Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries

IntroductionDomestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs.MethodsOur model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021–2030, and estimated total cost probabilistically using Monte Carlo simulation.ResultsAn estimated US$12.2–US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for ‘top-up’ promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%).ConclusionThe annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Costs of hand hygiene for all in household settings - estimating the price tag for the 46 least developed countries

Introduction: Domestic hand hygiene could prevent over 500,000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. Methods: Our model combines quantities of households with no handwashing facility (HWF) and prices of promotion campaigns, HWFs, soap, and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation. Results: An estimated US$ 12.2 - 15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is $334 million (24% of annual total), with a further $233 million for "top-up" promotion (17%). Together, these promotion costs represent $0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is $174 million (13%). The annual cost of soap is $497 million (36%), and water $127 million (9%). Conclusion: The annual cost of behaviour change promotion to those with no handwashing facility represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behaviour change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh

Background Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels. Methods The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline. Results For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (− 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, − 25% (− 35, − 15) Q2: − 34% (− 44, − 23%)] than the wealthiest household [Q5 DID: − 1% (− 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1–4 DID: 50–54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). Conclusion By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. Trial registration WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’.

Role of Structural Change in Economic Growth: An Empirical Evidence from a Panel of Asian Countries

Economic growth, although being a major quest of all the economies, is not an automatic phenomenon. Among its determinants, structural change in the form of reallocation of labour from low to high productivity sectors is of crucial importance. In view of the remarkable growth performance and unprecedented structural change of Asia in the last couple of decades, this paper empirically investigated the case of 20 selected Asian countries. By employing the data spanning from 1991 to 2018, the study shows three main results. First, by employing Shift Share Analysis framework, it reaffirms the findings of previous literature that structural change contributes to the aggregate productivity growth. Second, by utilizing Generalized Methods of Moments technique, the results find it to be an important booster of growth. Third, the results are reliable and consistent with alternative measures of structural change like Norm of Absolute Values and Modified Lilien Index. Taken together, these findings suggest that the governments in Asia (other regions like Africa and Latin America may alike) must chalk out policies for structural change promotion.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: Findings from a randomized controlled trial in rural Bangladesh

Background: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.Methods: The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.Results: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (-4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, -25% (-35, -15) Q2: -34% (-44, -23%)] than the wealthiest household [Q5 DID: -1% (-11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). Conclusion: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. Trial registration: WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’URL: https://clinicaltrials.gov/ct2/show/NCT01590095

Achieving Equitable Uptake of Handwashing and Sanitation by Addressing Both Supply and Demand-based Constraints: Findings From a Randomized Controlled Trial in Rural Bangladesh

Background: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.Methods: The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.Results: For hand cleanliness, the poorest mothers improved more (Q1 difference in difference, DID: 16%) than the wealthiest mothers (Q5 DID: 7%). The poorest households had largest improvements for observed presence of water and soap in handwashing station (Q1 DID: 82%) compared to the wealthiest households (Q5 DID: 39%). Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor (Q1DID, -25% Q2: -34%) than the wealthiest household (Q5 DID: -1%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement (Q1-4 DID: 50-54%) than the wealthier mothers (Q5 DID: 39%). Conclusion: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. Trial registration: WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’URL: https://clinicaltrials.gov/ct2/show/NCT01590095

“Sometimes I don’t have a pulse, and I’m still alive!” Healthcare providers on digital health techs

Background Digital health technologies (DHTs) are increasingly becoming an integral part of our lives, healthcare field included. The WHO recently has even released the first digital health guidelines for worldwide intervention. Commercially available DHTs (e.g. smartphones, smartwatches, apps) may hold significant potential in healthcare, upon successful and constructive integration. Literature on the topic is split between enthusiasm for the potential benefits, and concerns about reliability and effectiveness. Little is known about what healthcare professionals (HCPs) have experienced so far with patients and what they believe the main issues for implementation may be. This study aims to investigate current perceptions of HCPs towards self-tracked health-related outputs from devices and apps available to the public. Methods Nine HCPs volunteered to take part in semi-structured interviews. Data were thematically analysed adopting a pre-constructed framework (deductive approach) based on current (April 2019) literature and the findings from the first two interviews. Results The following main themes were identified and explored in detail: HCPs' experience, perceived knowledge and views on DHTs; advantages and disadvantages; barriers towards healthcare implementation and solutions; future perspectives. While most participants were adopters of DHTs and held positive views about them, their overall experience with patients and the technology was limited. Potential reasons for this included factors such as time/resources availability; colleagues' mindset; lack of evidence of effectiveness for practice; privacy/data security concerns. Conclusions The potential advantages of DHTs' adoption in healthcare are substantial - e.g. patient autonomy, time/resources saving, health and behaviour change promotion. However, future research is warranted focussing on addressing barriers, minimising disadvantages, and assessing the clinical value of commercially available DHTs. Key messages We explored healthcare providers’ views on the role of commercial digital health techs in clinical practice. Despite some privacy and reliability concerns, commercial digital health techs show promise.

HEADS UP: Design and Methods of a Louisiana State-Funded Surgical and Non-Surgical Weight Loss Program

This paper describes the methodology, design and procedures used in the HEADS UP Project, an observational study to examine the feasibility of a state-funded weight loss program. HEADS UP offered two weight loss approaches: bariatric surgery or a non-surgical intervention composed of medical management, a low-calorie liquid diet and lifestyle change promotion. Participants were recruited through a multi-stage screening process, in-person interviews, and an initial low-calorie diet program. Eligible participants were entered into a lottery system, with 100 participants selected for the surgical group and 200 selected for the non-surgical group annually for five years. Anthropometric, clinical, and psychosocial assessments were completed at baseline and follow-ups. More than 6800 individuals completed the initial web screening. Screening procedures yielded 1412 participants (490 surgical and 922 non-surgical). Approximately 84% of the total participant population were female and 38% were Black. Participants had an average body mass index of 47.9 and 43 kg/m2 in the surgical and non-surgical groups, respectively. Recruitment and enrollment results of the HEADS UP study demonstrated significant interest in both the surgical and non-surgical treatment programs for obesity. These results support the feasibility of providing a state-funded weight loss program within a healthcare setting.