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Meta-Analysis
. 2021 Jan 6;12(1):CD004265.
doi: 10.1002/14651858.CD004265.pub4.

Hand-washing promotion for preventing diarrhoea

Regina I Ejemot-Nwadiaro  1 , John E Ehiri  2 , Dachi Arikpo  3 , Martin M Meremikwu  4 , Julia A Critchley  5
Affiliations
Meta-Analysis

Hand-washing promotion for preventing diarrhoea

Regina I Ejemot-Nwadiaro et al. Cochrane Database Syst Rev. .

Abstract
in English, Spanish

Background: Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

Objectives: To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

Search methods: We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

Selection criteria: Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

Data collection and analysis: Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

Main results: We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

Authors' conclusions: Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

Antecedentes: La diarrea es responsable de 1 800 000 muertes de niños en los países de ingresos bajos y medios (PIBM). Una de las estrategias identificadas para prevenir la diarrea es el lavado de manos.

Objetivos: Evaluar los efectos de las intervenciones de promoción del lavado de manos sobre los episodios de diarrea en niños y adultos. MÉTODOS DE BÚSQUEDA: El 8 de enero de 2020 se realizaron búsquedas en CENTRAL, MEDLINE, Embase, en otras nueve bases de datos, la Plataforma de registros internacionales de ensayos clínicos (ICTRP) de la Organización Mundial de la Salud (OMS) y el metaRegister of Controlled Trials (mRCT), además de comprobación de referencias, búsqueda de citas y contacto con los autores de los estudios para identificar estudios adicionales. CRITERIOS DE SELECCIÓN: Ensayos controlados aleatorizados (ECA) individuales y por conglomerados que compararon los efectos de las intervenciones de lavado de manos sobre los episodios de diarrea en niños y adultos, con ninguna intervención. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos autores de la revisión, de forma independiente, evaluaron la elegibilidad de los ensayos, extrajeron los datos y evaluaron los riesgos de sesgo. Los análisis se estratificaron por guarderías infantiles o escuelas, comunidad y contextos hospitalarios. Cuando fue conveniente, se agruparon los cocientes de la tasa de incidencia (CTI) según el método de la varianza inversa genérica y un modelo de efectos aleatorios con un intervalo de confianza (IC) del 95%. Se utilizaron los criterios GRADE para evaluar la certeza de la evidencia.

Resultados principales: Se incluyeron 29 ECA: 13 ensayos de guarderías infantiles o escuelas en países principalmente de ingresos altos (54 471 participantes), 15 ensayos comunitarios en PIMB (29 347 participantes) y un ensayo hospitalario en pacientes con sida en países de ingresos altos (148 participantes). Todos los ensayos y evaluaciones de seguimiento fueron a corto plazo. La promoción del lavado de manos (actividades educativas, a veces con la provisión de jabón) en las guarderías infantiles o las escuelas previene alrededor de un tercio de los episodios de diarrea en los países de ingresos altos (cociente de tasa de incidencia [CTI] 0,70; IC del 95%: 0,58 a 0,85; nueve ensayos, 4664 participantes, evidencia de certeza alta), y podría prevenir una proporción similar en los PIMB, pero solo dos ensayos en zonas urbanas de Egipto y Kenya lo han evaluado (CTI 0,66; IC del 95%: 0,43 a 0,99; dos ensayos, 45 380 participantes, evidencia de certeza baja). Solo cuatro ensayos informaron sobre medidas de cambio en el comportamiento y los métodos de recopilación de datos fueron susceptibles de sesgo. En un ensayo de los EE.UU. se informó de que el comportamiento de lavado de manos mejoró; y en el ensayo de Kenya que proporcionó jabón gratuito, el lavado de manos no aumentó, pero sí el uso de jabón (datos no agrupados; tres ensayos, 1845 participantes, evidencia de certeza baja). La promoción del lavado de manos entre las comunidades en los PIMB probablemente previene alrededor de una cuarta parte de los episodios de diarrea (CTI 0,71; IC del 95%: 0,62 a 0,81; nueve ensayos, 15 950 participantes, evidencia de calidad moderada). Sin embargo, seis de estos nueve ensayos procedían de entornos asiáticos, y solo hubo un ensayo en América del Sur y dos en el África subsahariana. En siete ensayos, el jabón se suministró gratuitamente junto con la educación para el lavado de manos, y el tamaño del efecto medio general fue mayor que en los dos ensayos que no suministraron jabón (jabón suministrado: RR 0,66; IC del 95%: 0,58 a 0,75; siete ensayos, 12 646 participantes; solo educación: RR 0,84; IC del 95%: 0,67 a 1,05; dos ensayos, 3304 participantes). Hubo un aumento del lavado de manos en los momentos más importantes (antes de comer o cocinar, después de ir al baño o de limpiar el trasero del niño), y un aumento en el cumplimiento del procedimiento de higiene de las manos (resultado conductual) en los grupos de intervención, en comparación el control, en los ensayos comunitarios (datos no agrupados: cuatro ensayos, 3591 participantes; evidencia de certeza alta). La promoción del lavado de manos en el único ensayo realizado en un hospital en una población de alto riesgo mostró una reducción significativa de los episodios medios de diarrea (1,68 menos) en el grupo de intervención (diferencia de medias ‐1,68; IC del 95%: ‐1,93 a ‐1,43; un ensayo, 148 participantes, evidencia de certeza moderada). En este ensayo hospitalario la frecuencia del lavado de manos aumentó hasta siete veces al día en el grupo de intervención versus tres veces al día en el grupo control (un ensayo, 148 participantes, evidencia de certeza moderada). No se encontraron ensayos que evaluaran los efectos de la promoción del lavado de manos sobre las muertes relacionadas con la diarrea ni el coste‐efectividad.

Conclusiones de los autores: La promoción del lavado de manos probablemente reduce los episodios de diarrea en las guarderías infantiles de los países de altos ingresos y en las comunidades que viven en los PIMB, en aproximadamente el 30%. Los ensayos incluidos no aportan evidencia sobre el efecto a largo plazo de esta intervención.

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Conflict of interest statement

Regina Ejemot‐Nwadiaro: none known. John Ehiri: none known. Dachi Arikpo: none known. Martin Meremikwu: none known. Julia Critchley: none known.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
3
3
1.1
1.1. Analysis
Comparison 1: Hand washing intervention at child care centres and schools versus no intervention, Outcome 1: Incidence of diarrhoea; subgrouped by country income strata
1.2
1.2. Analysis
Comparison 1: Hand washing intervention at child care centres and schools versus no intervention, Outcome 2: Incidence of diarrhoea; subgrouped by co‐interventions
1.3
1.3. Analysis
Comparison 1: Hand washing intervention at child care centres and schools versus no intervention, Outcome 3: Incidence of diarrhoea; subgrouped by blinding
2.1
2.1. Analysis
Comparison 2: Hand washing intervention in the community versus no intervention, Outcome 1: Incidence of diarrhoea: rate ratios
2.2
2.2. Analysis
Comparison 2: Hand washing intervention in the community versus no intervention, Outcome 2: Mean longitudinal prevalence (pooled)
2.3
2.3. Analysis
Comparison 2: Hand washing intervention in the community versus no intervention, Outcome 3: Incidence of diarrhoea; subgrouped by co‐interventions
2.4
2.4. Analysis
Comparison 2: Hand washing intervention in the community versus no intervention, Outcome 4: Incidence of diarrhoea; subgrouped by blinding
2.5
2.5. Analysis
Comparison 2: Hand washing intervention in the community versus no intervention, Outcome 5: Incidence of diarrhoea; subgrouped by provision of soap
3.1
3.1. Analysis
Comparison 3: Hand washing intervention in hospital setting versus no intervention, Outcome 1: Episodes of diarrhoea
See this image and copyright information in PMC

Update of

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Clasen 2014b {published data only}
    1. Clasen T, Boisson S, Routray P, Torondel B, Jenkins M, Freeman M. The effectiveness of a rural sanitation intervention on health and ORISSA, India: a cluster randomized, controlled trial. 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH); 20141102-06; New Orleans, In: American Journal of Tropical Medicine and Hygiene 2014;91(5 SUPPL):215.
Clemens 1987 {published data only}
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Contzen 2015 {published data only}
    1. Contzen N, Meili IH, Mosler HJ. Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Social Science & Medicine 2015;124:103-14. - PubMed
Correa 2012 {published data only}
    1. Correa JC, Pinto D, Salas LA, Camacho JC, Rondón M, Quintero J. A cluster-randomized controlled trial of hand rubs for prevention of infectious diseases among children in Colombia. Revista Panamericana de Salud Pública 2012;31(6):476-84. - PubMed
Curtis 2001 {published data only}
    1. Curtis V, Kanki B, Cousen S, Diallo I, Kpozehouen A, Sangaré M, et al. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bulletin of the World Health Organization 2001;79(6):518-27. - PMC - PubMed
Doebbeling 1992 {published data only}
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Dreibelbis 2014 {published data only}
    1. Dreibelbis R, Freeman MC, Greene LE, Saboori S, Rheingans R. The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster-randomized trial in Kenya. American Journal of Public Health 2014;104(1):e91-7. - PMC - PubMed
Dreibelbis 2016 {published data only}
    1. Dreibelbis R, Kroeger A, Hossain K, Venkatesh M, Ram PK. Behavior change without behavior change communication: nudging handwashing among primary school students in Bangladesh. International Journal of Environmental Research and Public Health 2016;13(1):1-7. - PMC - PubMed
Duijster 2017 {published data only}
    1. Duijster D, Monse B, Dimaisip-Nabuab J, Djuharnoko P, Heinrich-Weltzien R, Hobdell M. 'Fit for school' - a school-based water, sanitation and hygiene programme to improve child health: results from a longitudinal study in Cambodia, Indonesia and Lao PDR. BMC Public Health 2017;17(302):1-15. - PMC - PubMed
Dyer 2000 {published data only}
    1. Dyer DL, Shinder A, Shinder F. Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism. Family Medicine 2000;32(9):633-8. - PubMed
Ecrumen 2018 {published data only}
    1. Ercumen A, Mertens A, Arnold BF, Benjamin-Chung J, Hubbard AE, Ahmed MA, et al. Effects of single and combined water, sanitation and handwashing interventions on fecal contamination in the domestic environment: a cluster-randomized controlled trial in rural Bangladesh. Environmental Science Technology 2018;52(21):12078-88. - PMC - PubMed
    1. Ercumen A, Pickering A, Kwong LH, Mertens A, Arnold BF, Benjamin-Chung J, et al. Do sanitation improvements reduce fecal contamination of water, hands, food, soil and flies? Evidence from a cluster-randomized controlled trial in rural Bangladesh. Environmental Science Technology 2018;52(21):2089-97. - PMC - PubMed
Ecrumen 2019 {published data only}
    1. Ercumen A, Benjamin-Chung J, Arnold BF, Lin A, Hubbard AE, Stewart C, et al. Effects of water, sanitation, handwashing and nutritional interventions on soil-transmitted helminth infections in young children: a cluster-randomized controlled trial in rural Bangladesh. PLOS Neglected Tropical Diseases 2019;3(5):1-24. - PMC - PubMed
Enebeli 2017 {published data only}
    1. Enebeli UU. The influence of sanitation on childhood diarrhoea in 2016 and its implications on integrated community case management of endemic childhood diseases in Abia State, Nigeria. American Journal of Tropical Medicine and Hygiene. Conference: 66th annual meeting of the American Society of Tropical Medicine and Hygiene, ASTMH 2017. United States 2017;97(5 Supplement 1):586-7.
Erismann 2017 {published data only}
    1. Erismann S, Diagbouga S, Schindler C, Odermatt P, Knoblauch AM, Gerold J, et al. School children's intestinal parasite and nutritional status one year after complementary school garden, nutrition, water, sanitation, and hygiene interventions in Burkina Faso. American Journal of Tropical Medicine and Hygiene 2017;97(3):904-13. - PMC - PubMed
Fan 2011 {published data only}
    1. Fan VY, Mahal A. What prevents child diarrhoea? The impacts of water supply, toilets, and hand-washing in rural India. Journal of Development Effectiveness 2011;3(3):340-70.
Freeman 2014 {published data only}
    1. Freeman MC, Clasen T, Dreibelbis R, Saboori S, Greene LE, Brumback B, et al. The impact of a school-based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster-randomized trial. Epidemiology and Infection 2014;142(2):340-51. - PMC - PubMed
Greene 2012 {published data only}
    1. Greene LE, Freeman MC, Akoko D, Saboori S, Moe C, Rheingans R. Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial. American Journal of Tropical Medicine and Hygiene 2012;87(3):385-93. - PMC - PubMed
Greenland 2016 {published data only}
    1. Greenland K, Chipungu J, Curtis V, Schmidt WP, Siwale Z, Mudenda M, et al. Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: a cluster randomised trial. Lancet Global Health 2016;4(12):E966-77. - PubMed
Guinan 2002 {published data only}
    1. Guinan M, McGuckin M, Ali Y. The effect of a comprehensive handwashing program on absenteeism in elementary schools. American Journal of Infection Control 2002;30(4):217-20. - PubMed
Hammond 2000 {published data only}
    1. Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer use on elementary school absenteeism. American Journal of Infection Control 2000;28(5):340-6. - PubMed
Hovi 2017 {published data only}
    1. Hovi T, Ollgren J, Savolainen-Kopra C. Intensified hand-hygiene campaign including soap-and-water wash may prevent acute infections in office workers, as shown by a recognized-exposure-adjusted analysis of a randomized trial. BioMed Central Infectious Diseases 2017;17(47):1-9. - PMC - PubMed
Hübner 2010 {published data only}
    1. Hübner NO, Hübner C, Wodny M, Kampf G, Kramer A. Effectiveness of alcohol-based hand disinfectants in a public administration: impact on health and work performance related to acute respiratory symptoms and diarrhoea. BMC Infectious Diseases 2010;10:250. - PMC - PubMed
Huda 2012 {published data only}
    1. Huda TM, Unicomb L, Johnston RB, Halder AK, Yushuf Sharker MA, Luby SP. Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Social Science & Medicine 2012;75(4):604-11. - PubMed
Jinadu 2007 {published data only}
    1. Jinadu MK, Adegbenro CA, Esmai AO, Ojo AA, Oyeleye BA. Health promotion intervention for hygienic disposal of children's faeces in a rural area of Nigeria. Health Education Journal 2007;66(3):222-8.
Johansen 2015 {published data only}
    1. Johansen A, Denbaek AM, Bonnesen CT, Due P. The Hi Five study: design of a school-based randomized trial to reduce infections and improve hygiene and well-being among 6-15 year olds in Denmark. BMC Public Health 2015;15:207. - PMC - PubMed
Kamm 2016 {published data only}
    1. Kamm KB, Vujcic J, Nasreen S, Luby SP, Zaman K, El Arifeen S, et al. Is pregnancy a teachable moment to promote handwashing with soap among primiparous women in rural Bangladesh? Follow-up of a randomised controlled trial. Tropical Medicine & International Health 2016;21(12):1562-71. - PubMed
Kang 2017 {published data only}
    1. Kang Y, Suh YK, Debele L, Juon HS, Christian P. Effects of a community-based nutrition promotion programme on child feeding and hygiene practices among caregivers in rural Eastern Ethiopia. Public Health Nutrition 2017;20(8):1461-72. - PMC - PubMed
Khan 1982 {published data only}
    1. Khan MU. Interruption of shigellosis by hand washing. Transactions of the Royal Society of Tropical Medicine and Hygiene 1982;76(2):164-8. - PubMed
Larson 2003 {published data only}
    1. Larson E, Aiello A, Lee LV, Della-Latta P, Gomez-Duarte C, Lin S. Short- and long-term effects of handwashing with antimicrobial or plain soap in the community. Journal of Community Health 2003;28(2):139-50. - PubMed
Larson 2004 {published data only}
    1. Larson EL, Lin SX, Gomez-Pichardo C, Della-Latta P. Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial. Annals of Internal Medicine 2004;140(5):321-9. - PMC - PubMed
Lee 1991 {published data only}
    1. Lee W, Stoeckel J, Jintaganont P, Romanarak T, Kullavanijaya S. The impact of a community based health education program on the incidence of diarrheal disease in Southern Thailand. Southeast Asian Journal of Tropical Medicine and Public Health 1991;22(4):548-56. - PubMed
Luby 2001b {published data only}
    1. Luby SP, Agboatwalla M, Raza A, Sobel J, Mintz ED, Baier K, et al. Microbiologic effectiveness of hand washing with soap in an urban squatter settlement, Karachi, Pakistan. Epidemiology and Infection 2001;127(2):237-44. - PMC - PubMed
Luby 2004 {published data only}
    1. Luby SP, Agboatwalla M, Hoekstra RM, Rahbar MH, Billhimer W, Keswick BH. Delayed effectiveness of home-based intervention in reducing childhood diarrhea, Karachi, Pakistan. American Journal of Medicine and Hygiene 2004;71(4):420-7. - PubMed
Luby 2007 {published data only}
    1. Luby SP, Agboatwalla M, Billhimer W, Hoekstra RM. Field trial of a low cost method to evaluate hand cleanliness. Tropical Medicine & International Health 2007;12(6):765-71. - PubMed
Luby 2008 {published data only}
    1. Luby SP, Mendoza C, Keswick BH, Chiller TM, Hoekstra RM. Difficulties in bringing point-of-use water treatment to scale in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2008;78(3):382-7. - PubMed
Luby 2010 {published data only}
    1. Luby SP, Kadir MA, Yushuf Sharker MA, Yeasmin F, Unicomb L, Sirajul Islam M. A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh. Tropical Medicine & International Health 2010;15(12):1508-16. - PubMed
Manjang 2018 {published data only}
    1. Manjang B, Hemming K, Bradley C, Ensink J, Martin J, Sowe J, et al. Promoting hygienic weaning food handling practices through a community based programme: intervention implementation and baseline characteristics for a cluster randomised controlled trial in rural Gambia. British Medical Journal Open 2018;8:e017573. - PMC - PubMed
Master 1997 {published data only}
    1. Master D, Hess Longe SH, Dickson H. Scheduled hand washing in an elementary school population. Family Medicine 1997;29(5):336-9. - PubMed
Morton 2004 {published data only}
    1. Morton JL, Schultz AA. Healthy Hands: Use of alcohol gel as an adjunct to handwashing in elementary school children. Journal of School Nursing 2004;20(3):161-7. - PubMed
Najnin 2017 {published data only}
    1. Najnin N, Leder K, Qadri F, Forbes A, Unicomb L, Winch PJ, et al. Impact of adding hand-washing and water disinfection promotion to oral cholera vaccination on diarrhoea-associated hospitalization in Dhaka, Bangladesh: evidence from a cluster randomized control trial. International Journal of Epidemiology 2017;46(6):2056-66. - PMC - PubMed
Naluonde 2018 {published data only}
    1. Naluonde T, Wakefield C, Markle L, Martin A, Tresphor C, Abdullah R, et al. A disruptive cue improves handwashing in school children in Zambia. Health Promotion International 2018;34(6):e119-28. - PubMed
Oncu 2018 {published data only}
    1. Oncu E, Vayisoglu SK, Lafci D, Yurtsever D, Bulut ER, Peker E. Comparison of interactive education versus fluorescent concretization on hand hygiene compliance among primary school students: a randomized controlled trial. Journal of School Nursing 2018;35(5):337-47. - PubMed
Oughton 2009 {published data only}
    1. Oughton MT, Loo VG, Dendukuri N, Fenn S, Libman MD. Hand hygiene with soap and water Is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infection Control and Hospital Epidemiology 2009;30(10):939-44. - PubMed
Overgaard 2016 {published data only}
    1. Overgaard H, Alexander N, Matiz MI, Jaramillo JF, Olano VA, Vargas S, et al. A cluster-randomized controlled trial to reduce diarrheal disease and dengue entomological risk factors in rural primary schools in Colombia. PLOS Neglected Tropical Diseases 2016;10(11):e005106. 1-26. - PMC - PubMed
Patel 2012 {published data only}
    1. Patel MK, Harris JR, Juliao P, Nygren B, Were V, Kola S, et al. Impact of a hygiene curriculum and the installation of simple handwashing and drinking water stations in rural Kenyan primary schools on student health and hygiene practices. American Journal of Tropical Medicine and Hygiene 2012;87(4):594-601. - PMC - PubMed
Peterson 1998 {published data only}
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Pinfold 1996 {published data only}
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Priest 2014 {published data only}
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Rosen 2009 {published data only}
    1. Rosen L, Zucker D, Brody D, Engelhard D, Manor O. The effect of a handwashing intervention on preschool educator beliefs, attitudes, knowledge and self-efficacy. Health Education Resources 2009;24(4):686-98. - PubMed
Saboori 2013 {published data only}
    1. Saboori S, Greene LE, Moe CL, Freeman MC, Caruso BA, Akoko D, et al. Impact of regular soap provision to primary schools on hand washing and E. coli hand contamination among pupils in Nyanza Province, Kenya: a cluster-randomized trial. American Journal of Tropical Medicine and Hygiene 2013;89(4):698-708. - PMC - PubMed
Savolainen‐Kopra 2012 {published data only}
    1. Savolainen-Kopra C, Haapakoski J, Peltola PA, Ziegler T, Korpela T, Anttila P, et al. Hand washing with soap and water together with behavioural recommendations prevents infections in common work environment: an open cluster-randomized trial. Trials 2012;13:10. - PMC - PubMed
Shafique 2013 {published data only}
    1. Shafique S, Jalal CS, Jolly SP, Shikder H, Sellen DW, Zlotkin S. Effects of water-based hand sanitizers and micronutrient powders along with nutrition and hygiene education to prevent infections and linear growth faltering among low birth weight infants in Bangladesh. FASEB Journal Conference 2013;27(Meeting Abstract Supplement):243.1.
Shahid 1996 {published data only}
    1. Shahid NS, Greenough WB 3rd, Samadi AR, Huq MI, Rahaman N. Handwashing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. Journal of Diarrhoeal Diseases Research 1996;14(2):85-9. - PubMed
Sinharoy 2017 {published data only}
    1. Sinharoy SS, Schmidt WP, Wendt R, Mfura L, Crossett E, Grepin KA, et al. Effect of community health clubs on child diarrhoea in western Rwanda: cluster-randomised controlled trial. Lancet Global Health 2017;5(7):e699-709. - PMC - PubMed
    1. Sinharoy SS, Schmidt WP, Wendt R, Mfura L, Crossett E, Grepin KA, et al. Impact of community health clubs on diarrhea and anthropometry in western Rwanda: cluster-randomized controlled trial. FASEB Journal. Conference: Experimental Biology 2017;31:(1 Supplement 1).
Sircar 1987 {published data only}
    1. Sircar BK, Sengupta PG, Mondal SK, Gupta DN, Saha NC, Ghosh S, et al. Effect of handwashing on the incidence of diarrhoea in a Calcutta slum. Journal of Diarrhoeal Diseases Research 1987;5(2):112-4. - PubMed
Slayton 2013 {published data only}
    1. Slayton RB, Murphy JL, Faith SH, Oremo J, Odhiambo A, Ayers T, et al. A cluster randomized controlled evaluation of the health impact of a novel antimicrobial hand towel on the health of children under two years old in rural communities in Nyanza province, Kenya. American Journal of Tropical Medicine and Hygiene (Conference Publication) 2013;85(Suppl 1):314. - PMC - PubMed
Vally 2019 {published data only}
    1. Vally H, McMichael C, Doherty C, Li X, Guevarra G, Tobias P. The impact of a school-based water, sanitation and hygiene intervention on knowledge, practices, and diarrhoea rates in the Philippines. International Journal of Environmental Research and Public Health 2019;16(21):1-14. - PMC - PubMed
Vindigni 2011 {published data only}
    1. Vindigni SM, Riley PL, Jhung M. Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance. Tropical Medicine & International Health 2011;16(4):466-77. - PubMed
White 2003 {published data only}
    1. White C, Kolble R, Carlson R, Lipson N, Dolan M, Ali Y, et al. The effect of hand hygiene on illness rate among students in university residence halls. American Journal of Infection Control 2003;31(6):364-70. - PubMed
Wilson 1991 {published data only}
    1. Wilson JM, Chandler GN, Muslihatun, Jamiluddin. Hand-washing reduces diarrhoea episodes: a study in Lombok, Indonesia. Transactions of the Royal Society of Tropical Medicine and Hygiene 1991;85(6):819-21. - PubMed
    1. Wilson JM, Chandler GN. Sustained improvements in hygiene behaviour amongst village women in Lombok, Indonesia. Transactions of the Royal Society of Tropical Medicine and Hygiene 1993;87(6):615-6. - PubMed
Zhang 2013 {published data only}
    1. Zhang C, Mosa AJ, Hayward AS, Matthews SA. Promoting clean hands among children in Uganda: a school-based intervention using 'tippy-taps'. Public Health 2013;127(6):586-9. - PMC - PubMed

References to studies awaiting assessment

Denbaek 2018 {published data only}
    1. Denbaek AM, Andersen A, Bonnesen CT, Laursen B, Ersboll AK, Due P, et al. Effect evaluation of a randomized trial to reduce infectious illness and illness-related absenteeism among schoolchildren: the Hi Five Study. Pediatric Infectious Disease Journal 2018;37(1):16-21. - PubMed

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References to other published versions of this review

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