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Intervention Review

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Hand washing for preventing diarrhoea

  1. Regina I Ejemot-Nwadiaro1,*,
  2. John E Ehiri2,
  3. Martin M Meremikwu3,
  4. Julia A Critchley4

Editorial Group: Cochrane Infectious Diseases Group

Published Online: 23 JAN 2008

DOI: 10.1002/14651858.CD004265.pub2


How to Cite

Ejemot-Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub2.

Author Information

  1. 1

    University of Calabar, Department of Public Health, College of Medical Sciences, Calabar, Cross River State, Nigeria

  2. 2

    Mel and Enid Zuckerman College of Public Health, University of Arizona, Division of Health Promotion Sciences, Tucson, Arizona, USA

  3. 3

    University of Calabar Teaching Hospital, Department of Paediatrics, Calabar, Cross River State, Nigeria

  4. 4

    Newcastle University, Institute of Health and Society, Newcastle, Tyne and Wear, UK

*Regina I Ejemot-Nwadiaro, Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Cross River State, PMB 11115, Nigeria. idulove@yahoo.com. reginaejemot@yahoo.com.

Publication History

  1. Publication Status: Edited (no change to conclusions), comment added to review
  2. Published Online: 23 JAN 2008

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This is not the most recent version of the article. View current version (03 SEP 2015)

 
Characteristics of included studies [ordered by study ID]
Bartlett 1988

MethodsCluster-randomized trial

Method of allocation sequence: unclear

Allocation concealment: unclear

Blinding: assessor

Inclusion of participants in the analysis: unclear

Length of follow up: 12 months

Cluster-adjustment method: not adjusted


ParticipantsNumber: 26 day-care centres, with 374 children

Inclusion criteria: not stated

Exclusion criteria: not stated

Age: < 3 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group meetings (directors and caregivers)
2. Provision of posters and handouts depicting the procedures taught

Control:
3. Visited to review surveillance procedures, but no instruction in disease prevention or management provided


OutcomesDiarrhoea rates


NotesLocation: Maricopa County, Arizona, USA

Duration: October 1981 to September 1984

Black 1981

MethodsCluster-randomized trial

Method of allocation sequence: unclear

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 6 months

Cluster-adjustment method: not adjusted


ParticipantsNumber: 4 day-care centres, with 116 children

Inclusion criteria: not stated

Exclusion criteria: not stated

Age: < 3 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group education

Control:
2. No intervention


Outcomes1. Diarrhoea rates

Not used in this review:
2. Estimate of load of diarrhoea causative agent


NotesLocation: suburban Atlanta, Georgia, USA

Duration: June 1976 to April 1977

Bowen 2007

MethodsCluster-randomized trial

Method of allocation sequence: random-number table

Allocation concealment: unclear

Blinding: none

Inclusion of all participants in the analysis: 93% (3962/4256) agreed to participate

Length of follow up: 2003 to 2004 school year

Cluster-adjustment method: adjusted


ParticipantsNumber: 87 schools (57 intervention; 30 Control); with 3962 children (2670 intervention; 1292 control)

Inclusion criteria: public primary schools; at least 20 students in first grade year in 2003 to 2004; no overnight boarders; at least 1 running water tap for every 30 first grade students

Exclusion criteria: no compulsory hand washing or provision of hand-cleaning products before school lunch; no commercial hand washing promotion programmes at school during previous 5 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Expanded programme: as standard programme plus continuous supply of Safeguard soap for school sinks; 1 student from each class recruited to assist peers with hand washing techniques, and remind them of key hand washing opportunities; teachers asked to encourage this student weekly but not instructed to enforce hand washing behaviour
2. Standard programme: Proctor and Gamble's 'Safeguard' promotion programme delivered in Chinese schools since 1999; teachers deliver programme to first grade children during single 40 minute classroom session; also single 2 h training session for each first grade teacher delivered by Proctor and Gamble staff; teacher's pack contains guidebook outlining hand washing, basic information on infectious disease transmission, 5 posters describing hand washing procedure, videotape, and 5 wall charts for classroom hygiene competition; student take-home pack includes hygiene board game, parent booklet on hand washing, and 50 g bar Safeguard soap

Control:
3. All 3 groups received government hygiene educational programme consisting of a cursory statement manual about hand washing after using toilet and before eating


Outcomes1. Diarrhoea rates

Not used in this review:
2. School absences
3. Rates of other common illnesses


NotesLocation: 3 counties in Fujian province, South-East China

Butz 1990

MethodsCluster-randomized trial

Method of allocation sequence: unclear

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 12 months

Cluster-adjustment method: not adjusted


ParticipantsNumber: 24 family day-care centres, with 108 children

Inclusion criteria: not stated

Exclusion criteria: unclear

Age: 1 month to 7 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training (in-home instruction to day-care providers)

Control:
2. No intervention


OutcomesIncidence of infectious disease symptoms (diarrhoea)


NotesLocation: Baltimore, Maryland, USA

Duration: 12 months

Carabin 1999

MethodsCluster-randomized trial

Allocation sequence: day-care centres were stratified by incidence of respiratory infections and block randomized by geographical areas

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 6 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 52 day-care centres, with 1729 children

Inclusion criteria: presence of at least 1 sandbox and 1 play area; at least 12 available toddler places

Exclusion criteria: not stated

Age: 18 months to 3 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group hygiene training (educators)
2. Handouts

Control:
3. No intervention


OutcomesDiarrhoea rates


NotesLocation: Quebec, Canada

Duration: September 1996 to November 1997

Haggerty 1994

MethodsCluster-randomized trial

Allocation sequence: unclear

Allocation concealment: unclear

Blinding: assessor

Inclusion of participants in the analysis: unclear

Length of follow up: 6 months

Cluster-adjustment method: adjusted and unadjusted results given


ParticipantsNumber: 18 sites, with 1954 children

Inclusion criteria: not stated

Exclusion criteria: not stated

Age: 3 months to 35 months


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training

Control:
2. No intervention


OutcomesDiarrhoeal rates


NotesLocation: Kikwit, Bandundu Province, Zaire (Democratic Republic of Congo)

Duration: October 1987 to December 1988

Han 1989

MethodsCluster-randomized trial

Allocation sequence: unclear

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 4 months

Cluster-adjustment method: not adjusted


ParticipantsNumber: 350 households (162 intervention and 188 control) with 494 children

Inclusion criteria: households with 1 or more children between 6 and 59 months; those in which regular follow up was possible; not allergic to soap; gave informed consent

Exclusion criteria: not stated

Age: < 5 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Small group education (households)

Control:
2. No intervention


Outcomes1. Incidence of diarrhoea
2. Incidence of dysentery


NotesLocation: Nga-Kha ward of Thin-Gun-Kyun township, Rangoon, Burma (now Myanmar)

Duration: June to November 1985

Huang 2007

MethodsIndividually randomized trial

Allocation sequence: unclear

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: 100%

Length of follow up: 1 year


ParticipantsNumber: 73 intervention, 75 control

Inclusion criteria: patients with acquired immune deficiency syndrome (AIDS) at local human immunodeficiency virus (HIV) clinic; HIV-1 infection verified by both ELISA and Western Blot; AIDS by CD4 counts and plasma HIV RNA; been on highly active anti-retroviral therapy (HAART) for at least 6 weeks and without diarrhoea for at least 3 months


InterventionsBoth groups: 3 dedicated study nurses educated participants on health problem associated with contaminated hands and provided specific hand washing instructions at enrolment; hand washing technique demonstrated by nurses, including wetting hands, lathering completely with soap, running together for at least 15 seconds, and drying hands with towels; all 148 participants then demonstrated adequate hand washing technique

Intervention (see  Table 2 for detailed description):
1. Weekly telephone call from nurses to determine number of hand washing episodes per day, ensure compliance, answer questions, re-educate participants on importance, and go over instructions

Control:
2. Weekly telephone calls but only to ascertain diarrhoea episodes


Outcomes1. Incidence of diarrhoea
2. Hand washing behaviour

Not used in this review:
3. Microbiological diagnosis of diarrhoea episodes


NotesLocation: USA (location unclear)

Duration: 1 year (exact dates unclear)

Kotch 1994

MethodsCluster-randomized trial

Allocation sequence: unclear

Allocation concealment unclear

Blinding: assessor

Inclusion of participants in the analysis: unclear

Length of follow up: 7 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 24 day-care centres, with 389 classrooms

Inclusion criteria: children < 3 years; present in the day care at least 20 h per week; absence of chronic illness or medication that would predispose to infection; youngest of potentially eligible children in the same family; consenting English-speaking parents with access a telephone; intending to remain in day-care centre throughout study

Exclusion criteria: not stated

Age: < 3 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training
2. Curriculum for caregivers

Control:
3. No intervention


OutcomesDiarrhoeal rates


NotesLocation: Cumberland County, North Carolina, USA

Duration: October 1988 to May 1989

Ladegaard 1999

MethodsCluster-randomized trial

Allocation sequence: unclear

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 4 months

Cluster-adjustment method: not adjusted


ParticipantsNumber: 8 day-care centres, with 475 children (212 intervention, 263 control)

Inclusion criteria: not stated

Exclusion criteria: not stated

Age: < 6 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Small group practical demonstration

Control:
2. No intervention


OutcomesDiarrhoeal rates


NotesLocation: Odense, Denmark

Duration: 6 months

Luby 2004a

MethodsCluster-randomized trial

Allocation sequence: computer-generated

Allocation concealment: serially numbered

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 12 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 36 neighbourhoods (25 intervention, 11 control), with 4691 children

Inclusion criteria: household located in the study area; have at least 2 children < 5 years; intention to reside in the house for the duration of study

Exclusion criteria: not stated

Age: < 15 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training using slide shows, pamphlets, and video tapes

Control:
2. No intervention


OutcomesDiarrhoeal rates


NotesLocation: low-income squatter settlements, Karachi, Pakistan

Duration: April 2002 to April 2003

Luby 2006

MethodsCluster-randomized trial

Allocation sequence: computer generated

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 9 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 18 clusters, with 544 households (262 intervention, 282 control)

Inclusion criteria: households with at least 1 child < 5 years; provided informed consent

Exclusion criteria: not stated

Age range: < 15 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training using slide shows, pamphlets, and video tapes

Control:
2. No receipt of products expected to change risk of diarrhoea but provided them with regular supply of children's books, note books, etc


Outcomes1. Primary diarrhoea rates
2. Persistent diarrhoea rates


NotesLocation: multi-ethnic squatter settlements in Central Karachi, Pakistan

Duration: April 2003 to December 2003

Roberts 2000

MethodsCluster-randomized trial

Allocation sequence: computer generated

Allocation concealment: unclear

Blinding: assessors

Inclusion of participants in the analysis: unclear

Length of follow up: 9 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 23 day-care centres, with 558 children

Inclusion criteria: day-care centres licensed in the Australian Capital Territory; children < 3 years as at January 1996; attendance for at least 3 days per week; have no underlying chronic illness that predisposes to infection

Exclusion criteria: not stated

Age: < 3 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Large group training
2. Booklets/newsletters
3. Songs about hand washing for children

Control:
4. No intervention


Outcomes1. Diarrhoeal rate
2. Knowledge, attitude, and practice of hand washing


NotesLocation: Australian Capital Territory, Australia

Duration: March to November 1996

Stanton 1987

MethodsCluster-randomized trial

Allocation sequence: table of random numbers

Allocation concealment: unclear

Blinding: none

Inclusion of participants in the analysis: unclear

Length of follow up: 6 months

Cluster-adjustment method: adjusted


ParticipantsNumber: 1923 families (937 intervention, 986 control)

Inclusion criteria: not stated

Exclusion criteria: not stated

Age: < 6 years


InterventionsIntervention (see  Table 2 for detailed description):
1. Small group discussion (only women or children)
2. Larger demonstrations (mixed audience)
3. Posters, games, pictorial stories, and 'flexiflans' for illustrations

Control:
4. No intervention


Outcomes1. Diarrhoeal rates
2. Change in knowledge, attitude, and practice of water sanitation behaviours


NotesLocation: Urban Dhaka, Bangladesh

Duration: October 1984 to May 1985

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ahmed 1993Observational study examining risk factors for diarrhoeal infections

Alam 1989Main intervention was provision of water supply through hand pumps

Barros 1999Observational study examining risk factors for diarrhoeal infections

Clemens 1987Observational study examining risk factors for diarrhoeal infections

Curtis 2001No concurrent control

Doebbeling 1992Outcome measure (incidence of nosocomial infection) not specific to diarrhoea episodes but to incidence of gastrointestinal infections in general

Dyer 2000Intervention was instant hand sanitizer

Guinan 2002Observational study

Hammond 2000Intervention did not involve hand washing

Khan 1982Case-control study

Larson 2003No relevant outcome measures (measured colony-forming units of bacteria)

Larson 2004Outcome measure not specific to incidence of diarrhoea

Lee 1991Controlled before-and-after study

Luby 2001Observational study

Luby 2004bNonrandomized study

Master 1997Outcome measure not specific on diarrhoeal episodes

Morton 2004Outcome measure not specific on diarrhoeal episodes

Peterson 1998Observational study examining risk factors for diarrhoeal infections

Pinfold 1996No comparable baseline information on diarrhoeal episodes provided

Shahid 1996No comparable baseline information provided

Sircar 1987No comparable baseline information on diarrhoea episodes provided

White 2003Outcome measure not specific to diarrhoeal morbidity

Wilson 1991Controlled before-and-after study

 
Comparison 1. Institutional-based trials: hand washing promotion vs no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Incidence of diarrhoea: cluster-adjusted rate ratios2Incidence rate ratio (Random, 95% CI)0.61 [0.40, 0.92]

 2 Incidence of diarrhoea: not cluster-adjusted rate ratiosOther dataNo numeric data

 
Analysis 1.2 Comparison 1 Institutional-based trials: hand washing promotion vs no intervention, Outcome 2 Incidence of diarrhoea: not cluster-adjusted rate ratios.
Incidence of diarrhoea: not cluster-adjusted rate ratios

StudyIncidence rate ratio9% confidence interval

Bartlett 19880.890.71 to 1.11

Black 19810.520.34 to 0.78

Butz 19900.720.54 to 0.94

Kotch 19940.840.73 to 0.98

Ladegaard 19990.670.43 to 1.05

 
Comparison 2. Community-based trials: hand washing promotion vs no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Incidence of diarrhoea: cluster-adjusted rate ratios4Incidence rate ratio (Random, 95% CI)0.68 [0.52, 0.90]

 2 Incidence of diarrhoea: not cluster-adjusted rate ratiosOther dataNo numeric data

 3 Incidence of diarrhoea: stratified by soap provision and type of intervention4Incidence rate ratio (Random, 95% CI)Subtotals only

    3.1 Soap provided and focus on hand washing
2Incidence rate ratio (Random, 95% CI)0.49 [0.39, 0.62]

    3.2 No soap provided and multiple hygiene interventions
2Incidence rate ratio (Random, 95% CI)0.84 [0.67, 1.05]

 4 Episodes1148Mean Difference (IV, Random, 95% CI)-1.68 [-1.93, -1.43]

 
Analysis 2.2 Comparison 2 Community-based trials: hand washing promotion vs no intervention, Outcome 2 Incidence of diarrhoea: not cluster-adjusted rate ratios.
Incidence of diarrhoea: not cluster-adjusted rate ratios

StudyIncidence rate ratio95% confidence interval

Han 19890.700.54 to 0.92

 
Table 1. Detailed search strategies

Search setCIDG SRaCENTRALMEDLINEbEMBASEbLILACSb

1handwashinghandwashinghand wash*hand wash$handwashing

2diarrheahand washinghand disinfec*hand disinfec*diarrhea

3diarrhoeal diseaseshand cleansinghand clean*hand clean$1 and 2

4hand hygienehand hygienehand hygiene

51 or 2 or 3 or 4hand sterilityhand sterility

6diarrheaHANDWASHINGHANDWASHING

75 and 61 or 2 or 3 or 4 or 5 or 61 or 2 or 3 or 4 or 5 or 6

8diarrheadiarrhea

9diarrhoeadiarrhoea

108 or 98 or 9

117 and 107 and 10

 aCochrane Infectious Diseases Group Specialized Register.
bSearch terms used in combination with the search strategy for retrieving trials developed by The Cochrane Collaboration (Higgins 2006); upper case: MeSH or EMTREE heading; lower case: free text term.
 
Table 2. Intervention details

TrialPromotional activityClassificationaMessage contentHand washing methodHand washing stylebMaterial provisionWater availability

Institution-based


Bartlett 19881. Large group meetings (directors and caregivers)
2. Provision of posters and handouts depicting the procedures taught
1. Hygiene education
2. Participatory learning*
Staff and child hand washing, diapering, food handling, and environmental cleaningUnclearNot specifiedNot specifiedAdequate

Black 1981Large group educationHygiene educationStaff and child hand washing before handling food and after defecationWater with bar soap and paper towelsUnclearBy the day-care centres' managementAdequate

Bowen 20071. Large group training
2. Posters, videotape, wall charts, games
3. Soap
4. Take home packs
5. Peer trainers and peer-monitoring
1. Hygiene education
2. Behaviour modification
Hand washing before eating and after toiletingWater with soapUnder running waterSupplies of soap to schools in "Expanded Intervention"; 1 bar of soap to homes in both expanded and standard interventionAdequate (criteria for taking part in trial)

Butz 1990Large group training (in-home instruction to day-care providers)1. Hygiene education
2. Provision of soap/hand rinse material
1. Modes of transmission of pathogens in the home
2. Indications of hand washing
3. Use of vinyl gloves and disposable diaper changing pad
4. Use of an alcohol-based hand rinse (if unable to wash hand with water plus soap)
Water with soapNot specifiedAll supplies provided by researchersAdequate

Carabin 19991. Large group hygiene training (educators)
2. Handouts
Hygiene education1. Wash hands before lunch and after using the toilets
2. Clean toys with bleach
3. Use of reminder cues for hand washing
4. Clean the sand box with bleach
5. Open windows at least 30 min every day
UnclearNot specifiedUnclearAdequate

Kotch 19941. Large group training
2. Curriculum for caregivers
Hygiene education1. Hand washing of children and staff
2. Disinfection of diapering areas and toilet
3. Physical separation of diapering areas from food preparation and serving areas
4. Hygienic diaper disposal
Water with soap plus disposable towelUnder running waterUnclearAdequate

Ladegaard 1999Small group practical demonstration1. Hygiene education
2. Participatory learningc
1. Hand washing after stool contact
2. Information on disease spread and when to wash hands to prevent diarrhoea
Water with soapUnder running waterUnclearAdequate

Roberts 20001. Large group training
2. Booklets/newsletters
3. Songs about hand washing for children
1. Hygiene education
2. Behaviour modification
1. Hand washing before eating and after toileting or changing a diaper (staff and child)
2. Wash toys daily in dishwashers
Water with soapUnder running waterUnclearAdequate

Community-based

Haggerty 1994Large group trainingHygiene education1. Hand washing before meal preparation and eating
2. Hand washing after defecation (wash both hand and buttocks for children)
3. Proper disposal of children's faeces
4. Disposal of animal faeces from yard
UnclearNot specifiedUnclearUnknown

Han 1989Small group education (households)1. Hygiene education
2. Provision of hand washing material
Hand washing:
1. After defecation
2. Before preparing or eating food
Water with bar soapNot specifiedPlain bar soap provided by researcherUnknown

Luby 2004a1. Large group training using slide shows, pamphlets, and video tapes; education at weekly field visits
2. Education at weekly field visits
Hygiene educationHand washing:
1. Before preparing food
2. Before eating food
Water with plain or antibacterial soapWater from a pitcher (though not clearly stated)Soap provided by researchersUnknown

Luby 20061. Large group training using slide shows, pamphlets, and video tapes
2. Education at twice-weekly visits
1. Hygiene education
2. Provision of hand washing material
Hand washing:
1. After stool contact/ defecation
2. Before food preparation/handling/eating
3. Before feeding infants
Water with antibacterial soapNot specifiedSoap provided by researchersUnknown

Stanton 19871. Small group discussion (only women or children)
2. Larger demonstrations (mixed audience)
3. Posters, games, pictorial stories, and 'flexiflans' for illustrations
Hygiene education1. Hand washing before food preparation
2. Defecation away from the house and in a proper site
3. Suitable disposal of waste and faeces
UnclearNot specifiedUnclearInadequate

High-risk group (AIDS patients)

Huang 2007Demonstration by nurses and patientsHygiene education1. Hand washing after toileting, before food preparation/handling, eating
2. After cleaning infants who had defecated
3. Before and after sex
Water with soapUnder running waterUnclear (probably not relevant in this population)Adequate

 aMessage classification.
bWhether done under running water; in a bowl by an individual or by several people.
cParticipatory learning involves a process that helps engage learners in an active role of inquiry in which they share experiences and reflect critically on practice in a context that many group members find stimulating and relatively safe (Martin 1997).
 
Table 3. Methodological quality assessment

TrialSequence generationAllocation concealmentBlindingInclusionaComparabilitybTime of collectionc

Institution-based

Bartlett 1988UnclearUnclearAssessorUnclearAdequateAdequate

Black 1981UnclearUnclearNoneUnclearAdequateAdequate

Bowen 2007AdequateUnclearNoneAdequateAdequateAdequate

Butz 1990UnclearUnclearNoneUnclearAdequateAdequate

Carabin 1999AdequateUnclearNoneUnclearUnclearAdequate

Kotch 1994UnclearUnclearAssessorUnclearUnclearAdequate

Ladegaard 1999UnclearUnclearNoneUnclearAdequateAdequate

Roberts 2000AdequateUnclearAssessorsUnclearUnclearAdequate

Community-based

Haggerty 1994UnclearUnclearAssessorUnclearInadequateAdequate

Han 1989UnclearUnclearNoneUnclearAdequateAdequate

Luby 2004aAdequateAdequateNoneUnclearAdequateAdequate

Luby 2006AdequateUnclearNoneUnclearAdequateAdequate

Stanton 1987AdequateUnclearNoneUnclearAdequateAdequate

High-risk group (AIDS patients)

Huang 2007UnclearUnclearNoneAdequateAdequateAdequate

 aInclusion of randomized participants in the analysis was reported at different levels of analysis (cluster, child, person-at-risk levels).
bComparability between intervention and control groups with respect to baseline characteristics (see methods).
cData collected at similar time periods for intervention and control sites.
 
Table 4. Incidence of diarrhoea

TrialCluster adjusted?Outcome and resultMethod of assessmentSample size

Institution-based

Bartlett 1988NoDiarrhoea rate per child-year of observation

Intervention: 0.71 (95% CI 0.65 to 0.77)
Control: 0.81 (95% CI 0.75 to 0.87)
1. Active day-care centre-based surveillance (weekly visits plus daily telephone calls to identify diarrhoeal illness
2. Family-based surveys (questionnaire every 2 weeks)
26 day-care centres with 374 children (196 intervention, 178 control) aged 0 to 3 years

Black 1981NoDiarrhoea incidence/100/child-weeks of observation

Intervention: 4.2/100/child-week
Control: 8.1/100/child-week
Daily record of attendance plus diarrhoea occurrence for each child by day-care personnel4 day-care centres (2 intervention, 2 control) with 116 children < 3 years

Bowen 2007YesMedian episodes of diarrhoea per 100 student weeks

Expanded intervention: 0 per 100 student-weeks
Standard intervention: 0 per 100 student-weeks
Control: 0 per 100 student-weeks
Teachers trained using standardized case definitions to identify 10 symptoms or signs of illness and record these among students in class, 1 day per week; if parent's reported infection as cause of absence, teachers recorded name of syndrome and asked parent if child suffered any of 10 individual symptoms; verified verbally that reports of diarrhoea met case definition3962 children within 87 primary schools

Butz 1990NoProportion of diarrhoea days per month

Diarrhoea episodes/child-days

Intervention: 93/10,159
Control: 133/10,424
Daily symptom record for each child by care providers24 family day-care homes with 108 children (58 intervention, 50 control) aged 1 month to 7 years

Carabin 1999YesDiarrhoea incidence: episodes/100 child-days at risk

Incidence rate ratio (95% Bayesian credible interval) 1.10 (0.81 to 1.50), adjusted for age and gender

Intervention alone: 0.77 (0.51 to 1.18)
Monitoring alone: 0.73 (0.54 to 0.97)
Daily record of diarrhoea episodes on calendar by educators52 day-care centres with 1729 children aged 18 months to 3 years

Kotch 1994YesDiarrhoea rates: incidence density (episodes/child-year)

Intervention (< 2 years): 4.54
Intervention (> 2 years): 2.85
Control (< 2 years): 5.12
Control (> 2 years): 2.79

All: risk ratio 1.19, 95% CI -0.48 to 1.96
Telephone interview methodology (biweekly calls to families)

5 week interval visits to day-care centres
24 day-care centres with 389 children < 3 years

Ladegaard 1999NoDiarrhoea episodes/child-month

Intervention: 33/848
Control: 61/1052

(34% reduction from 3.25 days per child in favour of children 3 years or more)
Information on absenteeism recorded on a form by child-care provider8 day-care centres with 475 children (212 intervention, 263 control) aged 6 years and below

Roberts 2000YesDiarrhoeal rates: episodes/child-year

Intervention: 1.9 episodes/child-year
Control: 2.7 episodes/child-year

All: risk ratio 0.50 (95% CI 0.36 to 0.68)
< 2 years: risk ratio 0.90 (95% CI, 0.67 to 1.19)
> 2 years: risk ratio 0.48 (95% CI 029 to 0.78)

(Adjusted for clustering by centre, confounding variables (age, sex, weight at birth, breastfeeding status, child care history, and home factors), and interactions between age and intervention status, and between having a sibling who attends child care and intervention status)
1. Biweekly telephone interviews (parents reports of symptoms)
2. Observation for compliance of recommended practices every 6 weeks
23 day-care centres (11 intervention, 12 control) with 558 children under 3 years

Community-based

Haggerty 1994YesDiarrhoea rates (mean episodes of diarrhoea )

Intervention site: 0.071
Control site: risk ratio 0.075

(risk ratio 0.94, 95% CI 0.85 to 1.05; P = 0.3)
1. Observation recording form
2. Diarrhoeal morbidity form
18 sites (9 intervention, 9 control) with 1954 children aged 3 months to 35 months

Han 1989NoIncidence density ratio

1. Diarrhoea
< 2 years: 0.69 (95% CI 0.48 to 1.10)
> 2 years: 0.67 (95% CI 0.45 to 0.98)
All: 0.70 (95% CI 0.54 to 0.92)

2. Dysentery
< 2 years: 0.59 (95% CI 0.22 to 1.55)
> 2 years: 1.21 (95% CI 0.52 to 2.80)
All: 0.93 (95% CI 0.39 to 2.23)
Daily surveillance (24 h recall) for diarrhoea and dysentery350 households (162 intervention, 188 control) with 494 children (236 intervention; 258 control) under 5 years

Luby 2004aYesIncidence density of diarrhoea (number of new episodes of diarrhoea divided by the at-risk person-weeks of observation)

Mean incidence

1. Primary diarrhoea
Intervention:
Antibacterial soap: 2.02
Plain soap: 1.91
Control: 4.06

2. Persistent diarrhoea
Intervention:
Antibacterial soap: 0.14
Plain soap: 0.12
Control: 0.17
Weekly observational visits to households36 neighbourhoods (25 intervention, 11 control) with 4691 children (3163 intervention, 1528 control) aged < 15 years

Luby 2006YesDiarrhoea episodes/100 child-weeks: for diarrhoea and persistent diarrhoea

1. Risk ratio: 0.57 (95% CI 0.35 to 0.86)
2. Diarrhoea, mean incidence: 3.71
3. Persistent diarrhoea, mean incidence: 0.09

-52% (-100% to 100%)
Weekly observational visits to households18 clusters (544 households; 262 intervention; 282 control) with children < 15 years

Stanton 1987YesRate of diarrhoea per 100 person-weeks
Incidence density ratio 0.75 (95% CI 0.66 to 0.84; P < 0.0001)

< 2 years: 0.54 (95% CI 0.43 to 0.66)
> 2 years: 0.68 (95% CI 0.54 to 0.85)
1. Biweekly histories of diarrhoea for children of all households
2. Single prolonged on-site visit to each sentinel family for hand washing-related behaviour observation
1923 families (937 intervention, 986 control) with children aged < 6 years

High-risk group (AIDS patients)

Huang 2007Not applicableMean episodes of diarrhoea over study period (1 year)

Intervention group: 1.24 (+/- 0.9)
Control group: 2.92 (+/- 0.6)
Daily hand washing diary to record number of hand washing episodes per day and diarrhoea diary to record stool frequency and characteristics; weekly telephone calls from study nurse to ascertain episodes of these outcomes75 in hand washing group, 73 controls

 CI: confidence interval.
 
Table 5. Behavioural change

TrialCluster adjusted?KAPa changesDetailInterventionControlP


nNnN

Institution-based

Kotch 1994YesHand washing behaviour, based on event sampling scoresbAfter changing a diaper0.750.37

After contact with child's mucus, saliva, vomit, etc0.660.21

Roberts 2000YesCompliance for hand washing by children in 11 intervention centres by a scorec; measured as risk ratio of diarrhoeal episodes (relative to control centres) with 95% confidence intervals1 (4 centres)0.52 (0.37 to 0.75)

2 (4 centres)0.53 (0.37 to 0.76)

3 (3 centres)0.43 (0.27 to 0.70)

Children ≥ 2 years0.34 (0.17 to 0.65)

Community-based

Stanton 1987YesComparison of hygienic practices after intervention (risk ratio 1.48, confidence interval 1.01 to 2.21)3979 (39/79 = 49%)2575 (25/75 = 33%)

High-risk group (AIDS patients)

Huang 2007Not applicableFrequency of hand washing per dayAt baseline and at the end of study3.3 (+/- 0.98)
7 times daily
3.4 (+/- 1.1)
4 times daily
< 0.05

 aKAP: knowledge, attitude, and practice.
bEvent sampling scores (0 = none; 0.5 = partially correct; 1.0 = as recommended in the training).
cCompliance score: 1 = lowest compliance rate (53% to 69%); 2 = moderate compliance rate (70% to 79%); 3 = high compliance rate (≥ 80%).