- INTRODUCTION
- METHODS AND MATERIALS
- Study setting and participants.
- Step 1: formative study.
- Structured observations.
- Baseline student survey.
- Qualitative interviews.
- Step 2: intervention development.
- Development of behavior change communication materials.
- Step 3: piloting the intervention.
- Structured observations.
- Pocket voting.
- Step 4: 14-month follow-up assessment.
- Research design and analysis.
- Ethics.
- RESULTS
- DISCUSSION
- Supplementary Material
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
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1.
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Dumre SP, Sapkota K, Adhikari N, Acharya D, Karki M, Bista S, Basanyat SR, Joshi SK, 2009. Asymptomatic throat carriage rate and antimicrobial resistance pattern of Streptococcus pyogenes in Nepalese school children. Kathmandu Univ Med J 7: 392–396 (KUMJ).
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Cauchemez S, Bhattarai A, Marchbanks TL, Fagan RP, Ostroff S, Ferguson NM, Swerdlow D, Sodha SV, Moll ME, Angulo FJ, 2011. Role of social networks in shaping disease transmission during a community outbreak of 2009 H1N1 pandemic influenza. Proc Natl Acad Sci USA 108: 2825–2830.
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Nasreen S, Azziz‐Baumgartner E, Gurley E, Winch P, Unicomb L, Sharker M, Southern D, Luby S, 2010. Prevalent high‐risk respiratory hygiene practices in urban and rural Bangladesh. Trop Med Int Health 15: 762–771.
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Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, Luby S, 2007. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 76: 1166–1173.
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26.
Master D, Hess Longe SH, Dickson H, 1997. Scheduled hand washing in an elementary school population. Fam Med 29: 336–339.
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Nicholson JA, Naeeni M, Hoptroff M, Matheson JR, Roberts AJ, Taylor D, Sidibe M, Weir AJ, Damle SG, Wright RL, 2014. An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Trop Med Int Health 19: 284–292.
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28.
Talaat M, Afifi S, Dueger E, El-Ashry N, Marfin A, Kandeel A, Mohareb E, El-Sayed N, 2011. Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt. Emerg Infect Dis 17: 619–625.
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29.
World Health Organization, 2008. World Health Statistics 2008. Geneva, Switzerland: World Health Organization Press, 1–110.
-
30.
Nizame FA, Nasreen S, Unicomb L, Southern D, Gurley ES, Arman S, Kadir MA, Azziz-Baumgartner E, Luby SP, Winch PJ, 2011. Understanding community perceptions, social norms and current practice related to respiratory infection in Bangladesh during 2009: a qualitative formative study. BMC Public Health 11: 901.
-
31.
Tellier R, 2006. Review of aerosol transmission of influenza A virus. Emerg Infect Dis 12: 1657–1662.
-
32.
Blanton E, Ombeki S, Oluoch GO, Mwaki A, Wannemuehler K, Quick R, 2010. Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households—Nyanza province, western Kenya, 2007. Am J Trop Med Hyg 82: 664–671.
-
33.
Onyango-Ouma W, Aagaard-Hansen J, Jensen B, 2005. The potential of schoolchildren as health change agents in rural western Kenya. Soc Sci Med 61: 1711–1722.
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34.
O’reilly C, Freeman M, Ravani M, Migele J, Mwaki A, Ayalo M, Ombeki S, Hoekstra R, Quick R, 2008. The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza province, western Kenya, 2006. Epidemiol Infect 136: 80–91.
-
35.
Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC public health 13: 1015.
-
36.
Seimetz E, Boyayo A-M, Mosler H-J, 2016. The influence of contextual and psychosocial factors on handwashing. Am J Trop Med Hyg 94: 1407–1417.
-
37.
Hulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, Nizame FA, Luby SP, Ram PK, Winch PJ, 2013. Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC Public Health 13: 877.
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38.
Najnin N, Arman S, Abedin J, Unicomb L, Levine DI, Mahmud M, Leder K, Yeasmin F, Luoto JE, Albert J, 2015. Explaining low rates of sustained use of siphon water filter: evidence from follow‐up of a randomised controlled trial in Bangladesh. Trop Med Int Health 20: 471–483.
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Bresee S, Caruso BA, Sales J, Lupele J, Freeman MC, 2016. ‘A child is also a teacher’: exploring the potential for children as change agents in the context of a school-based WASH intervention in rural eastern Zambia. Health Educ Res 31: 521–534.
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Pilot of an Elementary School Cough Etiquette Intervention: Acceptability, Feasibility, and Potential for Sustainability
Farhana Sultana
Farhana Sultana
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Fosiul A. Nizame
Fosiul A. Nizame
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Dorothy L. Southern
Dorothy L. Southern
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Leanne Unicomb
Leanne Unicomb
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Peter J. Winch
Peter J. Winch
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
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Stephen P. Luby
Stephen P. Luby
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
Stanford University, Stanford, California
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Stanford University, Stanford, California
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Schools convene many people together for a prolonged time, facilitating spread of respiratory pathogens and amplifying epidemics. Crowded Bangladeshi schools lack the infrastructure to support optimal cough etiquette behaviors. We collected formative data on current practices from four elementary schools, and developed and piloted a low-cost cough etiquette intervention, promoting coughing and sneezing into upper sleeves at four additional schools. We trained teachers to lead behavior change sessions during regular hygiene classes for 4 weeks. We evaluated intervention acceptability, feasibility, and potential for sustainability at 1 month and at 14 months after the intervention commenced. At baseline, among 63 observed students, 58 (92%) coughed/sneezed into open air, five (8%) covered coughs/sneezes with their hands, which were not subsequently washed with soap and water as they judged this infeasible. After 4 weeks, among 70 observed students, 27 (39%) coughed/sneezed into upper sleeves, 33 (47%) into open air, and 10 (12%) covered with hands. After 14 months, among 230 observed students, 13 (6%) used upper sleeves, 154 (67%) coughed/sneezed into open air, and 59 (26%) covered with hands. Students reported that coughing/sneezing into upper sleeves was simple and protected them and their classmates from germs. This school-based intervention was acceptable and feasible, and resulted in short-term reductions in coughing/sneezing into open air, but these habits of comparatively new behavior were not sustained as teachers ceased behavior change session delivery. Strategies to support longer-term adoption of habits should be considered.
- Supplemental Materials (PDF 35 KB)
Author Notes
Financial support: This study was supported by the United States Agency for International Development (USAID).
Authors’ addresses: Farhana Sultana, Fosiul A. Nizame, Dorothy L. Southern, and Leanne Unicomb, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh, E-mails: farhana.sultana@icddrb.org, fosiul@icddrb.org, dorothysouthern2016@gmail.com, and leanne@icddrb.org. Peter J. Winch, Johns Hopkins, Bloomberg School of Public Health, Baltimore, MA, E-mail: pwinch@jhu.edu. Stephen P. Luby, Stanford University, Stanford, CA, E-mail:sluby@stanford.edu.
- INTRODUCTION
- METHODS AND MATERIALS
- Study setting and participants.
- Step 1: formative study.
- Structured observations.
- Baseline student survey.
- Qualitative interviews.
- Step 2: intervention development.
- Development of behavior change communication materials.
- Step 3: piloting the intervention.
- Structured observations.
- Pocket voting.
- Step 4: 14-month follow-up assessment.
- Research design and analysis.
- Ethics.
- RESULTS
- DISCUSSION
- Supplementary Material
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Stebbins S, Downs JS, Vukotich CJ Jr, 2009. Using nonpharmaceutical interventions to prevent influenza transmission in elementary school children: parent and teacher perspectives. J Public Health Manag Pract 15: 112–117.
-
2.
Neuzil KM, Hohlbein C, Zhu Y, 2002. Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families. Arch Pediatr Adolesc Med 156: 986–991.
-
3.
Xue Y, Kristiansen I, de Blasio B, 2012. Dynamic modelling of costs and health consequences of school closure during an inflienza pandemic. BMC Public Health 12: 962 (1–17).
-
4.
World Health Organization, 2009. Water, Sanitation and Hygiene Standards for Schools in Low-Cost Settings. Adams J, Bartram J, Chartier Y, Sims J, eds. Geneva, Switzerland: WHO Press.
-
5.
Haque F et al. 2016. Influenza B virus outbreak at a religious residential school for boys in northern Bangladesh, 2011. Influenza Other Respi Viruses 11: 165–169.
-
6.
Sharma R, Joshi P, Tiwari K, Katyal R, Gill KS, 2005. Outbreak of dengue in national capital territory of Delhi, India during 2003. J Vector Ecol 30: 337–338.
-
7.
Gurav YK, Pawar SD, Chadha MS, Potdar VA, Deshpande AS, Koratkar SS, Hosmani AH, Mishra AC, 2010. Pandemic influenza A (H1N1) 2009 outbreak in a residential school at Panchgani, Maharashtra, India. Indian J Med Res 132: 67–71.
-
8.
Singh KP, Jain P, Prakash O, Khan DN, Gupta S, Prakash S, Singh DD, Jain A, 2014. Outbreaks of measles and chickenpox in eastern Uttar Pradesh, India. Clin Epidemiol Glob Health 2: 3–9.
-
9.
Dumre SP, Sapkota K, Adhikari N, Acharya D, Karki M, Bista S, Basanyat SR, Joshi SK, 2009. Asymptomatic throat carriage rate and antimicrobial resistance pattern of Streptococcus pyogenes in Nepalese school children. Kathmandu Univ Med J 7: 392–396 (KUMJ).
-
10.
Lessler J, Reich NG, Cummings DA, 2009. Outbreak of 2009 pandemic influenza A (H1N1) at a New York city school. N Engl J Med 361: 2628–2636.
-
11.
Centers for Disease Control Prevention, 2009. Performance of rapid influenza diagnostic tests during two school outbreaks of 2009 pandemic influenza A (H1N1) virus infection-Connecticut, 2009. MMWR Morb Mortal Wkly Rep 58: 1029–1032.
-
12.
Zhao H, Joseph C, Phin N, 2007. Outbreaks of influenza and influenza-like illness in schools in England and Wales, 2005/06. Euro Surveill 12: E3–E4.
-
13.
Jackson C, Vynnycky E, Hawker J, Olowokure B, Mangtani P, 2013. School closures and influenza: systematic review of epidemiological studies. BMJ Open 3: e002149.
-
14.
Salathé M, Kazandjieva M, Lee JW, Levis P, Feldman MW, Jones JH, 2010. A high-resolution human contact network for infectious disease transmission. Proc Natl Acad Sci USA 107: 22020–22025.
-
15.
Cauchemez S, Bhattarai A, Marchbanks TL, Fagan RP, Ostroff S, Ferguson NM, Swerdlow D, Sodha SV, Moll ME, Angulo FJ, 2011. Role of social networks in shaping disease transmission during a community outbreak of 2009 H1N1 pandemic influenza. Proc Natl Acad Sci USA 108: 2825–2830.
-
16.
Barry T, Manning S, Lee MS, Eggleton R, Hampton S, Kaur J, Baker MG, Wilson N, 2011. Respiratory hygiene practices by the public during the 2009 influenza pandemic: an observational study. Influenza Other Respi Viruses 5: 317–320.
-
17.
Nasreen S, Azziz‐Baumgartner E, Gurley E, Winch P, Unicomb L, Sharker M, Southern D, Luby S, 2010. Prevalent high‐risk respiratory hygiene practices in urban and rural Bangladesh. Trop Med Int Health 15: 762–771.
-
18.
Berry TD, Fournier AK, 2014. Examining university students’ sneezing and coughing etiquette. Am J Infect Control 42: 1317–1318.
-
19.
Centers for Disease Control and Prevention, 2013. Respiratory Hygiene/Cough Etiquette in Healthcare Settings. Available at: http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. Accessed October 13, 2013.
-
20.
Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, Rheingans R, 2012. Assessing the impact of a school‐based water treatment, hygiene and sanitation programme on pupil absence in Nyanza province, Kenya: a cluster‐randomized trial. Trop Med Int Health 17: 380–391.
-
21.
Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA, 2008. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev, Cd004265.
-
22.
Lopez-Quintero C, Freeman P, Neumark Y, 2009. Hand washing among school children in Bogotá, Colombia. Am J Public Health 99: 94–101.
-
23.
Waddington H, Snilstveit B, White H, Fewtrell L, 2009. Water, Sanitation and Hygiene Interventions to Combat Childhood Diarrhoea in Developing Countries. Delhi, India: International Initiative for Impact Evaluation.
-
24.
Rabie T, Curtis V, 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258–267.
-
25.
Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, Luby S, 2007. A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. Am J Trop Med Hyg 76: 1166–1173.
-
26.
Master D, Hess Longe SH, Dickson H, 1997. Scheduled hand washing in an elementary school population. Fam Med 29: 336–339.
-
27.
Nicholson JA, Naeeni M, Hoptroff M, Matheson JR, Roberts AJ, Taylor D, Sidibe M, Weir AJ, Damle SG, Wright RL, 2014. An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Trop Med Int Health 19: 284–292.
-
28.
Talaat M, Afifi S, Dueger E, El-Ashry N, Marfin A, Kandeel A, Mohareb E, El-Sayed N, 2011. Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt. Emerg Infect Dis 17: 619–625.
-
29.
World Health Organization, 2008. World Health Statistics 2008. Geneva, Switzerland: World Health Organization Press, 1–110.
-
30.
Nizame FA, Nasreen S, Unicomb L, Southern D, Gurley ES, Arman S, Kadir MA, Azziz-Baumgartner E, Luby SP, Winch PJ, 2011. Understanding community perceptions, social norms and current practice related to respiratory infection in Bangladesh during 2009: a qualitative formative study. BMC Public Health 11: 901.
-
31.
Tellier R, 2006. Review of aerosol transmission of influenza A virus. Emerg Infect Dis 12: 1657–1662.
-
32.
Blanton E, Ombeki S, Oluoch GO, Mwaki A, Wannemuehler K, Quick R, 2010. Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households—Nyanza province, western Kenya, 2007. Am J Trop Med Hyg 82: 664–671.
-
33.
Onyango-Ouma W, Aagaard-Hansen J, Jensen B, 2005. The potential of schoolchildren as health change agents in rural western Kenya. Soc Sci Med 61: 1711–1722.
-
34.
O’reilly C, Freeman M, Ravani M, Migele J, Mwaki A, Ayalo M, Ombeki S, Hoekstra R, Quick R, 2008. The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza province, western Kenya, 2006. Epidemiol Infect 136: 80–91.
-
35.
Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC public health 13: 1015.
-
36.
Seimetz E, Boyayo A-M, Mosler H-J, 2016. The influence of contextual and psychosocial factors on handwashing. Am J Trop Med Hyg 94: 1407–1417.
-
37.
Hulland KR, Leontsini E, Dreibelbis R, Unicomb L, Afroz A, Dutta NC, Nizame FA, Luby SP, Ram PK, Winch PJ, 2013. Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC Public Health 13: 877.
-
38.
Najnin N, Arman S, Abedin J, Unicomb L, Levine DI, Mahmud M, Leder K, Yeasmin F, Luoto JE, Albert J, 2015. Explaining low rates of sustained use of siphon water filter: evidence from follow‐up of a randomised controlled trial in Bangladesh. Trop Med Int Health 20: 471–483.
-
39.
Bresee S, Caruso BA, Sales J, Lupele J, Freeman MC, 2016. ‘A child is also a teacher’: exploring the potential for children as change agents in the context of a school-based WASH intervention in rural eastern Zambia. Health Educ Res 31: 521–534.
-
40.
Cialdini RB, Reno RR, Kallgren CA, 1990. A focus theory of normative conduct: recycling the concept of norms to reduce littering in public places. J Pers Soc Psychol 58: 1015–1026.
-
41.
Biran A, Rabie T, Schmidt W, Juvekar S, Hirve S, Curtis V, 2008. Comparing the performance of indicators of hand-washing practices in rural Indian households. Trop Med Int Health 13: 278–285.
-
42.
Cairncross S, Shordt K, Zacharia S, Govindan BK, 2005. What causes sustainable changes in hygiene behaviour? A cross-sectional study from Kerala, India. Soc Sci Med 61: 2212–2220.
-
43.
Damerell P, Howe C, Milner-Gulland EJ, 2013. Child-orientated environmental education influences adult knowledge and household behaviour. Environ Res Lett 8: 015016.
-
44.
Jenkins RL, 1979. The influence of children in family decision-making: parents’ perceptions. Adv Consum Res 6: 413–418.
-
45.
Han SS, Weiss B, 2005. Sustainability of teacher implementation of school-based mental health programs. J Abnorm Child Psychol 33: 665–679.
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