Hand washing education in Quezalguaque, Nicaragua

1. Hand washing education in Quezalguaque, Nicaragua APHA 136th Annual Conference, San Diego, CA – October 29, 2008 Denise Burke MPH, *Courtney Cawthon MPH, Casey Rebholz MPH, Karen Sherk MPH (*Presenting author)

2. Presenter Disclosures Courtney Cawthon The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. Learning Objective • To understand the design, monitoring and evaluation of a community hygiene intervention

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

5. Source: http://www.mapsofworld.com/nicaragua Source: Mayor’s office, Quezalguaque, Nicaragua

6. Setting • Many households don’t have electricity • Wells are main source of water • Sinks and latrines are often shared • 55% had no school or not completed primary school • Most live in close proximity to livestock Photos courtesy of Christine Yennaco, BUSPH ‘08

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

8. Disease Transmission Model Wagner and Lanois, 1958; PAHO

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

10. Qualitative evaluation (June 2-15, 2007) Key informant interviews Focus Groups Results Price is a barrier to purchasing hand soap Interest in home visits Prevention vs. Treatment Formative Phase Photo courtesy of Brookline Sister City Project

11. Source: Mayor’s office, Quezalguaque, Nicaragua

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

13. Enrollment and Data collection • Enrollment (July 9-25, 2007) • Children ≤ 5 years with a caregiver ≥ 18 years • Photos, symptom diaries • Baseline survey • Direct observations Photo courtesy of Christine Yennaco, BUSPH ‘08

14. Monitoring

15. Final Evaluation(January 2008) • Repeat baseline survey • Repeat direct observations

16. Results • 108 caregivers/149 children (94% retention) • 97% female caregivers • Average age: • Caregiver: 28 years (range 18-59) • Children: 2.6 years • Households • 1.4 children < 6 yr • 5.3 people • 1.6 adults employed

17. Results • Disease prevention knowledge • Hand washing behavior at key times • Health outcomes Photo courtesy of Christine Yennaco, BUSPH ‘08

18. Disease Prevention Knowledge • Table 1. Comparison of Knowledge of Hand Washing with Soap and Water to Prevent Disease, • and Importance of Key Activities for Hand Washing, at follow-up

19. Hand Washing Behavior • Table 2. Frequency of "Always" or "Almost Always" Washing Hands with Soap and Water with Key Activities, at follow-up *Among those with children wearing diapers, n=51

20. Health Outcomes Table 3. Comparison of overall disease burden of ARI and diarrhea at follow up *P-values only significant for diarrheal measures

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

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

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

24. Thanks to our Funders • APHA International Section & Colgate-Palmolive

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

26. Bibliography • Arbizu M. Correspondence between Dr. Martha Arbizu, Director of Quezalguaque Health Center, and Sarah Johnson of the Brookline Sister City Project. Feb 2007. • Burke D, Cawthon RC, Rebholz C, Sherk K. Quezalguaque General Health Survey 2006. • Children in Cambodia Face High Mortality Rate. Department of Planning and Health Information, Ministry of Health, the Reproductive Health Association of Cambodia, and PRB. Population Reference Bureau. Accessed August 20, 2007. http://www.prb.org/Articles/2002/ChildreninCambodiaFaceHighMortalityRate.aspx • Curtis V, Kanki B, Cousens S, Diallo I, Kpozehouen A, Sangare M, Nikiema M. Evidence of behaviour change following hygiene promotion programme in Burkina Faso. Bull World Health Organ. 2001; 79(6):518-27 • Favin M. Promoting Hygiene Behavior Change with in C-IMCI: The Peru and Nicaragua Experience. USAID Environmental Health Project Activity Report 143, October 2004. • Gorter A, Sandiford P, Praw J, Morales P, Perez M, Alberts H. Hygiene behavior in rural Nicaragua in relation to diarrhea. International Journal of Epidemiology. 1998; 27:1090-1100. • Gungoren B, Latipov R, Regallet G, Musabaev E. Effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural Uzbekistan. Trans R Soc Trop Med Hyg. 2007 Jun; 101(6):564-569. Epub April 5, 2007. • Handwashing Handbook: A guide for developing a hygiene promotion program to increase hand washing with soap. Global Public Private Partnership for Hand washing. World Bank 2005. • Luby S, Agboatwalla M, Painter J, Altaf A, Billhimer W, Hoekstra R. Effect of Intensive Hand washing Promotion on Childhood Diarrhea in High-Risk Communities in Pakistan. JAMA 2004; 291(21):2547-54. • MINSA, 10 most frequent causes of morbidity and mortality, Statistics from Ministry of Health of Quezalguaque, Nicaragua for the years 2005-2007. • Shahid NS, Greenough WB III, Samadi AR, Hug MI, Rahman N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res. 1996 Jun; 14(2):85-89. • Statisitics, At-a-glance: Nicaragua. UNICEF, Info by country. http://www.unicef.org/infobycountry/nicaragua_statistics.html Accessed. 21 October 2008.

27. ¿Questions?

28. Behavior Change Model