests: LLW serves as a non-compensated member of the board of directors of the charity, Dignity Period. The other authors have no competing interests to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Betsu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

There is currently no single, easy-to-use, reliable indicator to assess whether a face has been washed with soap in the context of trachoma elimination. This study aimed to compare survey report, script-based pictorial recall and facial cleanliness indicators as alternatives to structured observation for measuring face washing behaviour. This method validation study was nested in the Stronger-SAFE trial, Oromia Region, Ethiopia. Structured observation was conducted in randomly selected households for three hours from dawn. The primary caregiver in each household participated in a survey to capture (self)-reported behaviour and/or script-based pictorial recall, a routine-based diary activity to covertly capture information on face washing behaviour of themself and any children aged 1-12. Children 4-12 years old directly participated in the survey and pictorial recall in a subset of households. The facial cleanliness of children aged 1-12 was assessed qualitatively and using the quantitative Personal Hygiene Assessment Tool (qPHAT). Prevalence estimates, sensitivity, specificity and predictive values were computed for each behavioural indicator with observation data as the gold standard. The appropriateness of script-based pictorial recall was assessed using baseline and 3-month follow-up data. Baseline data were collected from 204 households in 68 clusters. Survey estimates of face washing and face washing with soap among caregivers and children were 32% to 60% and 5% to 31% higher than observed behaviour, respectively. Face washing prevalence estimates from pictorial recall were lower than survey estimates and comparable with observations for some face washing with soap indicators (0.3% to 13% higher than observations). Specificity of pictorial recall indicators was high (85% to 99%), but the sensitivity was low (0% to 67%), resulting in a low positive predictive value for all indicators. Both qualitative facial cleanliness indicators and qPHAT scores were poorly correlated with observed face washing earlier that morning. Pictorial recall overestimated face washing with soap among both caregivers and children following intervention delivery but not at baseline. Survey (self)-reported data on face washing is highly inaccurate. Script-based pictorial recall does not correctly classify those who wash their face with soap, and is subject to differential bias following intervention exposure, and facial cleanliness is a poor indicator of recent face washing in settings where faces become rapidly dirty again after washing. Alternatives to structured observation cannot be recommended to monitor the effectiveness of face washing interventions in community settings. Trial Registration ISRCTN registry ISRCTN40760473, https://doi.org/10.1186/ISRCTN40760473., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Greenland et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Students in school are more likely to be sick from communicable diseases like diarrheal illnesses, acute respiratory infections, and other illnesses linked to poor personal hygiene. Poor hygiene practices are common among school children and put their health at risk, which in turn has several consequences. These include significant school absences, transmission of infectious diseases to other students, and missed workdays for parents and guardians. However, there is limited evidence on the level of personal hygiene practice and its associated factors among school students. Thus, this study was aimed at determining personal hygiene practice level and its associated factors among elementary school grade (5-8) students in Fiche town, Oromia, Ethiopia, in 2022., Methods: A cross-sectional study design was conducted from April 29 to May 29, 2022, in Fiche town, Oromia regional state, among 534 elementary school students. A multi-stage probability sampling technique was used to select the individual students. A structured questionnaire was used to collect the data. The data was entered into epi-data version 4.6 and analyzed by SPSS version 26.0. Variables that scored a p-value less than 0.2 during bivariate analysis were included in multilevel logistic regression models to determine factors associated with personal hygiene practice. The odds ratio with a 95% confidence interval was estimated, and the level of significance was set at [Formula: see text] 0.05., Results: The magnitude of good personal hygiene (scored above the mean) was 59.2% (95% confidence interval (CI)) (55.1-63.0). A considerable proportion of students scored more than 50% in latrine use (62.5%), regular hand-washing (55.4%), and oral hygiene (55.20%) practices. Being female, having good personal hygiene knowledge, doing hygiene inspections at school, and having latrine accessibility was significantly associated with good personal hygiene among elementary school students., Conclusion: Considerable proportion of elementary school students in Fiche town have score poor personal hygiene practice. Interventions aimed that target improving knowledge of personal hygiene and hygiene inspection at school are crucial to enhance the personal hygiene among elementary school students., (© 2024. The Author(s).)

Carl Flügge is best known for the promotion of studies demonstrating the transmission of all manner of infections, but particularly tuberculosis, by coughed droplets. But it is seldom recognised that Flügge was also influential in a number of other fields comprising the practice of hygiene. One-hundred years following his death in 1923, we review literature related to the studies of Flügge and his colleagues and students and illustrate the particular emphasis he laid upon the environment within which disease and its transmission might be fostered or prevented, embracing and studying aspects essential to the health of any community ranging from fundamental microbiology in the laboratory to subjects as disparate as housing, clean water supply, nutrition, sanitation, socio-economic circumstances and climate. Very early in his career he promoted breast feeding for the prevention of seasonal gastro-enteritis and later the sheltering of cough as a means of preventing the transmission of infected respiratory droplets, not only as regards tuberculosis, but also concerning all manner of other respiratory infections. By the time of Flügge's death the complexification of available scientific methodologies comprising hygiene made it difficult for any individual to comprehend and study the wide range of hygiene-related subjects such as Flügge did. Carl Flügge was one of the last holistic hygienists and an originator of the study of environmental health as a pillar of hygiene., (© 2024. The Author(s).)

A group of helminthic and intestinal protozoa causes intestinal parasitic infections (IPIs), affecting more than 2.5 billion people worldwide. IPIs are diseases closely associated with poor hygiene and sanitation, concentrated in underdeveloped regions and among populations with low socioeconomic status. Consequently, most prevalence is in Sub-Saharan Africa and Asia, with local habits or risk factors that could affect its prevalence. The aim of this study was to determine how hygienic practices, sanitation, and local behavior of eating raw meat ( hinasumba ) contributed to the prevalence of IPI. A cross-sectional study was conducted in the Simalungun District of North Sumatera Province, involving 428 people of Batak Simalungun. There were 15 villages randomly selected across the district based on the local registry, which consequently, non-purposive sampling was conducted. Face-to-face interviews assessed various risk factors, such as demographic characteristics, water source, traditional raw meat consumption, or hinasumba as local risk factors, hygienic practices, and sanitation. The findings indicated that an overall prevalence rate of IPI was 42.9%, consisting of 87.5% with helminthic infection and 12.5% with protozoal infection. More than half of IPI cases were associated with Taenia sp. infections (21.8%), followed by hookworms' infections with a 6.1% positivity rate. Based on multivariate analysis, farming and consuming traditional delicacies, namely hinasumba , increased the likelihood of IPI occurrence among the population by 1.7 and 3 times, respectively. It can be concluded that the high prevalence of taeniasis in the study area was associated with local behavior and hinasumba consumption, which may contribute to determining the dominance of specific IPI species., Competing Interests: All the authors declare that there are no conflicts of interest., (© 2024 The Author(s).)

Background: Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures., Methods: A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms., Results: The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm 2 ) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm 2 ) in blended preparation and commercial formula only., Conclusion: Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted., (© 2024 American Society for Parenteral and Enteral Nutrition.)

The Water, Sanitation, and Hygiene (WASH) interventions have been acknowledged for their role in the public health and educational outcomes. While there are strong evidences that reveal that WASH facilities do reduce the prevalence of infectious diseases and improve the learning environment, data remain thin and equivocal on the differential impacts of WASH facilities on education by gender. The literature reviewed does not, in most cases; go to the extent of investigating if indeed both men and women students have unique needs especially in underprivileged areas. This is the point from which the present systematic review and meta-analysis intend to fill this gap by assessing the global evidence on the effect of WASH interventions on educational outcomes with due consideration given to gender. This systematic review will include international databases used for the search, such as PubMed, Google Scholar, Web of Science, Europe PubMed Central, and Scopus. Study eligibility will include cross-sectional studies published in English on the impact of WASH interventions on school attendance and academic performance, stratifying gender-specific outcomes. Data extracted will be analyzed using the STATA software version 17. The percentage of heterogeneity will be quantified through the I2 statistics to show the variability between the included studies. Based on the observed results, diversity will be checked among the outcomes of the study and based on that random-effect model will be used to estimate the pooled effect size. I will, therefore, make use of the Egger and Begg tests for checking statistical asymmetry. Publication bias will be assessed with funnel plots. These will ensure the methodologies used provide comprehensive and rigorous data analysis, which will give strong insights into the impacts of the WASH intervention on educational outcomes. Prospero registration number: Systematic review and Meta-analysis registration number: PROSPERO CRD42024536477., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Dibaba et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The current study assessed (i) the microbiological safety level profiles (MSLPs) of milkmen's hands and milking containers and (ii) the influence of hygiene and handling practices on MSLPs of raw and cultured milk, from six informal dairy farms in Zimbabwe. Interviews and direct observations were carried out during the assessment of hygiene and handling practices at six farms designated A to F. Microbiological criteria of the following six microbiological parameters: Total Bacterial Counts (TBCs), Coliform Counts (CCs), Total Escherichia coli Counts (TECs), Salmonella spp., Listeria monocytogenes and Klebsiella pneumonia, were used to determine contamination level (CL) at four different critical sampling locations (CSLs). The CSLs were raw milk (CSL1), cultured milk (CSL2), milkmen's hands (CSL3), and milking containers (CSL4). The microbiological criteria of the six microbiological parameters were used to score CLs as: intolerable (0), poor to average (1), average (2), and good (3). MSLPs at each CSL for the six farms were computed based on the CL scores to a maximum score of 18. A total of 192 samples were collected and analyzed. Salmonella spp. and L. monocytogenes were not detected at all the CSLs. All the farms failed to achieve a maximum MSLP score of 18 at all the CSLs. The relationship between MSLPs and hygiene and handling practices was tested using point-biserial correlation coefficients. The correlation study revealed that handling and hygiene practices (such as the duration between milking and storage, the type of milking container utilized at farms, the frequency of cleaning the milking parlor, the water source for hand and equipment washing, and the use of hand sanitizers) generally influenced the MSLPs on the farms. Both training and improvement in infrastructure are needed to improve the quality of milk and its products produced and sold in the informal value chain in Zimbabwe., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Literature on the challenges faced by those who menstruate to maintain menstrual health and hygiene during a crisis like COVID-19 is still developing. To address this gap, we conducted an online survey to understand the experiences of those who menstruate during India's COVID-19 national lockdown in 2020. We conducted a secondary analysis of qualitative data from a sub-sample of the 683 Indians who menstruate aged 18 to 49 years. The survey utilised one open-ended survey question. Data analysis was conducted using thematic analysis. Over 140 individuals aged 18 to 49 were included in the analysis. The survey findings point to six themes: (a) poor menstrual health; (b) limited access to sanitary items and water, and sanitation and hygiene facilities; (c) high price of sanitary items; (d) continuing stigma surrounding menstruation; (e) lack of alternatives to sanitary items; (f) poor availability of time to rest, think and adjust. Based on the findings, we propose that government and policymakers should aim to (a) conduct workshops for those who menstruate to teach them best practices for managing their menstrual health and bring conversations around these issues to the fore; (b) improve water, sanitation and hygiene facilities; and (c) strengthen distribution mechanisms for the sanitary items via government schemes.

Background: Despite being a normal occurrence, menstruation requires hygienic care and is associated with a number of myths and wrongdoings. Menstrual hygiene issues have been linked to major health issues, such as urinary tract and reproductive tract infections. Consequently, the purpose of this study was to evaluate the management of menstrual hygiene and related aspects among teenage students in Debre Markos town, North West, Ethiopia., Methods: From March 15 to April 15, 2019, teenage pupils in Debre Markos town participated in a cross-sectional mixed study. An in-depth interview and a self-administered structured questionnaire were used to gather data. Quantitative information was imported into Epi Data and then exported to SPSS for examination. A 95% Confidence Interval of p-value ≤ 0.05 was used to declare significance. The method of thematic content analysis was used to examine the qualitative data., Result: This study comprised 531 individuals in total, with a 96.2% response rate. Approximately 260 adolescent females (49%, 95% CI: 39.2, 59.2) had good management practices for menstrual hygiene. Girls whose mothers were private employees (AOR: 0.3, 95% CI: 0.09, 0.99), self-employed (AOR: 0.52, 95% CI: 0.28, 0.98) and housewives (AOR: 0.53, 95% CI: 0.29, 0.98), and parent-adolescent discussions about menstruation (AOR: 1.62, 95% CI: 1.40, 3.34) were significantly associated with good menstrual hygiene management. Adolescence aged 17 years or older (AOR: 2.13, 95% CI: 1.32, 3.44) were found to have good knowledge regarding menstrual hygiene (AOR: 1.59, 95% CI: 1.43, 2.94). The qualitative study found that ignorance, an unfavorable school climate, and cultural and economic factors were the main causes of teenagers' poor menstrual hygiene., Conclusion: Nearly half of adolescent girls had good menstrual hygiene practice. Menstrual hygiene practice was associated with adolescent age, knowledge of menstruation, maternal occupational and discussion with parents. Girls had difficulty to manage menstrual hygiene due to poor knowledge, unsafe school environment, and cultural barriers. Thus, school-based programs aimed at improving knowledge towards menstrual hygiene management are needed., (© 2024. The Author(s).)

Through Tanzania's National Sanitation Campaign, we study the effectiveness of two common elements of behavior change campaigns: endorsements from celebrities and testimonials. Using four experiments in Tanzania in early 2021 as part of the national campaign, we find that including endorsements and testimonials in text messages sent to individuals significantly increases self-reported hygiene behavior. These results mask important heterogeneity based on the source of endorsement or framing of the testimonial and provide insights into cost-effective approaches for changing behavior at scale., (© 2024. The Author(s).)

Lymphedema (LE) is one the most disfiguring chronic manifestations of lymphatic filariasis. Its management relies primarily on limb hygiene and local care. A previous study in Ghana demonstrating a beneficial effect of doxycycline on LE led to the current multicenter trial on the efficacy of doxycycline in filarial LE. A randomized placebo-controlled trial was initiated in two rural health districts in Mali. Patients with LE stages 1-3 were randomized to receive either doxycycline (200 mg/day) or placebo over a 6-week monitored treatment period and were then followed every 6 months for 2 years. Both groups received materials for limb hygiene that was carried out daily for the entire 2-year study. The primary endpoint was lack of progression in LE stage at 24 months. One hundred patients were enrolled in each study arm. The baseline sociodemographic characteristics of each group were largely similar. There was no significant difference at month 24 after treatment initiation in the number of subjects showing progression in LE stage between the two treatment arms (P = 0.5921). Importantly, however, the number of attacks of acute adenolymphangitis (ADLA) was reduced in both arms, but there was no significant difference between the two groups at any follow-up time point (all P >0.23). Doxycycline was well tolerated in those receiving the drug. When added to daily self-administered limb hygiene, a 6-week course of doxycycline (200 mg) was not superior to placebo in increasing the improvement associated with hygiene alone in LE volume, stage, or frequency of ADLA attacks over a 24-month period.

Background: Diarrheal disease is a significant cause of morbidity and mortality in under-fives in many low- and middle-income countries. Changes in food safety, hygiene practices, and nutrition around the weaning period may reduce the risk of disease and improve infant development. The MaaCiwara study aims to evaluate the effectiveness of a community-based educational intervention designed to improve food safety and hygiene behaviours, as well as child nutrition. This update article describes the statistical analysis plan for the MaaCiwara study in detail., Methods and Design: The MaaCiwara study is a parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures, involving 120 clusters of rural and urban communities. These clusters are randomised to either receive the community-based behaviour change intervention or to the control group. The study participants will be mother-child pairs, with children aged between 6 and 36 months. Data collection involves a day of observation and interviews with each participating mother-child pair, conducted at baseline, 4 months, and 15 months post-intervention. The primary analysis aims to estimate the effectiveness of the intervention on changes to complementary food safety and preparation behaviours, food and water contamination, and diarrhoea. The primary outcomes will be analysed generalised linear mixed models, at individual level, accounting for clusters and rural/urban status to estimate the difference in outcomes between the intervention and control groups. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. In addition, structural equation analysis will be conducted to examine the causal relationships between the different outcomes., Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) register: ISRCTN14390796 . Registered on 13 December 2021., (© 2024. The Author(s).)

Background: Promotion of facial cleanliness is recommended for the elimination of blinding trachoma, largely because of observational studies that have found an association between various measures of facial uncleanliness and trachoma. However, when a field grader assesses both facial cleanliness and trachoma, associations may be biased. Assessment of photographs of the face and conjunctiva by masked graders may provide a less biased estimate of the relationship between facial cleanliness and trachoma., Methods: Face photographs, conjunctival photographs, and conjunctival swabs were obtained on a random sample of 0-9-year-old children from each of 40 communities in Amhara region, Ethiopia. Face photographs were assessed for the presence of seven measures of an unclean face (i.e., wet nasal discharge, dry nasal discharge, wet ocular discharge, dry ocular discharge, food, dust/dirt, and flies) by three independent masked photo-graders. Conjunctival photographs were similarly graded in a masked fashion for signs of clinically active trachoma. Conjunctival swabs were processed for Chlamydia trachomatis DNA., Results: Of 2073 children with complete data, 808 (39%) had evidence of clinically active trachoma, 150 (7%) had evidence of ocular chlamydia infection, and 2524 (91%) had at least one measure of an unclean face. Dry ocular discharge had the strongest association with clinically active trachoma (age- and sex-adjusted prevalence ratio [PR] 1.4, 95% CI 1.2-1.6) and ocular chlamydia infection (PR 1.9, 95%CI 1.3-2.9), although significant associations were observed between each of the measures of facial uncleanliness and trachoma., Conclusions: Masked assessment of face and conjunctival photographs confirmed prior observational studies that have noted associations between various measures of facial uncleanliness and trachoma. The causal relationship between facial uncleanliness and trachoma is unclear since many features used to measure facial cleanliness (e.g., ocular discharge, nasal discharge, and flies) could be consequences of antecedent ocular chlamydia infection., Trial Registration: NCT02754583, clinicaltrials.gov., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Caleon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

In Lao PDR, 30% of children under age 5 years are affected by stunting. Stunting in childhood is associated with poorer outcomes for both physical and cognitive development. Baby WASH is a focused approach to water supply, sanitation, and hygiene for infants and children that targets numerous contextual and psychosocial factors including child handwashing, food hygiene, clean play spaces, and management of animal feces in the household environment. Using the risks, attitudes, norms, abilities, and self-regulation approach to behavior change (BC), the objective of this study was to investigate psychosocial factors of Baby WASH and nutrition related-behaviors, considering caregivers mental well-being, to design evidence-based BC interventions. A cross-sectional survey of 616 caregivers of a child under 2 years was conducted in Lao PDR. Caregivers well-being was significantly associated with handwashing before feeding a baby, controlling "mouthing," and the intention to exclusively breastfeed for the first 6 months. All psychosocial factors of the three behaviors were correlated with mental well-being. Results suggest that attitudinal and ability factors underlying handwashing with soap before feeding a child should be the primary focus of BC interventions. For controlling mouthing factors, interventions should target attitude and norm factors. To increase the intention of exclusive breastfeeding for the first 6 months attitude, ability, and self-regulation factors should be targeted through BC interventions. The findings of this study can be used to support the inclusion of vulnerable caregivers with poor mental well-being with BC interventions designed to improve child health and prevent stunting.

Background: Maternal Group B Streptococcus (GBS) colonization is influenced by many factors but results are inconsistent. Consideration of antenatal risk factors may help inform decision making on GBS microbiological culture screening where universal screening is not standard of care. We sought to identify independent predictors of GBS colonization at 34-37 weeks gestation incorporating vaginal symptoms, perineal hygiene measures, sexual activity, and a potential novel factor, constipation., Methods: In this prospective cross-sectional study, 573 women at 34-37 weeks gestation had an ano-vaginal swab taken and sent for selective culture for GBS. Women were asked about vaginal bleeding, discharge, irritation and candidiasis, antibiotic use during pregnancy, ano-vaginal hygiene practices such as douching and perineal cleansing after toileting, sexual intercourse related activities, and a potential novel factor for GBS carriage, constipation. Maternal basic demographics and obstetric-related characteristics were also collected. Bivariate analyses were performed to identify associates of GBS colonization. All variables with p < 0.05 found on bivariate analysis were then included into a model for multivariable binary logistic regression analysis to identify independent risk factors for GBS colonization., Results: GBS colonization was found in 235/573 (41.0%) of participants. Twenty six independent variables were considered for bivariate analysis. Eight were found to have p < 0.05. Following adjusted analysis, six independent predictors of GBS colonization were identified: ethnicity, previous neonatal GBS prophylaxis, antenatal vaginal irritation, antibiotic use, recent panty liner use, and frequency of sexual intercourse. Vaginal discharge and perineal cleansing were not associated after adjustment. Recent douching and constipation were not associated on bivariate analysis., Conclusion: The identification of independent predictors of GBS colonization in late pregnancy may inform the woman and care provider in their shared decision making for microbiological screening at 35-38 weeks gestation in locations where universal GBS screening is not standard of care., Ethics Oversight: This study was approved by the Medical Ethics Committee of University Malaya Medical Centre (UMMC) on August 9, 2022, reference number 2022328-11120., (© 2024. The Author(s).)

Introduction: People who inject drugs (PWID) are at high risk of developing injection-related infections, including abscesses. Access to water, sanitation, and hygiene (WASH) are key human rights and services; yet these services have been underexplored as predictors of abscesses among PWID., Methods: Longitudinal analysis was employed among a cohort of PWID to determine if WASH insecurity (lack of access) was associated with abscess incidence in the Tijuana, Mexico and San Diego, United States metropolitan area during 24-months of follow-up survey data from 2020 to 2023. We calculated abscess prevalence at baseline and tracked the incidence of new abscesses among individuals without an abscess during the previous visit. Time dependent Cox regression modeling was employed with variance clustered by participant to characterize the relationship between WASH insecurity and abscess incidence., Results: At baseline, hand hygiene insecurity, bathing insecurity in the previous six months and open defecation in the last week, were reported by 60 %, 54 % and 38 % of participants, respectively; 21 % reported an abscess in the last six months. The incidence of abscesses was 24.4 (95 %CI: 21.1-27.6) per 100 person-years. After adjusting for covariates, the hazard of developing an abscess remained significantly elevated among individuals using non-improved (with risk of contamination) water sources (e.g., surface water) for preparing drugs (adjusted HR [adjHR]: 1.49 [95 %CI: 1.01-2.21], experiencing bathing insecurity (adjHR: 1.59 [95 %CI: 1.12-2.24]) and open defecation (adjHR: 1.65 [95 %CI: 1.16-2.35])., Conclusions: PWID in the Tijuana-San Diego metropolitan area reported facing high rates of insecurity accessing WASH services. Abscess incidence was higher (four to nine times) than observed rate among PWID cohorts in other settings. Access to continuously available toilet facilities, bathing infrastructure, and safe water sources for preparing drugs for injection could prevent abscesses among PWID. Accessible WASH infrastructure should be ensured among PWID communities and promoted as a key component of harm reduction infrastructure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross-sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55-0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02-1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities., (© 2024 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse., (© 2024 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Inadequate safe water supply and poor sanitation and hygiene continue to be important risk factors for diarrhoea and stunting globally. We used data from the four rounds of the Ethiopian Demographic and Health Survey and applied the new World Health Organization (WHO)/UNICEF Joint Monitoring Program (JMP) service standards to assess progress in water, sanitation and hygiene (WASH) coverage between 2000 and 2016. We also performed an age-disaggregated pooled linear probability regression analysis followed by a decomposition analysis to determine whether changes in WASH practices have contributed to the changing prevalence of diarrhoea and stunting in children under 5 years of age. We observed a significant increase in the coverage of safe drinking water and adequate sanitation facilities over the period. At the national level, the use of a basic water source increased from 18% in 2000 to 50% in 2016. Open defecation declined from 82% to 32% over the same period. However, in 2016, only 6% of households had access to a basic sanitation facility, and 40% of households had no handwashing facilities. The reduction in surface water use between 2000 and 2016 explained 6% of the decline in diarrhoea observed among children aged 0-5 months. In children aged 6-59 months, between 7% and 9% of the reduction in stunting were attributable to the reduction in open defecation over this period. Despite progress, improvements are still needed to increase basic WASH coverage in Ethiopia. Our findings showed that improvements in water and sanitation only modestly explained reductions in diarrhoea and stunting., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Environmental factors greatly impact infectious disease-related mortality, yet there's a lack of comprehensive global studies on the contemporary burden and trends. This study aims to evaluate the global burden and trends of infectious disease mortality caused by air pollution, unsafe water, poor sanitation, and non-optimal temperature across Socio-Demographic Index (SDI) regions from 1990 to 2019., Methods: This observational study utilized data from the Global Burden of Diseases Study to examine mortality rates from infectious diseases attributed to environmental risk factors between 1990 and 2019, including air pollution, unsafe water, sanitation, handwashing facilities (UWSH), and non-optimal temperatures. Age-standardized mortality rates (ASMRs) and estimated annual percentage change (EAPC) were utilized to present infectious disease mortality, and its trajectory influenced by environmental risk factors over the years. Nonlinear regression was conducted to explore the association between the SDI and ASMRs across regions from 1990 to 2019., Results: In 2019, global infectious disease deaths linked to air pollution, UWSH, and non-optimal temperature reached a startling 2,556,992. Disease mortality varied widely across SDI regions, with the highest number of deaths due to air pollution and UWSH in Low SDI regions, and deaths from non-optimal temperature primarily in High SDI regions. Age disparities emerged, with children under five and the elderly most affected. However, an increasing mortality trend was observed among seniors (65-69, 75-79, and over 80) in High SDI regions due to enteric infections linked to UWSH. Globally, a consistent decrease in ASMR was seen from 1990 to 2019 for all diseases connected to these factors, except for respiratory infections linked to non-optimal temperature., Conclusions: Our study underscores the significant impact of air pollution, UWSH, and non-optimal temperatures on global infectious disease mortality, particularly among vulnerable groups such as children and the elderly. It's important to tackle these challenges with targeted interventions aiming to enhance environmental quality, improve water and sanitation systems, and control extreme temperatures. In addition, international cooperation is essential for bridging regional disparities and driving global public health initiatives forward, thereby helping achieve Sustainable Development Goals more effectively., (© 2024. The Author(s).)

Barriers to achieving and sustaining access to water, sanitation, hygiene, cleaning, and waste management (WASH) in health care facilities include a lack of supportive policy environment and adequate funding. While guidelines exist for assessing needs and making initial infrastructure improvements, there is little guidance on how to develop budgets and policies to sustain WASH services. We conducted costing and advocacy activities in Thakurbaba municipality, Nepal, to develop a budget and operations and maintenance policy for WASH in health care facilities in partnership with the municipal government. Our objectives for this study were to (1) describe the process and methods used for costing and advocacy, (2) report the costs to achieve and maintain basic WASH services in the 8 health care facilities of Thakurbaba municipality, and (3) report the outcomes of advocacy activities and policy development. We applied bottom-up costing to enumerate the resources necessary to achieve and maintain basic WASH services and their costs. The annual costs to achieve, operate, and maintain basic access to WASH services ranged from US$4881-US$9695 per facility. Cost findings were used to prepare annual budgets recommended to achieve, operate, and maintain basic services, which were presented to the municipal government and incorporated into an operations and maintenance policy. To date, the municipality has adopted the policy and established a recovery fund of US$3831 for repair and maintenance of infrastructure and an additional US$153 per facility for discretionary WASH spending, which were to be replenished as they were spent. Advocacy at the national level for WASH in health care facilities is currently being championed by the municipality, and findings from this project have informed the development of a nationally costed plan for universal access. This study is intended to provide a roadmap for how cost data can be collected and applied to inform policy., (© Chettry et al.)

Background: Adolescence is a pivotal stage in human development that presents unique challenges, especially for girls navigating the complexities of menstruation. Despite the importance of menstrual hygiene management for adolescent girls' well-being, this vital aspect of personal health is often overlooked, particularly in regions where cultural stigma prevails. This study examines knowledge, attitude, and practice of menstrual hygiene management among in-school adolescent girls in Abuja, Nigeria., Methods: The study employed a cross-sectional mixed-method design, integrating quantitative surveys with focus group discussions. A survey was conducted among 420 adolescent girls across four government junior secondary schools through a multistage sampling technique. Also, Focus Group Discussions were conducted among 80 respondents in groups of 10 discussants. The quantitative data set was subjected to descriptive and inferential statistical analysis, while the qualitative data were analysed using content analysis., Results: Findings revealed that the majority (53.45%) of the respondents had good knowledge of menstruation and menstrual hygiene management. Junior Secondary School (JSS) 3 students [OR = 2,09; 95% CI = 1.24-3.52] and those who started menstruation at age 15 years and above [OR = 7.52; 95% CI = 1.43-39.49] were associated with increased odds of having good knowledge of menstrual hygiene management. The attitude of most respondents (70.08%) towards menstrual hygiene management was good. Those in the JSS 3 class [OR = 6.47; 95% CI = 3.34-12.54], respondents who are Muslim [OR = 2.29; 95% CI = 1.63-5.48], and those whose parents had tertiary education [OR = 3.58; 95% CI = 1.25-10.25] were more likely to demonstrate more positive attitudes compared to their counterparts whose parents do not have tertiary education. In relation to practice, about 3 in 5 (57.80%) reportedly practise good menstrual hygiene management. Respondents who practice traditional religion [OR = 0.33; 95% CI = 0.02-4.56] were less likely to practise good menstrual hygiene management, while respondents who are the third child of their parents [OR = 2.09; 95% CI = 1.04-4.23] were more likely to practise menstrual hygiene compared to respondents with other birth orders. Qualitative results showed that participants had good knowledge of menstruation and menstrual hygiene management, and mothers were the main source of menstruation-related information. Participants had mixed feelings and reactions during their first menstruation, with 3 in 5 participants reporting experiencing menstruation-related stigma restrictions when menstruating., Conclusions: In-school adolescent girls in Abuja, Nigeria, have good menstruation-related knowledge and positive attitudes, as well as practise menstrual hygiene management. Students' class and age at first menstruation were major factors associated with good knowledge of menstruation and menstrual hygiene management; respondents' class, religion and parents' educational qualification were associated with a positive attitude, while respondents' religion and parity line were associated with menstrual hygiene practice. Future interventions should focus on conducting school and community-level awareness programs to increase knowledge and dispel myths and misconceptions about menstruation and menstrual hygiene management., (© 2024. The Author(s).)

Background: Menstrual Hygiene Management stands as a critical health concern for girls entering reproductive age on a global scale. This transition often induces fear and anxiety due to inadequate knowledge about menstruation and a lack of resources to comprehend bodily changes. Notably, school-aged girls in marginalized communities face formidable barriers to MHM, given the insufficient facilities, supplies, and awareness in educational institutions., Methods: A Mixed method study was conducted adopting a mixed-methods approach. It engaged 562 respondents across five local levels of Bajura district, including three municipalities (Badimalika, Budhiganga, and Tribeni) and two rural municipalities (Gaumul and Khaptad Chhedaha)., Results: The study unveiled over 90% awareness on on five out of seven MHM rights related statements and over 85% self-efficacy on 5 out of 8 statements regarding MHM among female adolescent respondents. However, their actual practices fell short of expectations, marked by the prevalence of restrictive norms and perceived risks pertinent to MHM. Notably, 27% (N=154) expressed fear of divine consequences for not adhering to menstrual customs. Malpractices were observed, including 66% using cloth during menstruation, inadequate pad changing frequencies, and some girls staying in Chhaugoth during menstruation. Despite a high awareness (97%) of menstrual rights, behavioral practices did not consistently align with this awareness., Conclusions: The study highlights high awareness and self-efficacy in menstrual hygiene management among female adolescents, yet challenges persist due to cultural norms, perceived risks, and insufficient infrastructure, necessitating multifaceted solutions for behavioral change and access to resources.

Background: Hygienic behavior as such belongs to health behavior, acquired at home, at school, at workplace or through the mass-media., Objective: The aim of the study was to analyze the perception of personal hygiene among different age groups and the sociodemographic factors related to hygiene behavior., Material and Methods: The author's questionnaire for children and seniors concerning selected hygienic behavior was used. The questionnaire was conducted in two groups: 200 primary school children in age: 8-11 years; 109 girls and 91 boys and 200 older people: young-old (60-74 years) and old-old (75+); 110 women and 90 men., Results: Girls longer than boys take morning hygiene behavior, but statistically boys spend more time on evening washing, cleaning and brushing. Seniors hygienic behavior depend on age: young-old are more likely take a shower every day (51.79%) than seniors in the old-old group (29.86%). The same statistically significant difference was noticed in case of washing hands before a meal., Conclusions: Children care more about personal hygiene than older people. Age, not gender, is a factor determining the frequency of hygiene practices among older people. Young-old care more about personal hygiene than old-old.

The microbiological quality of meat is influenced by the conditions of hygiene prevailing during production and handling. Thus, this study aimed to assess the prevalence of Salmonella enterica and its antimicrobial resistance, load of hygiene indicator bacteria including E. coli (ECC), coliforms (CC), total coliform (TCC), Enterobacteriaceae (EB) and aerobic plate count (APC), and meat handler's food safety knowledge and hygiene practices in butcher shops in two cities, Addis Ababa and Hawassa in Ethiopia, during 2020 and 2021. A total of 360 samples of beef carcasses (n = 120), knives (n = 60), chopping boards (n = 60), weighing balance (n = 60), and personnel's hands (n = 60) were randomly collected for microbial analysis. Besides, 120 participants were selected to participate in a food safety knowledge and hygiene practices assessment. The S. enterica isolates were identified by agglutination test followed by qPCR targeting invA gene. Phenotypic antimicrobial resistance profiles of S. enterica were determined using disk diffusion assays as described in CLSI. The ECC, CC, TCC, EB, and APC populations were quantified by plating onto petrifilm plates. A structured questionnaire was used to determine food safety knowledge and hygiene practices of participants. Overall prevalence of S. enterica was 16.7% (95% CI, 8.3-26.7) and location seems to have no effect (p = 0.806). Only 20% of the S. enterica were resistant to ampicillin and tetracycline. However, the majority (80%) of S. enterica isolates were susceptible to the panel of 11 antimicrobials tested. The overall mean ± SD (log CFU/cm 2 ) of ECC, CC, TCC, EB, and APC were 4.31 ± 1.15; 4.61 ± 1.33; 4.77 ± 1.32; 4.59 ± 1.38 and 5.87 ± 1.52, respectively. No significant difference (p = 0.123) in E. coli contamination was observed between samples of beef carcasses and chopping boards. The EB contamination showed no significant difference (p > 0.05) among sample sources. The APC contamination levels on beef carcass were significantly higher (p > 0.05) than other sample sources. A total of 56% (95% CI: 46.7 - 65.0) of the participants had poor knowledge and 65% (95% CI: 56.7 - 73.3) had poor hygiene practices towards food safety. This study highlighted the poor hygiene status of butcher facilities with a potential risk of beef safety. Thus, appropriate food safety control strategies and inspection is needed at retail establishments., (© 2024. The Author(s) under exclusive licence to Sociedade Brasileira de Microbiologia.)

Objective: To determine the effect of genital hygiene behavior (GHB) and vaginal douching (VD) of pregnant women on preterm labor (PTL)., Methods: This study, which was conducted with 365 pregnant women, is a cross-sectional study. Data were collected using a questionnaire and the Genital Hygiene Behavior Inventory (GHBI) was applied., Results: The ratios of PTL diagnosis and VD practice, and mean GHBI scores of the pregnant women were 35.1%, 9.6%, and 64.42 ± 10.44, respectively. The prevalence of receiving a diagnosis of PTL was significantly higher in those who changed their underwear two to three times a week, took baths while sitting, cleansed their perineum with water using their hands, removed pubic hair at intervals of 2 months or longer, and performed VD. It was found that poor GHB and VD practices increased the rate of PTL and, in particular, VD was found to increase the risk of PTL around eight-fold., Conclusion: These results can help pregnant women to understand the relationship between genital hygiene and PTL and show the importance of being educated by health professionals about this issue., (© 2023 International Federation of Gynecology and Obstetrics.)

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

Objective: To understand the relationship between the COVID-19 pandemic and menstrual hygiene management (MHM) among adolescent girls in Ethiopia and to explore which girls were most affected by pandemic disruptions., Design: Two rounds of data from surveys and interviews were collected with adolescent girls immediately prior to and during the COVID-19 pandemic. The primary analysis is cross-sectional, controlling for pre-COVID-19 covariates., Setting: The setting was three zones in two regions of Ethiopia: East Hararghe and East Shewa Zones in Oromia and South Gondar Zone in Amhara. Data were collected in December 2019-March 2020 and September 2020-February 2021., Participants: 742 adolescent girls, ages 11-25 years., Outcome Measures: Four primary outcomes were explored (1) the number of challenges girls experienced; (2) adolescent-identified challenges managing menstrual hygiene; (3) adolescent-identified difficulties accessing MHM products and (4) adolescent-identified difficulties accessing soap or water., Results: Girls who were more vulnerable to COVID-19 were more likely to have worse MHM outcomes. An SD increase in household vulnerability to COVID-19 was associated with an 8.7 percentage point increase in the likelihood that the respondent had difficulty getting MHM products (p<0.001), a 6 percentage point increase in the likelihood that she reported facing a challenge managing her menstruation (p=0.003) and a 5.2 percentage point increase in the likelihood she lacked soap or water (p=0.001). Qualitative themes, used to triangulate the quantitative findings, suggest that mobility restrictions, shutdowns of the local market, disruptions in supply chains, poverty, stigma and fear about contracting COVID-19 affected girls' access to MHM supplies., Conclusions: The results of this study suggest that MHM was left behind in the COVID-19 response. New programming and policy interventions need to address financial hardship and disruptions to supplies to manage menstruation as well as tackle the inequitable gender norms that stigmatise menstruation during emergencies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Access to water, sanitation, and hygiene (WASH) resources in schools is critical for disease prevention and control, especially during public health emergencies. In Belize, systematic, national data on WASH in schools are needed to inform public health decisions and interventions. From December 2021 to January 2022, a national survey was sent electronically to government and government-aided primary and secondary schools in Belize (N = 308) to gather information on WASH services. From the survey, 12 pilot schools were selected based on the highest self-reported need for WASH resources to participate in additional evaluation and intervention, which included environmental nudges, supplemental supply provision, and hand hygiene education. To understand how the progression of the COVID-19 pandemic may have influenced hand hygiene, facility assessments to evaluate access to hand hygiene resources were conducted in person when most schools reopened for face-to-face learning during the pandemic (March 2022) and 15 months later (June 2023). Among the schools participating in the national survey (N = 221), 55% reported times when water was not available at the schools. Almost 9 in 10 schools (89%) had a functional handwashing station, and 47% reported always having soap for handwashing. Between baseline and follow-up at the 12 pilot schools, we observed decreases in the proportion of functional handwashing access points (-11%), functional handwashing access points accessible for individuals with disabilities (-17%) and small children (-29%), and functional alcohol-based hand rub dispensers (-13%). Despite the ongoing COVID-19 pandemic, we observed gaps in WASH resources in schools in Belize during the onsite assessments at the pilot schools. Schools should be encouraged and provided with WASH resources to maintain vigilance for disease control measures.