Pavani Kalluri Ram

University at Buffalo, State University of New York | SUNY Buffalo · Department of Social and Preventive Medicine

In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, instal...

Observational data suggest maternal handwashing with soap prevents neonatal mortality. We tested the impact of a chlorhexidine-based waterless hand cleansing promotion on the behavior of mothers and other household members. In rural Bangladesh in 2014, we randomized consenting pregnant women to chlorhexidine provision and hand cleansing promotion o...

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated ef...

Acute respiratory infections (ARIs) cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (...

Abstract Background Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situ...

Combined water, sanitation, and handwashing (WSH) interventions have the potential to reduce fecal pathogens along more transmission pathways than single interventions alone. We measured Escherichia coli levels in 3909 drinking water samples, 2691 child hand rinses, and 2422 toy ball rinses collected from households enrolled in a two-year cluster-r...

Handwashing instructions vary in complexity, with some recommending multiple steps. To assess whether complex handwashing instructions changed handwashing procedure replication, we conducted a randomized non-inferiority trial in a low-income area, Dhaka. We randomly assigned mothers and children aged 5-10 years to one of three handwashing instructi...

To explore the consistency in impact evaluation based on reported diarrhea, we compared diarrhea data collected through two different surveys and with observed diarrhea-associated hospitalization for children aged ≤ 5 years from a non-blinded cluster-randomized trial conducted over 2 years in urban Dhaka. We have previously reported that the interv...

Objective The behavioural effect of large‐scale handwashing promotion programmes has been infrequently evaluated, and variation in the effect over time has not been described. We assess the effect of a large‐scale handwashing promotion programme on handwashing outcomes in a community setting in Dhaka, Bangladesh. Methods We analysed data from a cl...

Background: Handwashing prevalence in schools in Kenya is low due to lack of access to water and soap and lack of drive for handwashing. Soapy water made from detergent powder is an inexpensive alternative to bar soap and disgust and social norms change can be powerful drivers of handwashing, but their effectiveness has not been assessed in school...

Background Indoor air pollution, including fine particulate matter (PM2.5) and carbon monoxide (CO), is a major risk factor for pneumonia and other respiratory diseases. Biomass-burning cookstoves are major contributors to PM2.5 and CO concentrations. However, high concentrations of PM2.5 (> 1000 μg/m³) have been observed in homes in Dhaka, Banglad...

We assessed the impact of handwashing promotion on reported respiratory illness as a secondary outcome from among > 60,000 low-income households enrolled in a cluster-randomized trial conducted in Bangladesh. Ninety geographic clusters were randomly allocated into three groups: cholera-vaccine-only; vaccine-plus-behavior-change (handwashing promoti...

Table S1: Effect of the intervention on infant and young child feeding practices comparing the combined nutrition arm (N+WSH) to the nutrition‐only arm

Table S2: Effect of the intervention on infant and young child feeding practices in multivariable adjusted models

Water, sanitation and hygiene interventions have varying effectiveness in reducing fecal contamination in the domestic environment; delivering them in combination could yield synergies. We conducted environmental assessments within a randomized controlled trial in Bangladesh that implemented single and combined water treatment, sanitation, handwash...

Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590...

Available measures of handwashing are prone to bias. We tested the feasibility and reliability of weighing soap at repeated visits and subtracting the measured weight from the prior weight to assess daily per capita soap consumption in a low-income community in Dhaka, Bangladesh. Fieldworkers approached 220 households twice weekly over 2 months. Th...

Inappropriate complementary feeding contributes to linear growth faltering in early childhood. Behaviour change interventions have been effective at improving practice, but few studies have investigated the effects of multicomponent integrated interventions. We conducted a cluster‐randomized controlled trial in rural Bangladesh in which geographic...

We analyzed data from a cluster-randomized controlled trial conducted among 20 schools in Rajshahi, Bangladesh, to explore the role of social influence on handwashing with soap (HWWS) in a primary school setting. Using data collected through covert video cameras outside of school latrines, we used robust Poisson regression analysis to assess the im...

Background: Uptake matters for evaluating the health impact of water, sanitation and hygiene (WASH) interventions. Many large-scale WASH interventions have been plagued by low uptake. For the WASH Benefits Bangladesh efficacy trial, high uptake was a prerequisite. We assessed the degree of technology and behavioral uptake among participants in the...

Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and s...

Background: To design a maternal handwashing intervention for the newborn period, this qualitative study explored drivers of handwashing among mothers and other caregivers of neonates and infants in two rural areas of Bangladesh. Methods: We conducted 40 semi-structured observation sessions to observe handwashing behaviors of primiparous and mul...

Background: Poor nutrition and exposure to faecal contamination are associated with diarrhoea and growth faltering, both of which have long-term consequences for child health. We aimed to assess whether water, sanitation, handwashing, and nutrition interventions reduced diarrhoea or growth faltering. Methods: The WASH Benefits cluster-randomised...

Background: Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering. Methods: The WASH Benefits Bangladesh cluster-randomised trial enr...

Background: Information on the impact of hygiene interventions on severe outcomes is limited. As a pre-specified secondary outcome of a cluster-randomized controlled trial among >400 000 low-income residents in Dhaka, Bangladesh, we examined the impact of cholera vaccination plus a behaviour change intervention on diarrhoea-associated hospitalizat...

In 2009, a common set of questions addressing handwashing behavior was introduced into nationally representative Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), providing large amounts of comparable data from numerous countries worldwide. The objective of this analysis is to describe global handwashing patterns u...

Fine particulate matter (PM2.5) is a risk factor for pneumonia; ventilation may be protective. We tested behavioral and structural ventilation interventions on indoor PM2.5 in Dhaka, Bangladesh. We recruited 59 good ventilation (window or door in ≥ 3 walls) and 29 poor ventilation (no window, one door) homes. We monitored baseline indoor and outdoo...

One-quarter of neonatal deaths are attributed to infections. Maternal handwashing with soap may prevent neonatal sepsis. We examined impact of intensive handwashing promotion on handwashing behavior of mothers of neonates. In Matlab, Bangladesh, we randomly allocated pregnant women at 28–32 weeks’ gestation to intensive handwashing promotion or con...

We conducted a nonrandomized trial of strategies to promote soapy water for handwashing in rural Bangladesh and measured uptake. We enrolled households with children < 3 years for three progressively intensive study arms: promotion of soapy water (N = 120), soapy water promotion plus handwashing stations (N = 103), and soapy water promotion, statio...

Promoting multiple behavioral interventions together risks limiting sustained adoption of the individual behaviors. WASH Benefits, a large scale efficacy trial, randomly allocated 720 clusters of 5551 pregnant women to a control group, single interventions (water [W], sanitation [S], handwashing [H], nutrition [N]), or combined interventions (WSH a...

Objective: Promoting handwashing with soap to mothers of young children can significantly reduce diarrhea and pneumonia morbidity among children, but studies that measured long term behavior after interventions rarely found improvements in handwashing habits. Expecting mothers may experience emotional and social changes that create a unique enviro...

This study explored the steps of food preparation, related handwashing opportunities, current practices, and community perceptions regarding foods at high-risk of contamination such as mashed foods and salads. In three rural Bangladeshi villages, we collected qualitative and observational data. Food preparation was a complex and multistep process....

Bangladesh's maternal mortality and neonatal mortality remain unacceptably high. We assessed the availability and quality of emergency obstetric care (EmOC) and emergency newborn care (EmNC) services at health facilities in Bangladesh. We randomly sampled 50 rural villages and 50 urban neighborhoods throughout Bangladesh and interviewed the directo...

Inadequate hygiene and sanitation remain leading global contributors to morbidity and mortality in children and adults. One strategy for improving sanitation access is community-led total sanitation (CLTS), in which participants are guided into self-realization of the importance of sanitation through activities called "triggering." This qualitative...

Behavior change communication for improving handwashing with soap can be labor and resource intensive, yet quality results are difficult to achieve. Nudges are environmental cues engaging unconscious decision-making processes to prompt behavior change. In this proof-of-concept study, we developed an inexpensive set of nudges to encourage handwashin...

Background: Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provi...

Influenza-like illness (ILI) is an important public health concern in Bangladesh. Individuals with ILI are likely to transmit their illness to close contacts, including household members. Household-level risk factors for secondary ILI in a low-income, vulnerable population have not been characterized. We conducted secondary data analysis from parti...

With this paper, we aim to describe handwashing worldwide, as measured in Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS) in low- and middle-income countries between 1985 and 2008, and to explain the strengths, weaknesses and evolution of this data collection to inform future survey development. We searched report...

Diarrhea and acute respiratory infections account for nearly 30% of deaths among children displaced by humanitarian emergencies. Handwashing with soap reduces the risk of diarrhea and acute respiratory infection in non-emergency settings. However, the practice and the effectiveness of handwashing promotion efforts and the health benefits are not we...

Rationale: There is little evidence for the efficacy of handwashing for prevention of influenza transmission in resource-poor settings. We tested the impact of intensive handwashing promotion on household transmission of influenza-like illness and influenza in rural Bangladesh. Methods: In 2009-10, we identified index case-patients with influenz...

Objectives To identify household-level factors associated with influenza among young children in a crowded community in Dhaka, Bangladesh.Methods We conducted a case-control study using existing active surveillance for respiratory illness. Cases were children aged 12-59 months with laboratory-confirmed influenza. Controls were children frequency-ma...

We conducted a randomized, non-inferiority field trial in urban Dhaka, Bangladesh among mothers to compare microbial efficacy of soapy water (30 g powdered detergent in 1.5 L water) with bar soap and water alone. Fieldworkers collected hand rinse samples before and after the following washing regimens: scrubbing with soapy water for 15 and 30 secon...

In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods. Student hand cleaning behavior was monitored with video surve...

To inform interventions to reduce the high burden of pneumonia in urban settings such as Kamalapur, Bangladesh, we evaluated household air quality risk factors for radiographically confirmed pneumonia in children. In 2009-2010, we recruited children < 5 years of age with pneumonia and controls from a population-based surveillance for respiratory an...

The timing of a child's first acute lower respiratory infection (ALRI) is important, because the younger a child is when he or she experiences ALRI, the greater the risk of death. Indoor exposure to particulate matter less than or equal to 2.5 µm in diameter (PM2.5) has been associated with increased frequency of ALRI, but little is known about how...

Objective To evaluate household faecal contamination using children's toys among 100 rural Bangladeshi households categorised as ‘cleaner’ (toilet that reliably separates faeces from the environment and no human faeces in/around living space) or ‘less clean’ (no toilet or toilet that does not reliably separate faeces from the environment and human...

We tested whether soap presence in the home or a designated handwashing station was associated with diarrhoea and respiratory illness in Kenya. In April 2009, we observed presence of a handwashing station and soap in households participating in a longitudinal health surveillance system in rural Kenya. Diarrhoea and acute respiratory illness (ARI) i...

Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which...

In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations -- a dedicated, convenient location where both soap and water are available for handwa...

Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly com...

Exposure to particulate matter (PM2.5 ) from the burning of biomass is associated with increased risk of respiratory disease. In Dhaka, Bangladesh, households that do not burn biomass often still experience high concentrations of PM2.5 but the sources remain unexplained. We characterized the diurnal variation in the concentrations of PM2.5 in 257 h...

Structured observation is frequently used to measure handwashing at critical events, such as after fecal contact and before eating, but it is time-consuming. We aimed to assess the impact of reducing the duration of structured observation on the number and type of critical events observed. The study recruited 100 randomly selected households, 50 fo...

Handwashing is difficult in settings with limited resources and water access. In primary schools within urban Kibera, Kenya, we investigated the impact of providing waterless hand sanitizer on student hand hygiene behavior. Two schools received a waterless hand sanitizer intervention, two schools received a handwashing with soap intervention, and t...

Approximately half of all children under two years of age in Bangladesh suffer from an acute lower respiratory infection (ALRI) each year. Exposure to indoor biomass smoke has been consistently associated with an increased risk of ALRI in young children. Our aim was to estimate the effect of indoor exposure to particulate matter (PM2.5 ) on the inc...

Many community-based studies of acute child illness rely on cases reported by caregivers. In prior investigations, researchers noted a reporting bias when longer illness recall periods were used. The use of recall periods longer than 2–3 days has been discouraged to minimize this reporting bias. In the present study, we sought to determine the opti...