Wolf-Peter Schmidt

London School of Hygiene and Tropical Medicine | LSHTM

There is currently no single, easy-to-use, reliable indicator to assess whether a face has been washed with soap in the context of trachoma elimination. This study aimed to compare survey report, script-based pictorial recall and facial cleanliness indicators as alternatives to structured observation for measuring face washing behaviour. This metho...

In sanitation policies, "improved sanitation" is often broadly described as a goal with little rationale for the minimum standard required. We conducted a secondary analysis of data collected as part of a cluster randomized controlled trial in rural Ethiopia. We compared the performance of well-constructed and poorly constructed pit latrines in red...

Diarrhea and respiratory illness are leading causes of mortality and morbidity among young children. We assessed the impact of a homestead food production intervention on diarrhea and acute respiratory infection (ARI) in children in Bangladesh, secondary outcomes of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-rando...

Background Menstrual health (MH) is a recognised global public health challenge. Poor MH may lead to absence from school and work, and adverse health outcomes. However, reviews suggest a lack of rigorous evidence for the effectiveness of MH interventions on health and education outcomes. The objective of this paper is to describe the methods used i...

Scrub typhus is a common bacterial infection in Asia caused by Orientia tsutsugamushi. This serological cohort study estimated the incidence of infection in a rural population in South India. Participants were enrolled through systematic sampling in 46 villages at baseline, and revisited the following year. Blood samples were tested for IgG antibod...

Objective To estimate the effect of improving waste collection services on waste disposal behaviour and exposure to environmental risk factors in urban, low‐income communities in Pakistan. Methods We enrolled six low‐income communities in Islamabad (Pakistan), four of which received an intervention consisting of a door‐to‐door low‐cost waste colle...

Poor knowledge and management of menstruation impacts girls’ school attendance and academic performance. This paper aims to explore how menstrual hygiene management practices and related factors influence school absenteeism and drop-out among primary and secondary school girls in rural Gambia. Mixed-method studies were conducted among students and...

Titration assays can be used to define positivity either in terms of a change over time, i.e. seroconversion, or relative to a fixed threshold. The operating characteristics of these definitions depend on the precision of the assay. We present methods for estimating the distribution of errors, at the level of a single replicate, from the distributi...

Objective The clinical and serological characteristics of spotted fever group rickettsial (SFGR) infections in South Asia are poorly understood. We studied the clinical presentation and the IgM/IgG response in cases enrolled at two health care centres in South India. Method We enrolled 77 patients. Fifty‐seven of these patients were recruited at a...

We conducted a cluster-randomized trial in 48 rural villages of Ethiopia to assess the effect of community-led total sanitation (CLTS) on the diarrhea incidence of children. Twenty-four villages were randomly assigned to the intervention group and the other 24 were assigned to the control group. A CLTS intervention was implemented from January 2016...

Background In middle-income countries, malnutrition concentrates in marginalized populations with a lack of effective preventive strategies. Objective Identify risk factors for undernutrition in a peri-urban Ecuadorian community of children aged 12 to 59 months. Methods Data from a cross-sectional survey in 2011 of children 1 to 5 years were anal...

We conducted a controlled before-and-after trial to evaluate the impact of an onsite urban sanitation intervention on the prevalence of enteric infection, soil transmitted helminth re-infection, and diarrhea among children in Maputo, Mozambique. A non-governmental organization replaced existing poor-quality latrines with pour-flush toilets with sep...

Background Scrub typhus is a dominant cause of febrile illness in many parts of Asia. Immunity is limited by the great strain diversity of Orientia tsutsugamushi. It is unclear whether previous infection protects from severe infection or enhances the risk. Methods/principal findings We studied IgG antibody levels against O. tsutsugamushi at presen...

Inadequate menstrual hygiene management (MHM) practices have been associated with adverse health outcomes. This study aimed to describe MHM practices among schoolgirls from rural Gambia and assess risk factors associated with urogenital infections and depressive symptoms. A cross-sectional study was conducted among adolescent schoolgirls in thirtee...

Background: Effective and scalable behaviour change interventions to increase use of existing toilets in low income settings are under debate. We tested the effect of a novel intervention, the ‘5 Star Toilet’ campaign, on toilet use among households owning a toilet in a rural setting in the Indian state of Gujarat. Methods: The intervention include...

We conducted a controlled before-and-after trial to evaluate the impact of an onsite urban sanitation intervention on the prevalence of enteric infection, soil transmitted helminth re-infection, and diarrhea among children in Maputo, Mozambique. A non-governmental organization replaced existing poor-quality latrines with pour-flush toilets with sep...

Handwashing with soap at critical times helps prevent diarrhoeal diseases. Changing handwashing practices through behaviour change communication remains a challenge. This study designed and tested a scalable intervention to promote handwashing with soap. A cluster-randomised, controlled trial compared our intervention against standard practice. Sub...

Scrub typhus and spotted fever group rickettsioses are thought to be common causes of febrile illness in India, whereas murine typhus is rarely tested for. This cross-sectional study explored the risk factors associated with scrub typhus, tick-borne spotted fever, and murine typhus seropositivity in three different geographical settings, urban, rur...

Objective Scrub typhus is a common cause of fever in Asia. The antibody response to infection and its effect on subsequent infection are unclear. We studied the IgM and IgG antibody response after infection, accounting for clinical severity. Method We studied 197 scrub typhus patients for up to 2 years post‐infection. Overall, 501 blood samples we...

Background The burden of scrub typhus in endemic areas is poorly understood. This study aimed at estimating the proportion of hospitalisations and outpatient visits for undifferentiated fever in the community that may be attributable to scrub typhus. Methodology and principal findings The study was a retrospective cohort with a nested case-control...

Optical densities (IgG) for controls, outpatient cases and hospital cases. (TIF)

STROBE Statement—Checklist of items that should be included in reports of observational studies. (DOCX)

Background There are many different traps available for studying fly populations. The aim of this study was to find the most suitable trap to collect synanthropic fly populations to assess the impact of increased latrine coverage in the state of Odisha, India. Methods Different baits were assessed for use in sticky pot traps (60% sucrose solution,...

Enteric pathogens can be transmitted within the household and the surrounding neighborhood. The objective of this study was to understand the effect of neighborhood-level sanitation coverage on contamination of the household environment with levels of fecal indicator bacteria in rural Bangladesh. We conducted spot-check observations of sanitation f...

Background Enteric infections are common where public health infrastructure is lacking. This study assesses risk factors for a range of enteric infections among children living in low-income, unplanned communities of urban Maputo, Mozambique. Methods & findings We conducted a cross-sectional survey in 17 neighborhoods of Maputo to assess the preva...

Description of compound selection criteria for larger MapSan trial. (DOCX)

Additional methods for multiple imputation. (DOCX)

Flow diagram of enrollment and data collection activities. (TIF)

Definitions and coding schemes for analysis variables. (DOCX)

Crude and adjusted risk ratios from the multiple imputation risk factor analyses for four measures of enteric infection: Any enteric infection, any bacterial infection, any protozoan infection, and any viral infection. Multivariable models are adjusted for child age and sex, caregiver education, household wealth, and breastfeeding practices. (DOCX)

Crude and adjusted risk ratios and 95% confidence intervals for associations of caregiver reported diarrhea and enteric infection. Multivariable models are adjusted for child age and sex, caregiver education, household wealth, and breastfeeding practices. (DOCX)

Objective Community health clubs (CHCs)—multi‐session village‐level gatherings led by trained facilitators, designed to promote healthful behaviors—have been implemented in several African and Asian countries but have never been rigorously evaluated. We aimed to evaluate the impact of CHCs on child health and nutrition outcomes. Methods We conduct...

This study compared structured observation with a 24 h pictorial recall of household activities (‘sticker diary’) to measure the prevalence of handwashing with soap (HWWS) in the community. The study was done within a cluster-randomised trial evaluating a handwashing promotion programme in Bihar, India. HWWS at key occasions in mothers and school c...

Changing hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever's school-based "School of 5" handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts....

Objectives To assess access to adequate water, sanitation and hygiene (WASH) among people with disabilities at the household and individual level. Design Cross-sectional surveys. Setting Data were included from five district-level or regional-level surveys: two in Bangladesh (Bangladesh-1, Bangladesh-2), and one each in Cameroon, Malawi and India...

Information provision, which is a common behavior-change strategy, is only effective if the information is credible. Infectious disease prevention messages that rely on the germ theory may fail to persuade people who are unfamiliar with microbes. A novel program in rural Pakistan augments conventional hygiene instruction by demonstrating with micro...

Background: The Sustainable Development Goals include commitments to end poverty, and promote education for all, gender equality, the availability of water and decent work for all. An important constraint is the fact that each day, many millions of women and children, and much less frequently men, carry their household's water home from off-plot s...

We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged...

Community-led total sanitation (CLTS) is a common method for promoting sanitation in low-income settings. This cluster-randomized trial evaluated an intervention to improve inclusion of people with disability in CLTS through training facilitators. A qualitative study examined intervention acceptability. The trial included 171 disabled people (78 co...

Background The preferred method to evaluate public health interventions delivered at the level of whole communities is the cluster randomised trial (CRT). The practical limitations of CRTs and the need for alternative methods continue to be debated. There is no consensus on how to classify study designs to evaluate interventions, and how different...

Background: Community health clubs are multi-session village-level gatherings led by trained facilitators and designed to promote healthy behaviours mainly related to water, sanitation, and hygiene. They have been implemented in several African and Asian countries but have never been evaluated rigorously. We aimed to evaluate the effect of two vers...

Background While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. Methods We conducted a...

Household survey to assess sanitation decision making: “DM—survey.docx”. (XLSX)

Discussion guide—Latrine installation and its decision making in rural households of Odisha: “DM—IDI & FGD guidance.docx”. (DOCX)

Data set—Sanitation decision making in rural households in Odisha: “DM—dataset—10-02-16.xlsx”. (XLSX)

Background: Despite efforts to eradicate it, open defecation remains widely practiced in India, especially in rural areas. Between 2013 and 2014, 50 villages in one district of Odisha, India, received a sanitation programme under the Nirmal Bharat Abhiyan (NBA - "Clean India Campaign"), the successor of India's Total Sanitation Campaign. This pape...

Introduction Monitoring of sanitation programs is often limited to sanitation access and coverage, with little emphasis on use of the facilities despite increasing evidence of widespread non-use. Objectives We assessed patterns and determinants of individual latrine use over 12 months in a low- income rural study population that had recently recei...

In this study, we report on the results of a trial of an intervention to improve five food hygiene behaviors among mothers of young children in rural Nepal. This novel intervention targeted five behaviors; cleanliness of serving utensils, handwashing with soap before feeding, proper storage of cooked food, and thorough reheating and water treatment...

Background: Effective prevention and control of diarrhoea requires caregivers to comply with a suite of proven measures, including exclusive breastfeeding, handwashing with soap, correct use of oral rehydration salts, and zinc administration. We aimed to assess the effect of a novel behaviour change intervention using emotional drivers on caregive...

A substantial proportion of the total infectious disease burden world-wide is due to person-to-person spread of pathogens within households. A questionnaire-based survey on the determinants of hand-washing with soap and cleaning of household surfaces was conducted in at least 1000 households in each of twelve countries across the world (N = 12,239)...

Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of self-reported use, the standard method, by comparing survey-based respo...

Surface and groundwater contamination with fecal pathogens is a public health concern especially in low-income settings where these sources are used untreated. We modeled observed Cryptosporidium and Giardia contamination in community ponds (n=94; 79% contaminated), deep tubewells (DTWs) (n=107; 17%), and shallow tubewells (STWs) (n=96; 19%) during...

Efforts to eradicate open defecation and improve sanitation access are unlikely to achieve health benefits unless interventions reduce microbial exposures. This study assessed human fecal contamination and pathogen exposures in rural India, and the effect of increased sanitation coverage on contamination and exposure rates. In a cross-sectional stu...

To explore associations of environmental and demographic factors with diarrhoea and nutritional status among children in Rusizi district, Rwanda. We obtained cross-sectional data from 8,847 households in May-August 2013 from a baseline survey conducted for an evaluation of an integrated health intervention. We collected data on diarrhoea, water q...

Background: The purpose of this review was to understand whether adding antimicrobial agents to hand hygiene products could increase the health benefits of handwashing with plain soap (HWWS) in low-income settings. Methods: A review of experimental studies comparing the effects of HWWS with antimicrobial soap and waterless hand sanitizer on heal...

Background As part of the Total Sanitation Campaign (1999–2012), the Indian Government promoted construction and use of tens of millions of household latrines to improve public health in rural communities, areas where tubewells are often the main source of drinking water. In this study, we aimed to identify causes of tubewell contamination with the...

It is unclear how best to go about improving child feeding practices. We studied the effect of a novel behaviour change intervention, Gerakan Rumpi Sehat (the Healthy Gossip Movement), on infant and young child feeding practices in peri-urban Indonesia. The pilot intervention was designed based on the principles of a new behaviour change theory,...

Background: Open defecation is widely practiced in India. To improve sanitation and promote better health, the Government of India (GOI) has instituted large scale sanitation programmes supporting construction of public and institutional toilets and extending financial subsidies for poor families in rural areas for building individual household la...

In some common episodic conditions, such as diarrhea, respiratory infections, or fever, episode duration can reflect disease severity. The mean episode duration in a population can be estimated if both the incidence and prevalence of the condition are known. In this article, we discuss how an estimator of the average episode duration may be obtaine...

Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigo...

Exposure to animal livestock has been linked to zoonotic transmission, especially of gastrointestinal pathogens. Exposure to animals may contribute to chronic asymptomatic intestinal infection, environmental enteropathy and child under-nutrition in low-income settings. We conducted a cohort study to explore the effect of exposure to cows on growth...

The provision of information, which is a common public health strategy, may be ineffective if recommendations are not privately optimal for message recipients. This paper evaluates the response to a hygiene information campaign in rural Pakistan. In a theoretical model, baseline hygiene and health proxy for preferences, prices, and wealth, which jo...

An intervention trial of the 'SuperAmma' village-level intervention to promote handwashing with soap (HWWS) in rural India demonstrated substantial increases in HWWS amongst the target population. We carried out a process evaluation to assess the implementation of the intervention and the evidence that it had changed the perceived benefits and soci...

A third of the 2·5 billion people worldwide without access to improved sanitation live in India, as do two-thirds of the 1·1 billion practising open defecation and a quarter of the 1·5 million who die annually from diarrhoeal diseases. We aimed to assess the effectiveness of a rural sanitation intervention, within the context of the Government of I...

The effects of interventions such as sanitation or hand hygiene on hand contamination are difficult to evaluate. We explored the ability of a simple microbiological test to: (1) detect recontamination after handwashing; (2) reflect risk factors for microbial contamination and (3) be applicable to large populations. The study was done in rural Andhr...

Water, sanitation and hygiene (WASH) have traditionally been linked to acute gastro-intestinal infections. More recently it has been hypothesized that an important pathway through which inadequate WASH access impacts on the burden of disease is via a chronic inflammatory state in the intestines named environmental enteropathy. This condition is str...