Ejemot2008 Handwashing Review

Hand washing for preventing diarrhoea (Review)
Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 1
http://www.thecochranelibrary.com
Hand washing for preventing diarrhoea (Review) 1

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . . 3
SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . . 3
METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 01. Detailed search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 02. Intervention details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Table 03. Methodological quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 04. Incidence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 05. Behavioural change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Comparison 01. Institutional-based trials: hand washing promotion vs no intervention . . . . . . . . . . . 33
Comparison 02. Community-based trials: hand washing promotion vs no intervention . . . . . . . . . . . 34
COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Analysis 01.01. Comparison 01 Institutional-based trials: hand washing promotion vs no intervention, Outcome 01 35
Incidence of diarrhoea: rate ratios . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 01.02. Comparison 01 Institutional-based trials: hand washing promotion vs no intervention, Outcome 02 36
Incidence of diarrhoea (crude rate ratios): stratified by use of blinding . . . . . . . . . . . . . .
Analysis 02.01. Comparison 02 Community-based trials: hand washing promotion vs no intervention, Outcome 01 37
Incidence of diarrhoea: rate ratios . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incidence of diarrhoea: stratified by soap provision and type of intervention . . . . . . . . . . . .
Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hand washing for preventing diarrhoea (Review) i

Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA
Status: New
This record should be cited as:

Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database of Systematic Reviews
2008, Issue 1. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub2.
This version first published online: 23 January 2008 in Issue 1, 2008.

Date of most recent substantive amendment: 05 November 2007
ABSTRACT
Background
Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in
low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or
from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of
diarrhoea-causing pathogens.
Objectives
To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.
Search strategy
In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue
2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 to May 2007),
SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the
field.
Selection criteria
Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that
compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote
hand washing.
Data collection and analysis
Two authors independently assessed trial eligibility and methodological quality. Where appropriate, incidence rate ratios (IRR) were
pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).
Main results
Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based, five were community-based, and
one was in a high-risk group (AIDS patients). Interventions promoting hand washing resulted in a 29% reduction in diarrhoea episodes
in institutions in high-income countries (IRR 0.71, 95% CI 0.60 to 0.84; 7 trials) and a 31% reduction in such episodes in communities
in low- or middle-income countries (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials).
Authors’ conclusions
Hand washing can reduce diarrhoea episodes by about 30%. This significant reduction is comparable to the effect of providing clean
water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.
PLAIN LANGUAGE SUMMARY

Strategies to encourage hand washing can reduce the incidence of diarrhoea by about one third
Diarrhoea is a serious global public health problem, particularly in low-income and middle-income countries. The World Health
Organization estimates that over three million episodes occur each year, with many people dying, especially children aged less than five
years in low- and middle-income countries. Persistent diarrhoea can also contribute to malnutrition, reduced resistance to infections,
and sometimes impaired growth and development. The organisms causing diarrhoea can be transmitted from infected faeces to people
through food and water, person-to-person contact, or direct contact. Hand washing after defecation and handling faeces, and before
preparing and eating food can reduce the risk of diarrhoea. This review looked at trials of interventions to increase the use of hand
washing in institutions in high-income countries and in communities in low- or middle-income countries, and found many of the
interventions like educational programmes, leaflets, and discussions to be effective.
BACKGROUND premises, but also to increased risk of excreta handling by mothers,

caregivers, and children themselves (Curtis 1995). In some cultures
Diarrhoea is a serious global public health problem. The World children’s faeces are regarded as innocuous and adults may not
Health Organization (WHO) estimates that over 2.2 million wash their hands after handling them (Traore 1994). However,
deaths due to diarrhoeal infections occur annually, especially evidence suggests that children’s faeces are equally hazardous and
among children less than five years of age (Bern 1992; WHO may contain even higher concentrations of pathogens than those
2002). The yearly global diarrhoeal disease burden is estimated of adults owing to their increased interactions with contaminated
at 99.2 million disability adjusted life years (DALYs) lost through materials in their surroundings (Benneh 1993; Lanata 1998).
incapacitation and premature deaths, mainly in low- and middle-
income countries (Murray 1996). It is an important cause of mal- The WHO has identified a number of strategies to control diar-
nutrition in children in resource-poor countries. The synergistic rhoea (Feachem 1983). These include improvement of water sup-
relationship between malnutrition and infection is clearly exac- ply at the household or community level (Clasen 2006) as well as
erbated in diarrhoeal episodes as children tend to eat less during hygiene promotion interventions (Curtis 1997). The latter con-
episodes and their ability to absorb nutrients is reduced (WHO stitute a range of activities aimed at encouraging individuals and
2003). Thus, each episode contributes to malnutrition, reduced communities to adopt safer practices within domestic and com-
resistance to infections, and, when prolonged, to impaired growth munity settings to prevent hygiene-related diseases that lead to
and development (Martines 1993). diarrhoea (WELL 1999); hand washing is one such intervention.
Hand washing aims to decontaminate the hands and prevent cross
Diarrhoea disease pathogens are usually transmitted through the transmission (Kaltenthaler 1991; Larson 1995; Rotter 1999). The
faeco-oral route (Curtis 2000). The modes of transmission include practice of hand washing and the factors that influence hand wash-
ingestion of food and water contaminated by faecal matter, person- ing behaviour among individuals in communities are complex
to-person contact, or direct contact with infected faeces (Black (Hoque 1995a; Hoque 1995b); for example, washing hands with
1989). Some studies estimate that over 70% of all cases of diarrhoea water only or with soap may be influenced by both knowledge of
can be attributed to contaminated food and water (Esrey 1989; best practice and availability of water and soap. Washing with soap
Motarjemi 1993; Curtis 2000). and water not only removes pathogens mechanically, but may also
Epidemiological evidence shows that the most important risk fac- chemically kill contaminating and colonizing flora making hand
tors are behaviours that encourage human contact with faecal mat- washing more effective (Han 1989; Shahid 1996; Rotter 1999).
ter, including improper disposal of faeces and lack of hand washing Washing hands with soap under running water or large quanti-
after defecation, after handling faeces (including children’s faeces), ties of water with vigorous rubbing was found to be more effec-
and before handling food (LeBaron 1990; Traore 1994; Curtis tive than several members of a household dipping their hands in
1995; Lanata 1998). In particular, hand contact with ready-to- the same bowl of water (often without soap) (Kaltenthaler 1991),
eat food (ie food consumed without further washing, cooking, or which is common practice in many resource-poor countries, espe-
processing/preparation by the consumer) represents a potentially cially before eating (Ehiri 2001). This may contribute to, rather
important mechanism by which diarrhoea-causing pathogens con- than prevent, food contamination as pathogens present on hands
taminate food and water (PHS 1999). Also important are exposure of infected household members can be transferred to those who
of food to flies and consumption of contaminated water (Motar- subsequently dip their hands in the same bowl of water (Schmitt
jemi 1993; Schmitt 1997). 1997).
In many resource-poor countries, households may lack facilities Hand washing may require infrastructural, cultural, and be-
for proper disposal of excreta, and, even where available, these may havioural changes, which take time to develop, as well as substan-
not be adapted for children’s use (Lanata 1998; Yeager 1999). This tial resources (eg trained personnel, community organization, pro-
often leads not only to indiscriminate defecation in and around the vision of water supply and soap) (Cave 1999; Yeager 1999; Luby
2001a). Given the many possible ways to reduce diarrhoeal dis- are eligible if they undertook analyses of effects of hand washing
ease, it is important to assess the effectiveness of hand washing in- on diarrhoea.
terventions compared to other interventions, such as the provision
Control
of clean water at the household or community level and improve-
No hand washing promotion.
ment of sanitation (disposal of faeces). Clasen 2006 found a 27%
protection from diarrhoea related to providing clean water. Two Types of outcome measures
recent meta-analyses of hand washing have been published. Cur- Primary
tis 2003 specifically examined the effectiveness of hand washing
with soap in community-based studies and estimated that it could • Episodes of diarrhoea in individuals in the household, commu-
reduce diarrhoea risk by up to 47%. Fewtrell 2005 examined a nity, or day-care centres (self-reports collected through home
range of water, sanitation, and hygiene interventions in low- and visits; hospital/health centre/clinic records including admissions
middle-income countries. Most of the different types of interven- for diarrhoea-related dehydration).
tions had a similar degree of impact. The effect of hygiene inter- Diarrhoea is defined as:
ventions on diarrhoea incidence was estimated by Fewtrell 2005 - Acute/primary diarrhoea: passage of three or more loose or watery
at 44%. However both reviews included nonrandomized inter- stools in a 24-hour period, a loose stool being one that would take
vention studies. Curtis 2003 included case-control and cross-sec- the shape of a container; or definitions used by authors consistent
tional studies as well as prospective interventions. Fewtrell 2005 with this standard definition.
presented evidence of publication bias in the hygiene studies. In - Persistent diarrhoea: diarrhoea lasting 14 or more days.
this Cochrane Review, we assess whether the estimate of effect ob- - Dysentery: stool with blood.
served only in randomized controlled intervention trials is of sim-
ilar magnitude to those seen in previous reviews. We also include Secondary
both institution-based and community-based studies in countries • Diarrhoea-related death among children or adults in the house-
of any income level. hold or community.
• Behavioural changes such as changes in the proportion of peo-
OBJECTIVES ple who reported or are observed washing their hands after defe-
cation, disposal of children’s faeces, or before preparing or han-
To evaluate the effects of interventions to promote hand washing dling foods.
on diarrhoeal episodes in children and adults. • Changes in knowledge, attitudes, and beliefs about hand wash-
ing.
CRITERIA FOR CONSIDERING

STUDIES FOR THIS REVIEW SEARCH METHODS FOR
IDENTIFICATION OF STUDIES
Types of studies
See: Cochrane Infectious Diseases Group methods used in
Randomized controlled trials, including cluster-randomized trials,
reviews.
where the unit of randomization is an institution (eg day-care
centre), household, or community. We attempted to identify all relevant trials regardless of language
or publication status (published, unpublished, in press, and in
Types of participants
progress).
Individuals (adults and children) in institutional settings (eg day-
care centres, patients in hospitals), communities, or households. Databases
We searched the following databases using the search terms and
Types of intervention strategy described in Table 01: Cochrane Infectious Diseases
Intervention Group Specialized Register (May 2007); Cochrane Central
Activities that promote hand washing after defaecation or after dis- Register of Controlled Trials (CENTRAL), published in The
posal of children’s faeces and before preparing or handling foods; Cochrane Library (2007, Issue 2); MEDLINE (1966 to May
for example, small group discussions and larger meetings, mul- 2007); EMBASE (1974 to May 2007); and LILACS (1982
timedia communication campaigns with posters, radio/TV cam- to May 2007). We also searched the following databases
paigns, leaflets, comic books, songs, slide shows, use of T-shirts using diarrhea, diarrhoea, and handwashing as search terms:
and badges, pictorial stories, dramas, and games. Trials that focus PsycINFO (1967 to May 2007); Science Citation Index
exclusively on hand washing and those that promote hand washing and Social Sciences Citation Index (1981 to May 2007);
as part of a broader package of hygiene promotion interventions ERIC (Educational Resources Information Center; 1966 to
May 2007); SPECTR (The Campbell Collaboration’s Social, Data extraction strategy
Psychological, Educational, and Criminological Trials Register; Two authors (Ejemot and Critchley) independently extracted data
2000 to May 2007); Bibliomap and RoRe (Register of Review of on methods, types of participants, interventions, and outcomes
Effectiveness in Health Promotion) maintained by the Evidence from the selected trials using a standard form. Disagreements
for Policy and Practice Information and Co-ordinating Centre were resolved by discussion and consensus among authors in
(www.eppi.ioe.ac.uk) (1990 to May 2007); and The Grey consultation with a Cochrane Infectious Diseases Group Editor.
Literature (www.nyam.org/library/grey.shtml; 2002 to May We requested unpublished data and additional information from
2007). published trials from relevant contact individuals, groups, and
organizations.
Researchers and organizations contacted
To obtain information on published, unpublished, and ongoing We extracted data on each study site, including any measures of the
studies, we contacted relevant experts and international availability of water, soap, and literacy level of the communities.
organizations: World Bank (October 2006); Public-Private Where data were available, we extracted the socioeconomic status
Partnership for Handwashing (October 2006); WHO (October of study participants since resources for effective hand washing (eg
2006); UNICEF (October 2006); ICDDR,B (October running water and soap) may be more accessible to higher income
2006); IRC International Water & Sanitation Centre, The households. We carefully summarized details of the intervention
Netherlands (October 2006); and Child & Adolescent Health including: type of promotional activity; whether soap and water
and Development, WHO (October 2006). provision was part of the intervention; method of hand washing
Reference lists promoted (washing in a bowl or under running water); and
We also examined reference lists of articles for relevant studies. procedure of hand washing. For the cluster-randomized trials, we
extracted information on the number of clusters, average size of
clusters, unit of randomization, and whether the trials adjusted for
METHODS OF THE REVIEW clustering.
Trial selection We used the incidence rate ratio to summarize count (rate)
Two authors (Ejemot and Critchley) independently screened titles outcomes, and the weighted mean difference for continuous
and abstracts of relevant articles to assess their eligibility for outcomes. If we had analysed dichotomous outcomes we would
inclusion in the review. Hard copies of trials that were potentially have used relative risk as the summary statistic. We extracted
relevant to the review were retrieved for further assessment. point estimates of the cluster-adjusted summary statistics and
Decision on inclusion was reached by consensus among all 95% confidence intervals (CI) from each trial that provided
authors. We scrutinized each trial report to ensure that multiple cluster-adjusted data and noted the method used to adjust for
publications from the same trial were included only once. We listed clustering (see ’Data synthesis’ and ’Description of studies’ for
the excluded studies and the reasons for their exclusion. further details).
Assessment of methodological quality Data synthesis
Two authors (Ejemot and Critchley) independently assessed the We analysed the data using Review Manager 4.2. All results were
methodological quality of eligible studies using standard criteria. presented with 95% CI. For count outcomes, we pooled incidence
We assessed the methods to generate a randomized sequence rate ratios (IRR) in Review Manager 4.2 using the generic inverse
and conceal the sequence as adequate, inadequate, or unclear variance method with the random-effects model. We stratified
(Juni 2001). Double blinding is not possible in studies of hand the meta-analyses for cluster-adjusted measures versus non-cluster-
washing interventions since there is no obvious placebo. However, adjusted measures. When the outcomes and methods of measuring
outcome assessors could be blinded, and we assessed whether outcomes were too variable to make meta-analysis meaningful (for
or not this had occurred. It is very difficult to assess losses to changes in hand washing behaviour) we tabulated the results.
follow up in open cluster-randomized trials. Some children may
leave the study, but others are born or enter the study during We identified three categories of studies − institution-based
the follow-up period; hence participant numbers are in constant interventions (day-care centres or primary schools), community-
flux. Inclusion of all randomized participants in the analysis is based interventions, and intervention in people at high risk of
thus most clearly represented as the person-time at risk accrued diarrhoea (people with acquired immune deficiency syndrome
as a percentage of maximum possible person-time at risk in each (AIDS)). All but one of the institution-based interventions
study arm. We therefore reported on this measure and also on any were conducted in industrialized countries, and all community-
loss to follow up of both clusters and participants, and assessed based interventions were conducted in low- and middle-income
this as adequate if at least 90%. Also, as most of the studies countries. Only one trial in a high-risk group was identified, from
were cluster-randomized trials, we assessed whether the authors the USA. Given the differences between interventions in these
correctly adjusted for clustering in their analysis. settings, we analysed and presented the results separately.
Most trials reported either the incidence rate ratio and 95% CI, or heterogeneity. We used the random-effects model to pool data
the number of episodes of diarrhoea and the person-time at risk, if we detected heterogeneity and it was still considered clinically
but few reported the proportion of the population experiencing meaningful to combine the trials. We were unable to explore
at least one attack of diarrhoea. For this reason we changed our potential sources of heterogeneity in depth because of the limited
primary outcome from the relative risk of at least one diarrhoea number of trials in each setting. We explored and attempted
episode (specified in the protocol) to the incidence rate ratio for to explain heterogeneity where possible using pre-defined study
diarrhoea episodes. One study among AIDS patients in the USA characteristics (provision of hand washing material (soap) as part
reported information only on the mean number of diarrhoea of intervention, and type of promotional activity employed) and
episodes and standard deviation (Huang 2007). We therefore quality characteristics (whether outcome assessors were blind and
presented results from this trial as a continuous outcome. whether trials had adjusted for clustering and other confounders).
Adjustment for clustering

All the trials (except for Huang 2007) used a cluster design to
DESCRIPTION OF STUDIES
recruit participants. Only one trial author reported estimates of
the intra-cluster correlation coefficient (ICC) (Luby 2006). We
wrote to the trial authors for additional information, but only one Trial selection
replied and supplied additional data (Luby 2006). Our search yielded 37 potentially relevant studies: 14 met the
inclusion criteria and are described in the ’Characteristics of in-
Trials with a cluster design require more complex analysis than cluded studies’; one was in Danish (Ladegaard 1999), and the rest
trials that randomize individuals. Observations on participants were written in English. Eight trials were institution-based, five
in the same cluster tend to be correlated; therefore the intra- were community-based, and one was in a high-risk group. The
cluster variation must be accounted for during the analysis of the reasons for excluding 23 studies are in the ’Characteristics of ex-
trial. If this correlation is ignored in the analysis and the same cluded studies’.
techniques are employed as for individually randomized trials
the resulting measure of effect remains a valid estimate, but the Institution-based trials (8 trials)
associated variance of the estimate will be underestimated leading All eight trials in this group were randomized by cluster using
to unduly narrow CIs. For meta-analysis this means that trials primary schools (Bowen 2007), day-care centres (Black 1981;
analysed without allowing for this design effect will receive too Bartlett 1988; Butz 1990; Carabin 1999; Ladegaard 1999; Roberts
much weight. 2000), or classrooms in day-care centres (Kotch 1994) as the
unit of randomization. These trials were all conducted in high-
We extracted point estimates of the cluster-adjusted rate ratios and income countries except for Bowen 2007, which took place in
95% confidence intervals from each trial that provided cluster- Fujian province in China. The others were carried out in Aus-
adjusted data and noted the method used to adjust for clustering tralia (Roberts 2000), Europe (Ladegaard 1999), and North Amer-
(see ’Description of studies’). For trials that did not report on or ica (Black 1981; Bartlett 1988; Butz 1990; Kotch 1994; Carabin
were unclear on the method used to adjust for clustering, we either 1999), where resources and materials for hand washing are rela-
extracted information on the rate ratio and unadjusted 95% or, tively available and accessible.
wherever possible, estimated the unadjusted rate ratios and 95%
CI from the total number of diarrhoea episodes and person-time at Interventions
risk in each arm of the trial. Where data on person-time at risk were Multiple hygiene interventions were used in all trials except in
not directly provided by the authors, we estimated this as accurately Black 1981 and Bowen 2007, which used only a hand washing
as possible from the follow-up duration multiplied by the total intervention. The interventions are described in more detail in
Table 02.
number of children as the denominator for both intervention and
control groups respectively. All but one of the institution-based trials had intervention and
control arms (monitoring only). Bowen 2007 had three arms, for
Changes in hand washing behaviour
the standard intervention, expanded intervention (which included
Since the outcomes and methods of measuring behaviour changes
the standard intervention and peer-monitoring of hand-washing),
were too variable to make meta-analysis meaningful, we tabulated
and control. It is important to note that the control group in most
the results.
cases received quite frequent monitoring (estimating diarrhoea ill-
Heterogeneity and sensitivity analyses ness episodes on typically a fortnightly basis). This monitoring
We anticipated that the trials would be heterogeneous and may itself have influenced hand washing behaviour. The Carabin
therefore checked for heterogeneity by visually inspecting the 1999 trial attempted to tease out the effects of the intervention
forest plots, applying the chi-squared test with a P value of 0.10 alone from ’monitoring’. The ’monitoring’ effect in this trial was
indicating statistical significance, and also implementing the I2 test estimated as the difference in diarrhoea incidence rates within each
statistic with a value of 50% used to denote moderate levels of arm over one year of the trial (autumn 1997 to autumn 1996). The
crude effectiveness of intervention was estimated as the difference in Africa (Haggerty 1994) and Asia (Stanton 1987; Han 1989;
between the monitoring effect in the intervention group. Luby 2004a; Luby 2006).
Participants Three trials evaluated hand washing only interventions (Han

About 7711 participants were included. Participants were mainly 1989; Luby 2004a; Luby 2006). Luby 2004a had two hand wash-
day-care providers or educators, and young children. Five of the ing arms, one with plain soap and one with antibacterial soap.
trials involved children aged less than three years, one was in chil- These two arms had similar results and are combined in this re-
dren under six years (Ladegaard 1999), and one was with children view. Han 1989 used plain soap. Luby 2006 was a five-arm trial
aged less than seven years (Butz 1990). Bowen 2007 involved chil- that investigated water quality interventions, hand washing, and a
dren in the first grade at school in China. combination of the two; only the arm with antibacterial soap and
hand washing education is considered in this review.
The number of clusters ranged from four (Black 1981) to 87
(Bowen 2007). Primary outcome measures were assessed across The other two trials, Haggerty 1994 and Stanton 1987, used mul-
161 day-care centres and 87 schools. Participants were exposed tiple hygiene interventions that included hand washing with soap
to large group training sessions that employed multiple promo- (the type of soap used is not described). The interventions are de-
tional techniques (eg audio and video tapes, pamphlets, practi- scribed in more detail in Table 02.
cal demonstrations, drama, posters, games, peer monitoring). The Participants
aim was to provide education about personal hygiene, diarrhoea About 8055 participants were included. Participants were mainly
transmission, treatment, and prevention, and the importance of mothers or caregivers as well as children. In the community-based
and techniques for hand washing. Intervention and control groups trials, only one, Haggerty 1994, was with very young children (< 3
were generally comparable in important characteristics at baseline years); two others were with children aged less than five years (Han
(Table 02). 1989) or less than six years (Stanton 1987); and two involved older
Outcome measures children up to 15 years of age (Luby 2004a; Luby 2006). Changes
Episodes of diarrhoea were measured by all included trials, but in knowledge, attitude, and practice on hygiene were assessed in
none of the trials reported diarrhoea-related deaths (one of our sec- the mothers, while the primary outcome measures were assessed
ondary outcome measures). Two trials reported changes in knowl- in the children.
edge, attitude, and practice about hand washing (Kotch 1994; The number of clusters varied from 18 (Haggerty 1994) to 1923
Roberts 2000). No trial reported the proportion of people wash- (Stanton 1987). The participants were provided with hand wash-
ing their hands. Follow-up periods ranged from four months to ing materials and were involved in large-group hygiene education
12 months. training. The intervention and control groups were socioeconom-
ically comparable at baseline.
Four trials did not appear to have accounted for clustering in the Outcome measures
analysis for any outcome measure (Black 1981; Bartlett 1988; Butz Diarrhoea episodes were measured by all included trials; some
1990; Ladegaard 1999). Kotch 1994 adjusted for clustering by also assessed different types of diarrhoea. Han 1989 measured
comparing the mean incidence rate of intervention and non-in- dysentery rates, and Luby 2004a and Luby 2006 also assessed
tervention classrooms, but only a cluster adjusted 95% CI for a the rate of persistent diarrhoea. None of the trials reported on
difference outcome (excess mean episodes) and not a rate ratio was diarrhoea-related deaths or the proportion of people washing their
presented. We took the cluster-adjusted estimate of the numerator hands. Only one of the trials reported on changes in hand washing
(the mean incidence rate across the clusters) from the published behaviour (Stanton 1987). Length of follow up ranged from four
data and estimated the person-time at risk crudely by multiply- months to 12 months.
ing the number of bi-weekly contacts by the number of children
and assuming this was equally distributed between the interven-
All trials adjusted for clustering in some way, except for Han 1989.
tion and control groups. In the three other cluster-adjusted trials,
Luby 2004a and Stanton 1987 adjusted for clustering by estimat-
Bowen 2007 presented only the school level analysis (mean illness
ing rates at the group level; Luby 2006 adjusted for clustering by
and absence rates by school); Carabin 1999 adjusted for clustering
calculating an intra-class correlation coefficient based on an anal-
using a Bayesian hierarchical model, and Roberts 2000 estimated
ysis of variance level and design effect. Haggerty 1994 performed
robust standard errors in a Poisson regression model.
child and site level analyses; the 95% CIs were not provided for the
Community-based trials (5 trials) site-level analysis. We therefore estimated the denominator from
We included five cluster-randomized controlled trials that used the number of children by trial arm by assuming that all those who
entire communities (generally villages or neighbourhoods, except had remained in the trial for at least nine weeks had a total of 12
Han 1989, which used households) as units of randomization. weeks of follow up. The numerator (average number of episodes
These trials were conducted in low- and middle-income countries per child) was provided at the cluster level.
Trial in a high-risk group Four trials reported baseline similarity of diarrhoea morbidity and
We identified only one trial that individually randomized 148 socioeconomic characteristics (including population/household
adults with AIDS from one human immunodeficiency virus (HIV) size, socioeconomic status, hand washing and sanitary facilities,
clinic in the USA to receive intensive hand washing promotion and sources of water supply) between the intervention and con-
delivered by specialist nurses (Huang 2007). The intervention trol groups (Stanton 1987; Han 1989; Luby 2004a; Luby 2006).
included hygiene education, hand washing demonstrations by There were some differences at baseline in Haggerty 1994 (con-
nurses and participants, and weekly telephone calls to reinforce trols had diarrhoea episodes of longer duration than the interven-
hand washing messages. The major outcomes reported were mean tion group). All the trials reported collecting data at the same pe-
episodes of diarrhoea in each group and number of hand washing riod for intervention and control groups, and they all accounted
episodes per day. for clustering in the analysis, except for Han 1989.
Trial in a high-risk group

Huang 2007 did not clearly report the method of randomization
METHODOLOGICAL QUALITY or allocation concealment and did not use blinding. All 148 ran-
domized participants were followed for the trial’s one-year dura-
See Table 03 for a summary of the methodological quality assessment tion. Participants were similar at the start of the trial in terms of
for all trials. age, sex, ethnicity, hand washing episodes per day, CD4 count,
HIV load, and prophylaxis for opportunistic infections. The re-
Institution-based trials (8 trials) sults were presented as a continuous outcome only (mean and
Three of the eight trials used an adequate method to generate the standard deviation of number of diarrhoea episodes in each arm
allocation sequence (Carabin 1999; Roberts 2000; Bowen 2007); over the year). This should be viewed with caution as it is likely
the method was unclear in the others. The method used to conceal that the distribution of diarrhoea episodes may be highly skewed
allocation was unclear in all trials. Three trials reported blinding (the mean of 1.24 and standard deviation of 0.9 episodes in the
of the outcome assessors (Bartlett 1988, Kotch 1994, and Roberts intervention arm imply a non-normal distribution of diarrhoea
2000); the rest were open trials. It was difficult to assess the num- episodes). If so, the mean may not be the most appropriate mea-
ber of randomized participants included in the analysis as this sure of the ’average number’ of episodes per participant.
was reported at different levels (cluster, child, person time-at-risk).
However, all trials were able to account for the number of ran-
domized clusters included in the analysis.
RESULTS
Five trials reported adequate comparability between the interven-
tion and control groups with respect to diarrhoea incidence and so- The incidence rates of diarrhoea for each trial are reported in Table
ciodemographic characteristics (including mean total enrolment, 04.
percentage of drop outs, sex, age, and race composition of chil-
1. Institution-based trials (8 trials)
dren enrolled, diapering, and toilet facilities) at baseline (Black
1981; Bartlett 1988; Butz 1990; Ladegaard 1999; Bowen 2007). 1.1. Incidence of diarrhoea
Investigators in Bowen 2007 were forced to over or under-sample The incidence of diarrhoea was assessed in 7711 children aged
certain regions to obtain more ’control’ schools, after the origi- less than seven years in 161 day-care centres and 87 schools in
nal control schools were sent intervention packs by mistake and the eight trials. We separated the trials into those with crude rate
thus excluded. This trial reported small differences in household ratios (Black 1981; Bartlett 1988; Butz 1990; Kotch 1994; Lade-
sanitation and piped water at baseline, but no differences between gaard 1999) and those that adjusted for clustering and confounders
schools in number of students, class size, or hygiene infrastructure. (Carabin 1999; Roberts 2000; Bowen 2007). Both groups had
Comparability at baseline was unclear in the other trials. All trials similar risk reductions, and, overall, there was a 29% reduction in
reported collecting data at the same point in time for both the the incidence of diarrhoea in the intervention group (IRR 0.71,
intervention and control groups. 95% CI 0.60 to 0.84; 7 trials, Analysis 01.01).
Community-based trials (5 trials) All trials showed a benefit from the intervention, except for Bowen
Luby 2004a, Luby 2006, and Stanton 1987 reported adequate 2007, which showed no difference between each arm and for which
methods for generating allocation sequence. Only Luby 2004a it was not possible to calculate a rate ratio (the median episodes
reported adequate allocation concealment; it was unclear in the of diarrhoea were 0 per 100 student-weeks in the control group,
other trials. All were open trials, except for Haggerty 1994, which standard intervention group, and expanded intervention). Roberts
reported blinding of the outcome assessor. Inclusion of all ran- 2000 showed greater risk reduction than other trials, possibly due
domized participants in the analysis was unclear as it was reported to a more specific method of hand washing (an approximate “count
at different levels of analysis (cluster, household, child). to 10” to wash and “count to 10” to rinse).
All participants were monitored, at least fortnightly, to collect data Overall, the intervention reduced the incidence of diarrhoea by
on diarrhoea episodes. This monitoring itself may have helped to 31% (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials, Analysis 02.01).
improve compliance with hand washing. Only Carabin 1999 at-
Three trials assessed the effect of intervention on the incidence
tempted to investigate this effect by assessing rates in both groups
rate of different categories of diarrhoea (Han 1989; Luby 2004a;
compared to the pre-intervention period. They found that mon-
Luby 2006), and although they reported reductions in the risk of
itoring alone appeared to reduce the incidence of diarrhoea (IRR
diarrhoea with the interventions (Han 1989 reported on dysen-
0.73, 95% CI 0.54 to 0.97; Table 04), and that the intervention
tery, and Luby 2004a and Luby 2006 reported on persistent di-
effect did not appear to have any benefits over and above this
arrhoea), none of the results were statistically significant (Table
monitoring effect when adjusted for age and gender (IRR 0.77,
04). Some trials reported the results by participant age (Stanton
95% CI 0.51 to 1.18; Table 04) or adjusted for age, gender, sea-
1987; Han 1989; Luby 2004a; Luby 2006), with no discernible
son, and baseline incidence rate in each cluster (IRR 1.10, 95%
trend of which age group intervention had greater diarrhoeal re-
CI 0.81 to 1.50; Table 04). However, monitoring was particularly
ductions (Table 04). Han 1989 and Stanton 1987 reported greater
frequent (daily) in this trial. In the Bowen 2007 trial among first
diarrhoeal reduction for children aged less than two years, while
grade students in schools in China, monitoring may have been
Luby 2004a and Luby 2006 reported greater reductions for older
less intensive as in-class monitoring was carried out on only one
children.
day a week by teachers; reasons for absenteeism were noted when
recorded. As the trial was school-based, no illness information was All community-based trials, except Han 1989, provided cluster-
collected during weekends or school holidays. This design reduced adjusted rate ratios and 95% CIs. However, both the cluster-ad-
the burden of data collection of teachers, but it may also have re- justed result (IRR 0.68, 95% CI 0.52 to 0.90) and Han 1989
duced the ability of the trial to detect differences in the incidence (IRR 0.70, 95% CI 0.54 to 0.92) showed similar risk reduction;
of diarrhoea between each arm of the trial. refer to Analysis 02.02.
No trial reports clearly stated whether allocation was concealed, Only Haggerty 1994 used blinding (of outcome assessors), and
and we were therefore unable to assess whether this aspect of the benefit of hand washing seemed to be less in this trial than in
trial quality may be influencing results. Only blinding of the out- the others (IRR 0.94, 95% CI 0.85 to 1.05; Table 04).
come assessors was possible in the trials, and, amongst those trials
Three trials both provided soap and promoted hand washing only
with adjusted rate ratios, the one trial in which the assessors were
(Han 1989; Luby 2004a; Luby 2006); the reduction in the risk
blinded, Roberts 2000, appeared to show greater effect than the
of diarrhoea was greater in these trials (IRR 0.57, 95% CI 0.44
one in which they were not, Carabin 1999 (Analysis 01.01.02).
to 0.75) than in the two trials that did not provide soap and
However, a sensitivity analysis among the studies estimating crude
promoted multiple hygiene interventions (IRR 0.84, 95% CI 0.67
rate ratios showed that the three unblinded trials −Black 1981,
to 1.05) (Analysis 02.02). With only a small number of trials, these
Butz 1990, and Ladegaard 1999− appeared to find a greater ben-
differences may be due to chance or, even if real, it is impossible
efit from the intervention (IRR 0.65, 95% CI 0.53 to 0.80) than
to discern which components (providing soap, or focusing on one
the two trials that used blinding (IRR 0.86, 95% CI 0.76 to 0.97)
message only) may be most effective.
(Analysis 01.02). However, two of the open trials randomized a
small number of clusters; Black 1981 used two clusters per arm 2.2. Behavioural changes
and Ladegaard 1999 used eight clusters, and this may have influ- Stanton 1987 reported that the intervention group exhibited a
enced the intervention method applied. Black 1981 also focused greater increase in hygiene practices (IRR 1.48, 95% CI 1.01 to
exclusively on hand washing, while the other trials promoted mul- 2.21), though this increase is of borderline statistical significance
tiple hygiene interventions. (P = 0.056) (Table 05).
1.2. Behavioural changes 3. Trial in a high-risk group
Two trials reported behavioural changes (Kotch 1994; Roberts
3.1. Episodes of diarrhoea
2000). As described in Table 05, Kotch 1994 reported that hand
In Huang 2007, the intensive hand washing intervention reduced
washing behaviour based on ’event sampling scores’ improved in
the mean number of episodes of diarrhoea over the one-year pe-
the intervention classrooms compared with control classrooms.
riod of study (2.92 in control group; 1.24 in intervention group;
Roberts 2000 reported that the intervention improved compliance
a reduction of 1.68 episodes, 95% CI -1.93 to -1.43; Analysis
with infection control procedures in three day-care centres. This
02.03).
was associated with a lower illness incidence in children greater
than or equal to two years (RR 0.34, 95% CI 0.17 to 0.65), 3.2. Behavioural changes
reflecting a two-third reduction in diarrhoeal episodes. At the beginning of the trial there was no difference in daily hand
washing frequency between intervention and control groups (3.4
2. Community-based trials(5 trials)
± 1.1 in control group; 3.3 ± 0.98 in intervention group), but at
2.1. Incidence of diarrhoea the end of the trial, the intervention group reported hand washing
seven times a day compared with four times daily in the control interventions based on any such models would be more or less
group (P < 0.05). effective. Hygiene education may have a ’herd effect’ in cluster-
randomized trials (hand washing by some community members
will benefit others indirectly by reducing the number of pathogens
DISCUSSION in the local environment) and may have other benefits beyond
reductions in diarrhoea such as saving mother’s time (looking after
The included trials demonstrated distinct benefits from the pro- sick children). Generally, the included trials did not assess such
motion of hand washing for reducing the incidence of diarrhoea outcome measures, and nor did this review.
in different settings. However, the methodological quality of the Many trials promoted a whole range of hygiene interventions in
included trials limits a clear interpretation of the evidence pre- addition to hand washing. There did not appear to be any greater
sented. Of the 14 trials, only six reported using an adequate risk reduction for those promoting several hygiene interventions
method to generate the allocation sequence (Stanton 1987; Cara- compared with those promoting hand washing only, though this
bin 1999; Roberts 2000; Luby 2004a; Luby 2006; Bowen 2007). is difficult to assess with only a limited number of trials. The
The method was unclear in the other trials, and, thus, selection bias contribution of the different hygiene education components in
may have been introduced. Only one trial, Luby 2004a, clearly re- achieving the benefits is also unclear.
ported adequately concealed allocation; this is difficult to achieve
in trials of this nature since cross-contamination is recognized as It is possible that bias was introduced by the intensive monitor-
a problem (Hayes 2000). Blinding can also be difficult to achieve ing of outcomes in both intervention and control groups in these
in these trials, and only four trials attempted blinding of outcome trials. Carabin 1999 attempted to explore this by assessing the ef-
assessors (Bartlett 1988; Haggerty 1994; Kotch 1994; Roberts fects of the intervention itself from that of monitoring. The ef-
2000). The inclusion of all randomized participants in the anal- fect of monitoring on diarrhoeal episodes was significant, but the
ysis was reported at different levels of analysis (eg cluster, child, intervention itself had no statistically significant effect. Monitor-
household, person-time at risk), which made it difficult to assess. ing of hand washing may therefore be more important than other
Also, people tended to enter and leave naturally over the course facets of the intervention on compliance and effectiveness. This is
of a study since most trials were conducted in communities and known as the Hawthorne effect (Feachem 1983) whereby the mere
institutions, and not closed populations. However, all the institu- fact of being under observation leads to improvement in a trial
tional-based trials reported adequate inclusion of all the random- outcome (in this case, increased frequency of hand washing and
ized clusters, while in most of the community-based trials this was reduction of diarrhoea). Carabin 1999 used particularly frequent
not explicitly reported. monitoring (daily); less frequent monitoring may have reduced
the importance of this effect.
One trial reported differences at baseline between the intervention
and control groups (Haggerty 1994), while three trials did not Provision of hand washing materials by the investigators may in-
report on this clearly (Kotch 1994; Carabin 1999; Roberts 2000). crease hand washing effectiveness (although there were too few
This might be a problem if there were few clusters. All the included trials to make strong conclusions) as these trials showed slightly
trials reported collecting data over the same period in both trial greater risk reductions in diarrhoea episodes than ones that did
arms. not.
Although this review shows that hand washing can be effective,
There was wide variation in the benefits of hand washing promo-
most of the trials should be regarded as ’efficacy’ trials in the sense
tion on the incidence of diarrhoea reported by individual trials.
that they include intense follow up and monitoring (all contacted
This heterogeneity is not surprising as the trials differed greatly
intervention communities at least fortnightly, some more often to
in terms of setting, population, and hand washing intervention.
ascertain diarrhoea episodes and reinforce the hygiene promotion
However, the pooled estimates from the included trials show a
messages); many also provided hand washing materials and replen-
29% risk reduction for the institution-based trials and 31% for the
ished supplies regularly. One large-scale trial from Burkina Faso
community-based trials. There was also an important reduction
that is not included in this review suggested that changes in hand
in mean episodes (1.68 fewer episodes in the intervention group)
washing behaviour could be maintained in the longer term (three
in a high-risk population (AIDS patients), but this is based on one
years) in a large community (a city of approximately 300,000 resi-
trial with 148 participants and requires confirmation. In most tri-
dents) (Curtis 2001) and may be cost-effective (Borghi 2002), but
als, the interventions were based on hygiene promotion (providing
this trial did not assess trends in hospitalization for diarrhoea and
education about diarrhoea transmission and treatment, and hand
requires replicating in other communities. Bowen 2007, included
washing behaviours).
in this review, was larger and had less intensive monitoring (car-
Most trials did not appear to have used any explicit ’behavioural ried out by teachers), but it was not able to detect any difference
change’ model, though two trials applied ’participatory learning between either of the intervention and control groups in terms
processes’ (Bartlett 1988; Ladegaard 1999). It is not clear whether of diarrhoea episodes (there was a median of 0 episodes per 100
student-weeks in all groups). However, Bowen 2007 did find a sta- AUTHORS’ CONCLUSIONS
tistically significant reduction in overall illness (mostly accounted
for by differences in rates of upper respiratory tract infections) of Implications for practice
35% and 71% in the standard and expanded intervention groups
respectively, and reductions in absenteeism of 44% and 42% re- Hand washing interventions are efficacious in reducing diarrhoeal
spectively, compared with controls. This highlights the difficulties episodes by about 30% and should be promoted. The challenge
in the design of effectiveness studies with more limited monitor- is to find effective ways of getting people to wash their hands
ing but with sufficient power and sensitivity to detect differences appropriately.
in diarrhoea episodes. Most trials in this review were relatively Implications for research
small with short-term follow up, and it is unclear if their level of
This review shows that hand washing can be efficacious, but in
effectiveness would be maintained if they were scaled up to larger
communities in low-income and middle-income countries there
regions with less intensive monitoring over a longer time period.
is a need for large-scale trials with less intensive monitoring and
long-term follow up. Although some monitoring is inevitable to
All institution- and community-based trials in this review were completely ascertain diarrhoea episodes, this should be reduced
conducted in children aged less than 15 years, and mostly in chil- to a minimum and should be supported by community-level out-
dren aged less than seven years. Therefore results cannot be gener- come measures for severe diarrhoea (hospitalizations or consul-
alized to all ages. In future studies, comparison of effects in young tations with a doctor for diarrhoea). Data collectors should be
(less than three years) and older children may inform decisions of blinded to the outcome measure where possible. There is also a
whom to target and optimal message delivery mode suitable for
need for investigators to collect data on the effects of the inter-
the two settings (institutions in high-income settings; communi- vention on types of diarrhoea (acute, persistent, and dysentery) as
ties in low- and middle-income countries). Older children are able risk of diarrhoeal mortality is different for each type.
to make their own decisions about hand washing, while toddlers
will always be dependent on adults to help them.
POTENTIAL CONFLICT OF
The approximate 30% reduction in diarrhoea morbidity observed INTEREST
in our review suggests less benefit than was reported by previous
reviews of hand washing and hygiene interventions (Curtis 2003; None known.
Fewtrell 2004; Fewtrell 2005), which estimated reductions of 47%
and 44% respectively. However it is higher than the estimated 27%
diarrhoea reduction of providing clean water (Clasen 2006). In ACKNOWLEDGEMENTS
this review, we included only randomized controlled trials where
specific hand washing interventions were tested with or without We thank all the authors that assisted us with information on their
additional hygiene promotion. We excluded observational, case- trials. We are particularly grateful to Dr S Luby of the Centers for
control, and controlled before-and-after studies, some of which Disease Control and Prevention (CDC). We thank Karin Schiöler
were included in previous reviews. Unlike one previous review for assisting with translation of the Danish study.
(Curtis 2003), we also avoided double-counting of studies since
This document is an output from a project funded by the UK De-
this may overestimate the intervention effect, tends to breakdown
partment for International Development (DFID) for the benefit
the assumption of study independence, and narrows the 95% CIs.
of low-income and middle-income countries. The views expressed
Also, we combined incidence rate ratios for diarrhoea as a primary
are not necessarily those of DFID.
outcome and attempted to extract or estimate these from the paper
if they were not reported. Guevara 2004 supports the use of rate
ratios in meta-analyses of studies of this nature as it improves
the clinical interpretability of findings. Some trials reported odds SOURCES OF SUPPORT
ratios, but these may overestimate the risk reduction for a common
External sources of support
outcome such as diarrhoea episodes if they are combined with rate
ratios in a meta-analysis, as in one previous review (Curtis 2003). • Department for International Development (DFID) UK
Thus the stringent inclusion criteria for this Cochrane Review and Internal sources of support
the methods of analysis may be responsible for the lower magni- • University of Calabar NIGERIA
tude of effect observed than in the earlier meta-analyses. Nonethe- • Institute of Tropical Diseases Research and Prevention
less this review provides strong evidence that hand washing inter- (ITDR&P), Calabar NIGERIA
ventions reduce diarrhoeal morbidity by about 30%. • University of Alabama at Birmingham USA

• International Health Group, Liverpool School of Tropical
Medicine UK
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∗
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Indicates the major publication for the study
TABLES
Characteristics of included studies
Study Bartlett 1988

Methods Cluster-randomized trial
Method of allocation sequence: unclear
Allocation concealment: unclear
Blinding: assessor
Inclusion of participants in the analysis: unclear
Length of follow up: 12 months
Participants Number: 26 day-care centres, with 374 children
Inclusion criteria: not stated
Exclusion criteria: not stated
Age: < 3 years
Interventions Intervention*:
1. Large group meetings (directors and caregivers)
2. Provision of posters and handouts depicting the procedures taught
Control
3. Visited to review surveillance procedures, but no instruction in disease prevention or management provided
Outcomes Diarrhoea rates
Notes Location: Maricopa County, Arizona, USA
Duration: October 1981 to September 1984
Allocation concealment B – Unclear

Characteristics of included studies (Continued )
Study Black 1981
Blinding: none
Age: < 3 years
1. Large group education
Control
2. No intervention
Outcomes 1. Diarrhoea rates
Not used in this review:

2. Estimate of load of diarrhoea causative agent
Notes Location: suburban Atlanta, Georgia, USA
Duration: June 1976 to April 1977
Study Bowen 2007

Method of allocation sequence: random-number table
Blinding: none
Inclusion of all participants in the analysis: 93% (3962/4256) agreed to participate
Length of follow up: 2003-4 school year
Participants Number: 87 schools (57 intervention; 30 Control); with 3962 children (2670 intervention; 1292 control)
Inclusion criteria: public primary schools; at least 20 students in first grade year in 2003-4; no overnight
boarders; at least 1 running water tap for every 30 first grade students
Exclusion criteria: no compulsory hand washing or provision of hand-cleaning products before school lunch;
no commercial hand washing promotion programmes at school during previous 5 years
Interventions Intervention:
1. Expanded programme: as standard programme plus continuous supply of Safeguard soap for school sinks;
1 student from each class recruited to assist peers with hand washing techniques, and remind them of key
hand washing opportunities; teachers asked to encourage this student weekly but not instructed to enforce
hand washing behaviour
2. Standard programme: Proctor and Gamble’s ’Safeguard’ promotion programme delivered in Chinese
schools since 1999; teachers deliver programme to first grade children during single 40 minute classroom
session; also single 2-h training session for each first grade teacher delivered by Proctor and Gamble staff;
teacher’s pack contains guidebook outlining hand washing, basic information on infectious disease trans-
mission, 5 posters describing hand washing procedure, videotape, and 5 wall charts for classroom hygiene
competition; student take-home pack includes hygiene board game, parent booklet on hand washing, and
50 g bar Safeguard soap
Control
3. All 3 groups received government hygiene educational programme consisting of a cursory statement
manual about hand washing after using toilet and before eating
Outcomes 1 Diarrhoea rates
2. School absences
3. Rates of other common illnesses
Notes Location: 3 counties in Fujian province, South-East China
Study Butz 1990

Blinding: none
Participants Number: 24 family day-care centres, with 108 children
Exclusion criteria: unclear
Age: 1 month to 7 years
1. Large group training (in-home instruction to day-care providers)
Control
2. No intervention
Outcomes Incidence of infectious disease symptoms (diarrhoea)
Notes Location: Baltimore, Maryland, USA
Duration: 12 months
Study Carabin 1999

Allocation sequence: day-care centres were stratified by incidence of respiratory infections and block ran-
domized by geographical areas
Blinding: none
Inclusion criteria: presence of at least 1 sandbox and 1 play area; at least 12 available toddler places
Age: 18 months to 3 years
1. Large group hygiene training (educators)
2. Handouts
Control
3. No intervention
Outcomes Diarrhoea rates

Notes Location: Quebec, Canada
Duration: September 1996 to November 1997
Study Haggerty 1994

Allocation sequence: unclear
Blinding: assessor
Participants Number: 18 sites, with 1954 children
Age: 3 months to 35 months
1. Large group training
Control:
2. No intervention
Outcomes Diarrhoeal rates
Notes Location: Kikwit, Bandundu Province, Zaire (Democratic Republic of Congo)
Duration: October 1987 to December 1988
Study Han 1989

Blinding: none
Participants Number: 350 households (162 intervention and 188 control) with 494 children
Inclusion criteria: households with 1 or more children between 6 and 59 months; those in which regular
follow up was possible; not allergic to soap; gave informed consent
Age: < 5 years
1. Small group education (households)
Control:
2. No intervention
Outcomes 1. Incidence of diarrhoea
2. Incidence of dysentery
Notes Location: Nga-Kha ward of Thin-Gun-Kyun township, Rangoon, Burma (now Myanmar)
Duration: June to November 1985
Study Huang 2007

Methods Individually randomized trial
Blinding: none
Inclusion of participants in the analysis: 100%
Length of follow up: 1 year
Participants Number: 73 intervention, 75 control
Inclusion criteria: AIDS patients at local HIV clinic; HIV-1 infection verified by both ELISA and Western
Blot; AIDS by CD4 counts and plasma HIV RNA; been on HAART for at least 6 weeks and without
diarrhoea for at least 3 months
Interventions Both groups: 3 dedicated study nurses educated participants on health problem associated with contaminated
hands and provided specific hand washing instructions at enrolment; hand washing technique demonstrated
by nurses, including wetting hands, lathering completely with soap, running together for at least 15 seconds,
and drying hands with towels; all 148 participants then demonstrated adequate hand washing technique
Intervention:
1. Weekly telephone call from nurses to determine number of hand washing episodes per day, ensure com-
pliance, answer questions, re-educate participants on importance, and go over instructions
Control:
2. Weekly telephone calls but only to ascertain diarrhoea episodes
Outcomes 1. Incidence of diarrhoea
2. Handwashing behaviour
3. Microbiological diagnosis of diarrhoea episodes
Notes Location: USA (location unclear)
Duration: 1 year (exact dates unclear)
Allocation concealment D – Not used
Study Kotch 1994

Allocation concealment unclear
Blinding: assessor
Participants Number: 24 day-care centres, with 389 classrooms
Inclusion criteria: children < 3 years; present in the day care at least 20 h per week; absence of chronic
illness or medication that would predispose to infection; youngest of potentially eligible children in the same
family; consenting English-speaking parents with access a telephone; intending to remain in day-care centre
throughout study
Age: < 3 years
2. Curriculum for caregivers
Control:
3. No intervention
Notes Location: Cumberland County, North Carolina, USA
Duration: October 1988 to May 1989
Study Ladegaard 1999

Blinding: none
Participants Number: 8 day-care centres, with 475 children (212 intervention, 263 control)
Age: < 6 years
1. Small group practical demonstration
Control:
2. No intervention
Notes Location: Odense, Denmark
Duration: 6 months
Study Luby 2004a

Allocation sequence: computer-generated
Allocation concealment: serially numbered
Blinding: none
Participants Number: 36 neighbourhoods (25 intervention, 11 control), with 4691 children
Inclusion criteria: household located in the study area; have at least 2 children < 5 years; intention to reside
in the house for the duration of study
Age: < 15 years
1. Large group training using slide shows, pamphlets, and video tapes
Control:
2. No intervention
Notes Location: low-income squatter settlements, Karachi, Pakistan
Duration: April 2002 to April 2003
Allocation concealment A – Adequate
Study Luby 2006

Allocation sequence: computer generated
Blinding: none
Participants Number: 18 clusters, with 544 households (262 intervention, 282 control)
Inclusion criteria: households with at least 1 child < 5 years; provided informed consent
Age range: < 15 years
1. Large group training using slide shows, pamphlets, and video tapes
Control:
2. No receipt of products expected to change risk of diarrhoea but provided them with regular supply of
children’s books, note books, etc
Outcomes 1. Primary diarrhoea
2. Persistent diarrhoea
rates
Notes Location: multi-ethnic squatter settlements in Central Karachi, Pakistan
Duration: April 2003 to December 2003
Allocation concealment D – Not used
Study Roberts 2000

Allocation sequence: computer generated
Blinding: assessors
Inclusion criteria: day-care centres licensed in the Australian Capital Territory; children < 3 years as at January
1996; attendance for at least 3 days per week; have no underlying chronic illness that predisposes to infection
Age: < 3 years
2. Booklets/newsletters
3. Songs about hand washing for children
Control:
4. No intervention
Outcomes 1. Diarrhoeal rate
2. Knowledge, attitude, and practice of hand washing
Notes Location: Australian Capital Territory, Australia
Duration: March to November 1996
Study Stanton 1987

Allocation sequence: table of random numbers
Blinding: none
Participants Number: 1923 families (937 intervention, 986 control)
Age: < 6 years
1. Small group discussion (only women or children)
2. Larger demonstrations (mixed audience)
3. Posters, games, pictorial stories, and ’flexiflans’ for illustrations
Control:
4. No intervention
Outcomes 1. Diarrhoeal rates
2. Change in knowledge, attitude, and practice
of water sanitation behaviours
Notes Location: Urban Dhaka, Bangladesh
Duration: October 1984 to May 1985
*See Table 02 for a detailed description of the interventions; AIDS: acquired immune deficiency syndrome; HAART: highly active anti-retroviral therapy;
HIV: human immunodeficiency virus
Characteristics of excluded studies
Study Reason for exclusion

Ahmed 1993 Observational study examining risk factors for diarrhoeal infections
Alam 1989 Main intervention was provision of water supply through hand pumps
Barros 1999 Observational study examining risk factors for diarrhoeal infections
Clemens 1987 Observational study examining risk factors for diarrhoeal infections
Curtis 2001 No concurrent control
Doebbeling 1992 Outcome measure (incidence of nosocomial infection) not specific to diarrhoea episodes but to incidence of
gastrointestinal infections in general
Dyer 2000 Intervention was instant hand sanitizer
Guinan 2002 Observational study
Hammond 2000 Intervention did not involve hand washing
Khan 1982 Case-control study
Larson 2003 No relevant outcome measures (measured colony-forming units of bacteria)
Larson 2004 Outcome measure not specific to incidence of diarrhoea
Lee 1991 Controlled before-and-after study
Luby 2001 Observational study
Luby 2004b Nonrandomized study
Master 1997 Outcome measure not specific on diarrhoeal episodes
Morton 2004 Outcome measure not specific on diarrhoeal episodes
Peterson 1998 Observational study examining risk factors for diarrhoeal infections

Characteristics of excluded studies (Continued )
Pinfold 1996 No comparable baseline information on diarrhoeal episodes provided
Shahid 1996 No comparable baseline information provided
Sircar 1987 No comparable baseline information on diarrhoea episodes provided
White 2003 Outcome measure not specific to diarrhoeal morbidity
Wilson 1991 Controlled before-and-after study
Characteristics of ongoing studies
ADDITIONAL TABLES
Table 01. Detailed search strategies
Search set CIDG SRˆ CENTRAL MEDLINEˆˆ EMBASEˆˆ LILACSˆˆ

1 handwashing handwashing hand wash* hand wash$ handwashing
2 diarrhea hand washing hand disinfec* hand disinfec* diarrhea
3 diarrhoea diseases hand cleansing hand clean* hand clean$ 1 and 2
4 - hand hygiene hand hygiene hand hygiene -
5 - 1 or 2 or 3 or 4 hand sterility hand sterility -
6 - diarrhea HANDWASHING HANDWASHING -
7 - 5 and 6 1 or 2 or 3 or 4 or 5 or 6 1 or 2 or 3 or 4 or 5 or 6 -
8 - - diarrhoea diarrhoea -
9 - - diarrhoea diarrhoea -
10 - - 8 or 9 8 or 9 -
11 - - 7 and 10 7 and 10 -
ˆCochrane Infectious ˆˆSearch terms used
Diseases Group Specialized in combination with
Register the search strategy for
retrieving trials developed
by The Cochrane
Collaboration (Higgins
2006); upper case: MeSH
or EMTREE heading;
lower case: free text term

Hand washing for preventing diarrhoea (Review) Table 02. Intervention details
Promotional Hand washing Hand washing

Trial activity Classificationˆ Message content method styleˆˆ Material provision Water availability
INSTITUTION-
BASED
Bartlett 1988 1. Large group 1. Hygiene Staff and child Unclear Not specified Not specified Adequate
meetings (directors education hand washing,
and caregivers) 2. Participatory diapering, food
2. Provision learning* handling, and
of posters and environmental
handouts depicting cleaning
the procedures
taught
Black 1981 Large group Hygiene education Staff and child Water with bar Unclear By the day- Adequate
education hand washing soap and paper care centres’
before handling towels management
food and after
defecation
Bowen 2007 1. Large group 1. Hygiene 1. Hand washing Water with soap Under running Supplies of Adequate (criteria
training education before eating and water soap to schools for taking part in
2. Posters, 2. Behaviour after toileting in “Expanded trial)
videotape, wall modification Intervention”; 1 bar
charts, games of soap to homes
3. Soap in both expanded
4. Take home packs and standard
5. Peer trainers and intervention
peer-monitoring
Butz 1990 Large group 1. Hygiene 1. Modes of Water with soap Not specified All supplies Adequate
training (in-home education transmission of provided by
instruction to day- 2. Provision of pathogens in the researchers
care providers) soap/hand rinse home
material 2. Indications of
hand washing
3. Use of vinyl
gloves and
disposable diaper
changing pad
23
Hand washing for preventing diarrhoea (Review) Table 02. Intervention details (Continued )

4. Use of an
alcohol-based hand
rinse (if unable to
wash hand with
water plus soap)
Carabin 1999 1. Large group Hygiene education 1. Wash hands Unclear Not specified Unclear Adequate
hygiene training before lunch and
(educators) after using the
2. Handouts toilets
2. Clean toys with
bleach
3. Use of reminder
cues for hand
washing
4. Clean the sand
box with bleach
5. Open windows
at least 30 min
every day
Kotch 1994 1. Large group Hygiene education 1. Hand washing of Water with soap Under running Unclear Adequate
training children and staff plus disposable water
2. Curriculum for 2. Disinfection of towel
caregivers diapering areas and
toilet
3. Physical
separation of
diapering areas
from food
preparation and
serving areas
4. Hygienic diaper
disposal
Ladegaard 1999 Small group 1. Hygiene 1. Hand washing Water with soap Under running Unclear Adequate
practical education after stool contact water
24

demonstration 2. Participatory 2. Information

learning* on disease spread
and when to wash
hands to prevent
diarrhoea
Roberts 2000 1. Large group 1. Hygiene 1. Hand washing Water with soap Under running Unclear Adequate
training education before eating and water
2. Book- 2. Behaviour after toileting or
lets/newsletters modification changing a diaper
3. Songs about (staff and child)
hand washing for 2. Wash toys daily
children in dishwashers
COMMUNITY-
BASED
Haggerty 1994 Large group Hygiene education 1. Hand washing Unclear Not specified Unclear Unknown
training before meal
preparation and
eating
2. Hand washing
after defecation
(wash both hand
and buttocks for
children)
3. Proper disposal
of children’s faeces
4. Disposal of
animal faeces from
yard
Han 1989 Small group 1. Hygiene Hand washing: Water with bar Not specified Plain bar soap Unknown
education education 1. After defecation soap provided by
(households) 2. Provision of 2. Before preparing researcher
hand washing or eating food
material
25
Luby 2004a 1. Large group Hygiene education Hand washing: Water with plain or Water from a Soap provided by Unknown
training using slide 1. Before preparing antibacterial soap pitcher (though researchers
shows, pamphlets, food not clearly stated)
and video tapes; 2. Before eating
education at weekly food
field visits
2. Education at
weekly field visits
Luby 2006 1. Large group 1. Hygiene Hand washing: Water with Not specified Soap provided by Unknown
training using slide education 1. After stool antibacterial soap researchers
shows, pamphlets, 2. Provision of contact/ defecation
and video tapes hand washing 2. Before
2. Education at material food prepara-
twice-weekly visits tion/handling/eating
3. Before feeding
infants
Stanton 1987 1. Small group Hygiene education 1. Hand washing Unclear Not specified Unclear Inadequate
discussion (only before food
women or children) preparation
2. Larger 2. Defecation away
demonstrations from the house and
(mixed audience) in a proper site
3. Posters, games, 3. Suitable disposal
pictorial stories, of waste and faeces
and ’flexiflans’ for
illustrations
3. HIGH-RISK
GROUP (AIDS
PATIENTS)
Huang 2007 Demonstration by Hygiene education 1. Hand washing Water with soap Under running Unclear (probably Adequate
nurses and patients after toileting, water not relevant in this
before food prepa- population)
ration/handling,
eating
2. After cleaning
infants who had
defecated
3. Before and after
26

sex
ˆMessage ˆˆWhether done
classification under running
*Participatory water; in a bowl by
learning involves a an individual or by
process that helps several people
engage learners
in an active role
of inquiry in
which they share
experiences and
reflect critically
on practice in a
context that many
group members
find stimulating
and relatively safe
(Martin 1997)
27
Table 03. Methodological quality assessment
Time of
Trial Sequenceˆ Concealmentˆ Blinding Inclusionˆˆ Comparability* collection**
INSTITUTION-
BASED
Bartlett 1988 Unclear Unclear Assessor Unclear Adequate Adequate
Black 1981 Unclear Unclear None Unclear Adequate Adequate
Bowen 2007 Adequate Unclear None Adequate Adequate Adequate
Butz 1990 Unclear Unclear None Unclear Adequate Adequate
Carabin 1999 Adequate Unclear None Unclear Unclear Adequate
Kotch 1994 Unclear Unclear Assessor Unclear Unclear Adequate
Ladegaard 1999 Unclear Unclear None Unclear Adequate Adequate
Roberts 2000 Adequate Unclear Assessors Unclear Unclear Adequate

COMMUNITY-
BASED
Haggerty 1994 Unclear Unclear Assessor Unclear Inadequate Adequate
Han 1989 Unclear Unclear None Unclear Adequate Adequate
Luby 2004a Adequate Adequate None Unclear Adequate Adequate
Luby 2006 Adequate Unclear None Unclear Adequate Adequate
Stanton 1987 Adequate Unclear None Unclear Adequate Adequate

HIGH-RISK
GROUP (AIDS
PATIENTS)
Huang 2007 Unclear Unclear None Adequate Adequate Adequate

ˆGeneration ˆÎnclusion of *Comparability **Data collected
of allocation randomized between at similar time
sequence, participants in intervention periods for
concealment of the analysis and control intervention and
allocation was reported at groups with control sites
different levels of respect to baseline
analysis (cluster, characteristics (see
child, person-at- methods)
risk levels)
Table 04. Incidence of diarrhoea
Trial Outcome and result Method of assessment Sample size
INSTITUTION-BASED
Bartlett 1988 Diarrhoea rate per child-year of 1. Active day-care centre-based 26 day-care centres with 374
Table 04. Incidence of diarrhoea (Continued )
observation surveillance (weekly visits plus children (196 intervention,

Intervention: 0.71 (95% CI daily telephone calls to identify 178 control) aged 0 to 3 years
0.65 to 0.77) diarrhoeal illness
Control: 0.81 (95% CI 0.75 to 2. Family-based surveys
0.87) (questionnaire every 2 weeks)
Black 1981 Diarrhoea Daily record of attendance plus 4 day-care centres (2

incidence/100/child-weeks of diarrhoea occurrence for each intervention, 2 control) with
observation child by day-care personnel 116 children < 3 years
Intervention: 4.2/100/child-
week
Control: 8.1/100/child-week
Bowen 2007 Median episodes of diarrhoea Teachers trained using 3962 children within 87
per 100 student weeks standardized case definitions primary schools
“Expanded intervention” 0 per to identify 10 symptoms or
100 student-weeks signs of illness and record
Standard intervention: 0 per these among students in class,
100 student-weeks 1 day per week; if parent’s
Control: 0 per 100 student- reported infection as cause
weeks of absence, teachers recorded
name of syndrome and asked
parent if child suffered any
of 10 individual symptoms;
verified verbally that reports of
diarrhoea met case definition
Butz 1990 Proportion of diarrhoea days Daily symptom record for each 24 family day-care homes with
per month child by care providers 108 children (58 intervention,
Diarrhoea episodes/child-days 50 control) aged 1 month to 7
Intervention: 93/10,159 years
Control: 133/10,424
Carabin 1999 Diarrhoea incidence: Daily record of diarrhoea 52 day-care centres with 1729
episodes/100 child-days at risk episodes on calendar by children aged 18 months to 3
Incidence rate ratio (95% educators years
Bayesian credible interval) 1.10
(0.81 to 1.50), adjusted for age
and gender
Intervention alone: 0.77 (0.51
to 1.18)
Monitoring alone: 0.73 (0.54
to 0.97)
Kotch 1994 Diarrhoea rates: incidence Telephone interview 24 day-care centres with 389
density (episodes/child-year) methodology (biweekly calls to children < 3 years
Intervention (< 2 years): 4.54 families)
Intervention (> 2 years): 2.85 5 week interval visits to day-
Control (< 2 years): 5.12 care centres
Control (> 2 years): 2.79
All: relative risk 1.19, 95% CI
-0.48 to 1.96
Ladegaard 1999 Diarrhoea episodes/child- Information on absenteeism 8 day-care centres with 475
month recorded on a form by child- children (212 intervention,
Intervention: 33/848 care provider 263 control) aged 6 years and
Control: 61/1052 below
(34% reduction from 3.25 days
per child in favour of children
3 years or more)
Roberts 2000 Diarrhoeal rates: 1. Biweekly telephone 23 day-care centres (11
episodes/child-year interviews (parents reports of intervention, 12 control) with
Intervention: 1.9 symptoms) 558 children under 3 years
episodes/child-year 2. Observation for compliance
Control: 2.7 episodes/child- of recommended practices
year every 6 weeks
All: relative risk 0.50 (95% CI
0.36 to 0.68)
< 2 years: relative risk 0.90
(95% CI, 0.67 to 1.19)
> 2 years: relative risk 0.48
(95% CI 029 to 0.78)
(Adjusted for clustering by
centre, confounding variables
(age, sex, weight at birth,
breastfeeding status, child care
history, and home factors),
and interactions between
age and intervention status,
and between having a sibling
who attends child care and
intervention status)
COMMUNITY-BASED
Haggerty 1994 Diarrhoea rates (mean episodes 1. Observation recording form 18 sites (9 intervention, 9
of diarrhoea ) 2. Diarrhoeal morbidity form control) with 1954 children
Intervention site: 0.071 aged 3 months to 35 months
Control site: relative risk 0.075
(relative risk 0.94, 95% CI
0.85 to 1.05; P = 0.3)
Han 1989 Incidence density ratio Daily surveillance (24 h recall) 350 households (162
1. Diarrhoea for diarrhoea and dysentery intervention, 188 control) with
< 2 years: 0.69 (95% CI 0.48 494 children (236 intervention;
to 1.10) 258 control) under 5 years
> 2 years: 0.67 (95% CI 0.45
to 0.98)
All: 0.70 (95% CI 0.54 to
0.92)
2. Dysentery
< 2 years: 0.59 (95% CI 0.22

to 1.55)
> 2 years: 1.21 (95% CI 0.52
to 2.80)
All: 0.93 (95% CI 0.39 to
2.23)
Luby 2004a Incidence density of diarrhoea Weekly observational visits to 36 neighbourhoods (25
(number of new episodes of households intervention, 11 control)
diarrhoea divided by the at-risk with 4691 children (3163
person-weeks of observation) intervention, 1528 control)
Mean incidence aged < 15 years
1. Primary diarrhoea
Intervention
Antibacterial soap: 2.02
Plain soap: 1.91
Control: 4.06
2. Persistent diarrhoea
Intervention
Antibacterial soap: 0.14
Plain soap: 0.12
Control: 0.17
Luby 2006 Diarrhoea episodes/100 child- Weekly observational visits to 18 clusters (544 households;
weeks: for diarrhoea and households 262 intervention; 282 control)
persistent diarrhoea with children < 15 years
1. Risk ratio: 0.57 (95% CI
0.35 to 0.86)
2. Diarrhoea, mean incidence:
3.71
3. Persistent diarrhoea, mean
incidence: 0.09
-52% (-100% to 100%)
Stanton 1987 Rate of diarrhoea per 100 1. Biweekly histories of 1923 families (937
person-weeks diarrhoea for children of all intervention, 986 control) with
Incidence density ratio 0.75 households children aged < 6 years
(95% CI 0.66 to 0.84; P < 2. Single prolonged on-site visit
0.0001) to each sentinel family for hand
< 2 years: 0.54 (95% CI 0.43 washing-related behaviour
to 0.66) observation
> 2 years: 0.68 (95% CI 0.54
to 0.85)
HIGH-RISK GROUP (AIDS
PATIENTS)
Huang 2007 Mean episodes of diarrhoea Daily hand washing diary 75 in hand washing group, 73
over study period (1 year) to record number of hand controls
Intervention group: 1.24 (+/- washing episodes per day and
0.9) diarrhoea diary to record stool
Control group: 2.92 (+/- 0.6) frequency and characteristics;

weekly telephone calls from
study nurse to ascertain
episodes of these outcomes
CI: confidence interval
Table 05. Behavioural change
Intervention Intervention
Trial KAPˆ changes Detail (n) (N) Control (n) Control (N) P
INSTITU-
TION-BASED
Kotch 1994 Hand washing After changing - 0.75 0.37 -
behaviour, a diaper
based on event
sampling
scoresˆˆ
After contact - 0.66 0.21 -
with child’s
mucus, saliva,
vomit, etc
Roberts 2000 Compliance for 1 (4 centres) - 0.52 (0.37 to - -
hand washing 0.75)
by children in
11 intervention
centres by
a score*;
measured as
relative risk
of diarrhoeal
episodes
(relative to
control centres)
with 95%
confidence
intervals
2 (4 centres) - 0.53 (0.37 to - -
0.76)
3 (3 centres) - 0.43 (0.27 to - -
0.70)
Children >= 2 - 0.34 (0.17 to - -
years 0.65)
COMMU-
NITY-BASED
Stanton 1987 Comparison - 39 79 (39/79 = 25 75 (25/75 =
of hygienic 49%) 33%)
practices after
intervention
(relative
risk 1.48,
confidence
interval 1.01 to
2.21)
HIGH-RISK
GROUP (AIDS
PATIENTS)
Huang 2007 Frequency of At baseline and 3.3 (+/- 0.98) 3.4 (+/- 1.1) < 0.05
hand washing at the end of 7 times daily 4 times daily
per day study
ˆKAP:
knowledge,
attitude, and
practice
ˆÊvent
sampling scores
(0 = none;
0.5 = partially
correct; 1.0 = as
recommended
in the training)
*Compliance
score: 1 = lowest
compliance rate
(53% to 69%);
2 = moderate
compliance
rate (70% to
79%); 3 = high
compliance rate
(>= 80%)
ANALYSES
Comparison 01. Institutional-based trials: hand washing promotion vs no intervention
No. of No. of
Outcome title studies participants Statistical method Effect size
01 Incidence of diarrhoea: rate 7 Incidence rate ratio (Random) 95% CI 0.71 [0.60, 0.84]
ratios
02 Incidence of diarrhoea (crude Incidence rate ratio (Random) 95% CI Subtotals only
rate ratios): stratified by use of
blinding
Comparison 02. Community-based trials: hand washing promotion vs no intervention
No. of No. of
Outcome title studies participants Statistical method Effect size
01 Incidence of diarrhoea: rate 5 Incidence rate ratio (Random) 95% CI 0.69 [0.55, 0.87]
ratios
02 Incidence of diarrhoea: Incidence rate ratio (Random) 95% CI Subtotals only
stratified by soap provision and
type of intervention
03 Episodes Weighted Mean Difference (Fixed) 95% CI Totals not selected
COVER SHEET
Title Hand washing for preventing diarrhoea
Authors Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA
Contribution of author(s) Regina Ejemot extracted and analysed data, and drafted the review. John Ehiri developed
the protocol and commented on the review. Julia Critchley extracted and analysed data,
and edited the review. Martin Meremikwu helped finalize the data extraction form and
commented on the review.
Issue protocol first published 2003/2
Review first published 2008/1
Date of most recent amendment 09 November 2007
Date of most recent 05 November 2007
SUBSTANTIVE amendment
What’s New 2007, Issue 1 (deviations from protocol): We added methods for assessing blinding, changed
our primary outcome measure from the relative risk of at least one diarrhoea episode to the
incidence rate ratio for diarrhoea episodes, pooled rate ratios in our analyses rather than
relative risks since all studies presented diarrhoea as episodes, and removed “or standard
hygiene promotion” as a control because it is included in the “no hand washing promotion”
control group. Henry Ejere, a co-author on the protocol, did not participate in preparation
of the review.
Date new studies sought but Information not supplied by author
none found
Date new studies found but not Information not supplied by author
yet included/excluded
Date new studies found and Information not supplied by author

included/excluded
Date authors’ conclusions Information not supplied by author

section amended
Contact address Dr Regina Ejemot
Lecturer
Dept. of Public Health, College of Medical Sciences
University of Calabar
Calabar
NIGERIA
E-mail: reginaejemot@yahoo.com; idulove@yahoo.com
DOI 10.1002/14651858.CD004265.pub2
Cochrane Library number CD004265
Editorial group Cochrane Infectious Diseases Group
Editorial group code HM-INFECTN
GRAPHS AND OTHER TABLES
Analysis 01.01. Comparison 01 Institutional-based trials: hand washing promotion vs no intervention,

Outcome 01 Incidence of diarrhoea: rate ratios
Review: Hand washing for preventing diarrhoea
Comparison: 01 Institutional-based trials: hand washing promotion vs no intervention
Outcome: 01 Incidence of diarrhoea: rate ratios
Study log [Incidence rate ratio] Incidence rate ratio (Random) Weight Incidence rate ratio (Random)
(SE) 95% CI (%) 95% CI
01 Crude rate ratios

Bartlett 1988 -0.12 (0.12) 18.2 0.89 [ 0.71, 1.11 ]
Black 1981 -0.65 (0.21) 10.4 0.52 [ 0.34, 0.78 ]
Butz 1990 -0.33 (0.14) 15.8 0.72 [ 0.54, 0.94 ]
Kotch 1994 -0.17 (0.08) 22.3 0.84 [ 0.73, 0.98 ]
Ladegaard 1999 -0.40 (0.23) 9.3 0.67 [ 0.43, 1.05 ]
Subtotal (95% CI) 76.0 0.77 [ 0.66, 0.89 ]

Test for heterogeneity chi-square=6.68 df=4 p=0.15 I² =40.1%
Test for overall effect z=3.37 p=0.0008
02 Adjusted rate ratios

Carabin 1999 -0.26 (0.21) 10.1 0.77 [ 0.51, 1.17 ]
Roberts 2000 -0.69 (0.16) 13.8 0.50 [ 0.36, 0.69 ]
Subtotal (95% CI) 24.0 0.61 [ 0.40, 0.92 ]

Total (95% CI) 100.0 0.71 [ 0.60, 0.84 ]
0.2 0.5 1 2 5
Favours intervention Favours control

Analysis 01.02. Comparison 01 Institutional-based trials: hand washing promotion vs no intervention,
Outcome 02 Incidence of diarrhoea (crude rate ratios): stratified by use of blinding
Comparison: 01 Institutional-based trials: hand washing promotion vs no intervention
Outcome: 02 Incidence of diarrhoea (crude rate ratios): stratified by use of blinding
(SE) 95% CI (%) 95% CI
01 Blinding used
Bartlett 1988 -0.12 (0.12) 30.6 0.89 [ 0.71, 1.11 ]
Kotch 1994 -0.17 (0.08) 69.4 0.84 [ 0.73, 0.98 ]
Subtotal (95% CI) 100.0 0.86 [ 0.76, 0.97 ]

02 No blinding
Black 1981 -0.65 (0.21) 24.5 0.52 [ 0.34, 0.78 ]
Butz 1990 -0.33 (0.14) 54.9 0.72 [ 0.54, 0.94 ]
Ladegaard 1999 -0.40 (0.23) 20.6 0.67 [ 0.43, 1.05 ]
Subtotal (95% CI) 100.0 0.65 [ 0.53, 0.80 ]

0.2 0.5 1 2 5

Analysis 02.01. Comparison 02 Community-based trials: hand washing promotion vs no intervention,
Outcome 01 Incidence of diarrhoea: rate ratios
Comparison: 02 Community-based trials: hand washing promotion vs no intervention
Outcome: 01 Incidence of diarrhoea: rate ratios
(SE) 95% CI (%) 95% CI
01 Adjusted for clustering

Haggerty 1994 -0.06 (0.05) 24.5 0.94 [ 0.85, 1.04 ]
Luby 2004a -0.76 (0.13) 19.3 0.47 [ 0.36, 0.61 ]
Luby 2006 -0.56 (0.23) 13.0 0.57 [ 0.36, 0.89 ]
Stanton 1987 -0.29 (0.06) 24.1 0.75 [ 0.66, 0.85 ]
Subtotal (95% CI) 80.9 0.68 [ 0.52, 0.90 ]

Test for heterogeneity chi-square=29.00 df=3 p=<0.0001 I² =89.7%
02 Unadjusted for clustering

Han 1989 -0.35 (0.14) 19.1 0.70 [ 0.54, 0.92 ]
Subtotal (95% CI) 19.1 0.70 [ 0.54, 0.92 ]

Test for heterogeneity: not applicable
Total (95% CI) 100.0 0.69 [ 0.55, 0.87 ]
Test for heterogeneity chi-square=29.96 df=4 p=<0.0001 I² =86.7%
0.1 0.2 0.5 1 2 5 10


Outcome 02 Incidence of diarrhoea: stratified by soap provision and type of intervention
Outcome: 02 Incidence of diarrhoea: stratified by soap provision and type of intervention
(SE) 95% CI (%) 95% CI
01 Soap provided and focus on hand washing

Han 1989 -0.35 (0.14) 38.3 0.70 [ 0.54, 0.92 ]
Luby 2004a -0.76 (0.13) 38.9 0.47 [ 0.36, 0.61 ]
Luby 2006 -0.56 (0.23) 22.8 0.57 [ 0.36, 0.89 ]
Subtotal (95% CI) 100.0 0.57 [ 0.44, 0.75 ]

02 No soap provided and multiple hygiene interventions

Haggerty 1994 -0.06 (0.05) 51.1 0.94 [ 0.85, 1.04 ]
Stanton 1987 -0.29 (0.06) 48.9 0.75 [ 0.66, 0.85 ]
Subtotal (95% CI) 100.0 0.84 [ 0.67, 1.05 ]

03 Episodes
x Ladegaard 1999 0.00 (0.00) 0.0 Not estimable
Subtotal (95% CI) 0.0 Not estimable

Test for heterogeneity: not applicable
Test for overall effect: not applicable
0.1 0.2 0.5 1 2 5 10


Outcome 03 Episodes
Outcome: 03 Episodes
Study Intervention Control Weighted Mean Difference (Fixed) Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI 95% CI
Huang 2007 73 1.24 (0.90) 75 2.92 (0.60) -1.68 [ -1.93, -1.43 ]
-10.0 -5.0 0 5.0 10.0



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Hand washing for preventing diarrhoea (Review)

Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA

Hand washing for preventing diarrhoea (Review) 1

Hand washing for preventing diarrhoea (Review) i

Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA

This record should be cited as:

This version first published online: 23 January 2008 in Issue 1, 2008.

PLAIN LANGUAGE SUMMARY

BACKGROUND premises, but also to increased risk of excreta handling by mothers,

CRITERIA FOR CONSIDERING

Adjustment for clustering

Participants Three trials evaluated hand washing only interventions (Han

Trial in a high-risk group

Hand washing for preventing diarrhoea (Review) 10

Hand washing for preventing diarrhoea (Review) 13

Characteristics of included studies

Study Bartlett 1988

Hand washing for preventing diarrhoea (Review) 14

Not used in this review:

Study Bowen 2007

Study Butz 1990

Study Carabin 1999

Hand washing for preventing diarrhoea (Review) 16

Study Haggerty 1994

Study Han 1989

Study Huang 2007

Study Kotch 1994

Study Ladegaard 1999

Study Luby 2004a

Study Luby 2006

Study Roberts 2000

Study Stanton 1987

Characteristics of excluded studies

Study Reason for exclusion

Hand washing for preventing diarrhoea (Review) 21

Characteristics of ongoing studies

Table 01. Detailed search strategies

Search set CIDG SRˆ CENTRAL MEDLINEˆˆ EMBASEˆˆ LILACSˆˆ

Hand washing for preventing diarrhoea (Review) 22

Promotional Hand washing Hand washing

Promotional Hand washing Hand washing

Promotional Hand washing Hand washing

demonstration 2. Participatory 2. Information

Promotional Hand washing Hand washing

Bartlett 1988 Unclear Unclear Assessor Unclear Adequate Adequate

Black 1981 Unclear Unclear None Unclear Adequate Adequate

Bowen 2007 Adequate Unclear None Adequate Adequate Adequate

Butz 1990 Unclear Unclear None Unclear Adequate Adequate

Carabin 1999 Adequate Unclear None Unclear Unclear Adequate

Kotch 1994 Unclear Unclear Assessor Unclear Unclear Adequate

Ladegaard 1999 Unclear Unclear None Unclear Adequate Adequate

Roberts 2000 Adequate Unclear Assessors Unclear Unclear Adequate

Haggerty 1994 Unclear Unclear Assessor Unclear Inadequate Adequate

Han 1989 Unclear Unclear None Unclear Adequate Adequate

Luby 2004a Adequate Adequate None Unclear Adequate Adequate

Luby 2006 Adequate Unclear None Unclear Adequate Adequate

Stanton 1987 Adequate Unclear None Unclear Adequate Adequate

Huang 2007 Unclear Unclear None Adequate Adequate Adequate

Table 04. Incidence of diarrhoea

Trial Outcome and result Method of assessment Sample size

Trial Outcome and result Method of assessment Sample size

observation surveillance (weekly visits plus children (196 intervention,

Black 1981 Diarrhoea Daily record of attendance plus 4 day-care centres (2

Trial Outcome and result Method of assessment Sample size