An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhea. Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. Diarrhoea prevention in a high-risk rural Kenyan population through point-of-use chlorination, safe water storage, sanitation, and rainwater harvesting. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications. [Effect of hygiene measures, water sanitation and oral rehydration therapy on diarrhea in children less than five years old in the south of Ivory Coast].
An educational intervention was designed to improve three water-sanitation behaviors empirically shown to be associated with high rates of childhood diarrhea in Dhaka, Bangladesh: lack of handwashing before preparing food, open defecation by children in the family compound, and inattention to proper disposal of garbage and feces, increasing the opportunity for young children to place waste products in their mouth. Fifty-one communities, each comprising 38 families, were randomized either to receive (n = 25) or not to receive (n = 26) the intervention. During the six months after the intervention, the rate of diarrhea (per 100 person-weeks) in children under six years of age was 4.3 in the intervention communities and 5.8 in the control communities (26% protective efficacy; p less than 0.0001). A corresponding improvement in handwashing practices before preparing food was noted, although no improvement was observed for defecation and waste disposal practices. These data suggest that educational interventions for water-sanitation practices can have an important beneficial effect upon childhood diarrhea in developing countries, particularly when the interventions are designed in a simple way to promote naturally occurring salutory behaviors that are empirically associated with lower rates of childhood diarrhea. Diarrhoeal disease is a leading cause of morbidity in young children in rural Zaire. Few diarrhoea prevention programmes have been implemented in Bandundu Province, where available data suggest an annual prevalence rate of 10%. The urgent need to reduce diarrhoeal morbidity in Zaire, together with the potential effectiveness and feasibility of hygiene education as a diarrhoea prevention strategy, led to the development of the present research project.
                A randomized, controlled trial of an education intervention to reduce diarrhoea through improved personal and domestic hygiene behaviours was conducted in 18 geographically separate village clusters (sites) in rural Zaire. For 12 weeks baseline information on the diarrhoeal morbidity of 2082 children aged 3-35 months was collected at weekly home visits, and structured observations of hygiene practices related to diarrhoea were made on a subset of 300 families. Intervention messages addressed disposal of animal faeces from the yard, handwashing after defecation and before meal preparation and eating, and disposal of children's faeces. Three months after the start of the intervention and exactly 1 year after the baseline studies, a second diarrhoeal morbidity study and a second observational study were conducted in order to evaluate the intervention.
                Children in intervention communities experienced an 11% reduction in the risk of reporting diarrhoea during the peak diarrhoeal season, compared to controls (P < 0.025). The largest differences were seen among children aged 24-35 months, with those from intervention communities reporting significantly fewer episodes, shorter mean durations and hence fewer days of diarrhoea. There was some evidence that greater reductions in diarrhoea occurred in sites where the quality of the intervention, a scored measure of volunteer efficacy and community participation, was highest.
                The results of this study suggest that hygiene education may be an effective approach to reduce the incidence and duration of diarrhoeal episodes in rural Zaire. Children aged 2 years appear to benefit the most. A Hawthorne effect of the education may contribute to diarrhoeal reductions. A water quality intervention that consists of water treatment, safe storage, and community education was field tested in Kitwe, Zambia. A total of 166 intervention households were randomly selected from one community and 94 control households from another. Baseline surveys were conducted and the intervention was distributed. Weekly active diarrhea surveillance, biweekly water testing, and a follow-up survey were conducted. Compliance was high in intervention households: 97% reported using disinfectant and 72-95% had measurable chlorine in their water in biweekly testing. The percentage of intervention households storing water safely increased from 41.5% to 89.2%. Stored water in intervention households was significantly less contaminated with Escherichia coli than water in control households (P < 0.001). Diarrheal disease risk for individuals in intervention households was 48% lower than for controls (95% confidence interval = 0.3, 0.9). This intervention is a useful tool for preventing waterborne diseases in families in developing countries who lack access to potable water. Lack of access to safe water and sanitation contributes to diarrhoea moribidity and mortality in developing countries. We evaluated the impact of household water treatment, latrines, shallow wells, and rainwater harvesting on diarrhoea incidence in rural Kenyan children. We compared diarrhoea rates in 960 children aged <5 years in 556 households in 12 randomly selected intervention villages and six randomly selected comparison villages during weekly home visits over an 8-week period. On multivariate analysis, chlorinating stored water [relative risk (RR) 0.44, 95% confidence interval (CI) 0.28-0.69], latrine presence (RR 0.71, 95% CI 0.54-0.92), rainwater use (RR 0.70, 95% CI 0.52-0.95), and living in an intervention village (RR 0.31, 95% CI 0.23-0.41), were independently associated with lower diarrhoea risk. Diarrhoea risk was higher among shallow well users (RR 1.78, 95% CI 1.12-2.83). Chlorinating stored water, latrines, and rainwater use all decreased diarrhoea risk; combined interventions may have increased health impact. A novel water quality intervention that consists of point-of-use water disinfection, safe storage and community education was field tested in Bolivia. A total of 127 households in two periurban communities were randomized into intervention and control groups, surveyed and the intervention was distributed. Monthly water quality testing and weekly diarrhoea surveillance were conducted. Over a 5-month period, intervention households had 44% fewer diarrhoea episodes than control households (P = 0.002). Infants < 1 year old (P = 0.05) and children 5-14 years old (P = 0.01) in intervention households had significantly less diarrhoea than control children. Campylobacter was less commonly isolated from intervention than control patients (P = 0.02). Stored water in intervention households was less contaminated with Escherichia coli than stored water in control households (P < 0.0001). Intervention households exhibited less E. coli contamination of stored water and less diarrhoea than control households. This promising new strategy may have broad applicability for waterborne disease prevention. To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap.
                The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea.
                Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectant-disinfectant plus hand washing with soap neighbourhoods.
                With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment. Patients with AIDS frequently develop diarrhoeal illness. In this randomized, controlled study, 260 patients were screened for those who had not had diarrhoea in the preceding 3 months and who had received a stable highly active antiretroviral therapy regimen for at least 6 weeks prior to the study enrollment. A total of 148 patients met the inclusion criteria and were enrolled: 75 patients were randomly assigned to an intensive handwashing intervention (i.e. handwashing after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex) and 73 patients were randomly assigned to the control group. Patients in both groups were called weekly by telephone to determine compliance with handwashing and to determine the number of diarrhoeal episodes for the preceding week. Patients were observed for 1 year. Patients assigned to the intensive handwashing intervention group washed their hands more frequently compared with the control group (seven vs four times a day, respectively; P <0.05) and developed fewer episodes of diarrhoeal illness (1.24+/-0.9 vs 2.92+/-0.6 new episodes of diarrhoea, respectively; P <0.001) during the 1 year observation. The most common pathogens identified in both groups in patients who developed diarrhoeal illness were Giardia lamblia, Cryptosporidium, Entamoeba histolytica and Shigella flexneri. These data suggest that intensive handwashing reduces diarrhoeal illness in patients with AIDS. The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity. The purpose is to assess the impact of compliance with measures of hygiene and water supply and oral rehydration on the diarrhoea with under 5 years of age in four villages of southern Côte d'Ivoire. The method used is to compare morbidity and mortality of children, firstly between two groups of villages without such measures, secondly in two villages before and after implementing them. Initially, an exhaustive survey has determined the incidence rate of diarrhoea, the proportion of deaths resulting from such diarrhoea as well as the mortality rate 1988. Two similar survey were made in 1990 and 1992. The results show a 50% reduction of the incidence rate of diarrhoea and a 85% reduction of the proportion of deaths related to diarrhoea in the villages with intervention. The mortality rate to diarrhoea was likewise reduced by 85%. These results show the importance of the improvement and accessibility to drinkable water and hygiene in the prevention of diarrhoea in areas children.
This review provides some evidence that interventions to improve excreta disposal are effective in preventing diarrhoeal disease. However, this conclusion is based primarily on the consistency of the evidence of beneficial effects. The quality of the evidence is generally poor and does not allow for quantification of any such effect. The wide range of estimates of the effects of the intervention may be due to clinical and methodological heterogeneity among the studies, as well as to other important differences, including exposure levels, types of interventions, and different degrees of observer and respondent bias. Rigorous studies in multiple settings are needed to clarify the potential effectiveness of excreta disposal on diarrhoea.