Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program
Abstract
:1. Introduction
2. Methods
2.1. Study Site and Population
2.2. Study Design and Intervention
2.3. Data Collection
2.4. Data Analysis
2.5. Ethics
3. Results
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Institute for Health Metrics and Evaluation Results Tool. Available online: http://ghdx.healthdata.org/gbd-results-tool (accessed on 9 April 2024).
- Troeger, C.; Forouzanfar, M.; Rao, P.C.; Khalil, I.; Brown, A.; Reiner, R.C.; Fullman, N.; Thompson, R.L.; Abajobir, A.; Ahmed, M.; et al. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect. Dis. 2017, 17, 909–948. [Google Scholar] [CrossRef] [PubMed]
- Ingelbeen, B.; Hendrickx, D.; Miwanda, B.; van der Sande, M.A.B.; Mossoko, M.; Vochten, H.; Riems, B.; Nyakio, J.P.; Vanlerberghe, V.; Lunguya, O.; et al. Recurrent Cholera Outbreaks, Democratic Republic of the Congo, 2008–2017. Emerg. Infect. Dis. 2019, 25, 856–864. [Google Scholar] [CrossRef] [PubMed]
- Ali, M.; Nelson, A.R.; Lopez, A.L.; Sack, D.A. Updated global burden of cholera in endemic countries. PLoS Negl. Trop. Dis. 2015, 9, e0003832. [Google Scholar] [CrossRef] [PubMed]
- Kotloff, K.L.; Blackwelder, W.C.; Nasrin, D.; Nataro, J.P.; Farag, T.H.; van Eijk, A.; Adegbola, R.A.; Alonso, P.L.; Breiman, R.F.; Faruque, A.S.; et al. The Global Enteric Multicenter Study (GEMS) of diarrheal disease in infants and young children in developing countries: Epidemiologic and clinical methods of the case/control study. Clin. Infect. Dis. 2012, 55 (Suppl. S4), S232–S245. [Google Scholar] [CrossRef] [PubMed]
- Colwell, R.R.; Huq, A.; Islam, M.S.; Aziz, K.M.; Yunus, M.; Khan, N.H.; Mahmud, A.; Sack, R.B.; Nair, G.B.; Chakraborty, J.; et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proc. Natl. Acad. Sci. USA 2003, 100, 1051–1055. [Google Scholar] [CrossRef] [PubMed]
- D’Mello-Guyett, L.; Gallandat, K.; Van den Bergh, R.; Taylor, D.; Bulit, G.; Legros, D.; Maes, P.; Checchi, F.; Cumming, O. Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines. PLoS ONE 2020, 15, e0226549. [Google Scholar] [CrossRef] [PubMed]
- Wolfe, M.; Kaur, M.; Yates, T.; Woodin, M.; Lantagne, D. A Systematic Review and Meta-Analysis of the Association between Water, Sanitation, and Hygiene Exposures and Cholera in Case-Control Studies. Am. J. Trop. Med. Hyg. 2018, 99, 534–545. [Google Scholar] [CrossRef] [PubMed]
- Taylor, D.L.; Kahawita, T.M.; Cairncross, S.; Ensink, J.H. The Impact of Water, Sanitation and Hygiene Interventions to Control Cholera: A Systematic Review. PLoS ONE 2015, 10, e0135676. [Google Scholar] [CrossRef] [PubMed]
- Rothe, C.; Schlaich, C.; Thompson, S. Healthcare-associated infections in sub-Saharan Africa. J. Hosp. Infect. 2013, 85, 257–267. [Google Scholar] [CrossRef] [PubMed]
- Abubakar, U.; Amir, O.; Rodríguez-Baño, J. Healthcare-associated infections in Africa: A systematic review and meta-analysis of point prevalence studies. J. Pharm. Policy Pract. 2022, 15, 99. [Google Scholar] [CrossRef]
- Bouzid, M.; Cumming, O.; Hunter, P.R. What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systematic review of the evidence from low-income and middle-income countries. BMJ Glob. Health 2018, 3, e000648. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization (WHO). Prevention of Hospital-Acquired Infections: A Practical Guide; World Health Organization: Geneva, Switzerland, 2002. [Google Scholar]
- Hill, P.S.; Pavignani, E.; Michael, M.; Murru, M.; Beesley, M.E. The “empty void” is a crowded space: Health service provision at the margins of fragile and conflict affected states. Confl. Health 2014, 8, 20. [Google Scholar] [CrossRef] [PubMed]
- UN News. Eastern DR Congo: Health System at Breaking Point Warns WHO; United Nations: Geneva, Switzerland, 2023. [Google Scholar]
- World Health Organization and the United Nations Children’s Fund. WASH in Health Care Facilities: Global Baseline Report 2019; WHO and UNICEF: Geneva, Switzerland, 2019. [Google Scholar]
- Bisimwa, L.; Williams, C.; Bisimwa, J.C.; Sanvura, P.; Endres, K.; Thomas, E.; Perin, J.; Cikomola, C.; Bengehya, J.; Maheshe, G.; et al. Formative Research for the Development of Evidence-Based Targeted Water, Sanitation, and Hygiene Interventions to Reduce Cholera in Hotspots in the Democratic Republic of the Congo: Preventative Intervention for Cholera for 7 Days (PICHA7) Program. Int. J. Environ. Res. Public Health 2022, 19, 12243. [Google Scholar] [CrossRef]
- George, C.M.; Ahmed, S.; Talukder, K.A.; Azmi, I.J.; Perin, J.; Sack, R.B.; Sack, D.A.; Stine, O.C.; Oldja, L.; Shahnaij, M.; et al. Shigella Infections in Household Contacts of Pediatric Shigellosis Patients in Rural Bangladesh. Emerg. Infect. Dis. 2015, 21, 2006–2013. [Google Scholar] [CrossRef] [PubMed]
- George, C.M.; Hasan, K.; Monira, S.; Rahman, Z.; Saif-Ur-Rahman, K.M.; Rashid, M.U.; Zohura, F.; Parvin, T.; Islam Bhuyian, M.S.; Mahmud, M.T.; et al. A prospective cohort study comparing household contact and water Vibrio cholerae isolates in households of cholera patients in rural Bangladesh. PLoS Negl. Trop. Dis. 2018, 12, e0006641. [Google Scholar] [CrossRef] [PubMed]
- Weil, A.A.; Khan, A.I.; Chowdhury, F.; LaRocque, R.C.; Faruque, A.; Ryan, E.T.; Calderwood, S.B.; Qadri, F.; Harris, J.B. Clinical outcomes in household contacts of patients with cholera in Bangladesh. Clin. Infect. Dis. 2009, 49, 1473–1479. [Google Scholar] [CrossRef] [PubMed]
- Mathur, P. Hand hygiene: Back to the basics of infection control. Indian J. Med. Res. 2011, 134, 611–620. [Google Scholar] [CrossRef] [PubMed]
- Longembe, E.B.; Kitronza, P.L. Compliance with hand-hygiene practice in the General Reference Hospitals of the city of Kisangani, Democratic Republic of the Congo. Pan Afr. Med. J. 2020, 35, 57. [Google Scholar] [CrossRef]
- Zohura, F.; Bhuyian, M.S.I.; Saxton, R.E.; Parvin, T.; Monira, S.; Biswas, S.K.; Masud, J.; Nuzhat, S.; Papri, N.; Hasan, M.T.; et al. Effect of a water, sanitation and hygiene program on handwashing with soap among household members of diarrhoea patients in healthcare facilities in Bangladesh: A cluster-randomised controlled trial of the CHoBI7 mobile health program. Trop. Med. Int. Health 2020, 25, 1008–1015. [Google Scholar] [CrossRef]
- Zohura, F.; Bhuyian, S.I.; Monira, S.; Begum, F.; Biswas, S.K.; Parvin, T.; Sack, D.; Sack, R.B.; Leontsini, E.; Saif-Ur-Rahman, K.M.; et al. Observed Handwashing with Soap Practices Among Cholera Patients and Accompanying Household Members in a Hospital Setting (CHoBI7 Trial). Am. J. Trop. Med. Hyg. 2016, 95, 1314–1318. [Google Scholar] [CrossRef]
- Fewtrell, L.; Kaufmann, R.B.; Kay, D.; Enanoria, W.; Haller, L.; Colford, J.M., Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: A systematic review and meta-analysis. Lancet Infect. Dis. 2005, 5, 42–52. [Google Scholar] [CrossRef] [PubMed]
- Islam, M.S.; Luby, S.P.; Sultana, R.; Rimi, N.A.; Zaman, R.U.; Uddin, M.; Nahar, N.; Rahman, M.; Hossain, M.J.; Gurley, E.S. Family caregivers in public tertiary care hospitals in Bangladesh: Risks and opportunities for infection control. Am. J. Infect. Control 2014, 42, 305–310. [Google Scholar] [CrossRef]
- Horng, L.M.; Unicomb, L.; Alam, M.U.; Halder, A.K.; Shoab, A.K.; Ghosh, P.K.; Opel, A.; Islam, M.K.; Luby, S.P. Healthcare worker and family caregiver hand hygiene in Bangladeshi healthcare facilities: Results from the Bangladesh National Hygiene Baseline Survey. J. Hosp. Infect. 2016, 94, 286–294. [Google Scholar] [CrossRef]
- Nalule, Y.; Buxton, H.; Flynn, E.; Oluyinka, O.; Sara, S.; Cumming, O.; Dreibelbis, R. Hygiene along the continuum of care in the early post-natal period: An observational study in Nigeria. BMC Pregnancy Childbirth 2020, 20, 589. [Google Scholar] [CrossRef]
- Olivier, C.; Kunneke, H.; O’Connell, N.; Von Delft, E.; Wates, M.; Dramowski, A. Healthcare-associated infections in paediatric and neonatal wards: A point prevalence survey at four South African hospitals. S. Afr. Med. J. 2018, 108, 418–422. [Google Scholar] [CrossRef] [PubMed]
- Ejemot-Nwadiaro, R.I.; Ehiri, J.E.; Arikpo, D.; Meremikwu, M.M.; Critchley, J.A. Hand-washing promotion for preventing diarrhoea. Cochrane Database Syst. Rev. 2021, 12, Cd004265. [Google Scholar] [CrossRef] [PubMed]
- Dreibelbis, R.; Winch, P.J.; Leontsini, E.; Hulland, K.R.S.; Ram, P.K.; Unicomb, L.; Luby, S.P. The Integrated Behavioural Model for Water, Sanitation, and Hygiene: A systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 2013, 13, 1015. [Google Scholar] [CrossRef] [PubMed]
- WHO. Diarrhoeal Disease; WHO: Geneva, Switzerland, 2024. [Google Scholar]
- Williams, C.; Thomas, E.D.; Kuhl, J.; Bisimwa, L.; Coglianese, N.; Bauler, S.; François, R.; Saxton, R.; Sanvura, P.; Bisimwa, J.C.; et al. Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program). Int. J. Hyg. Environ. Health 2021, 238, 113850. [Google Scholar] [CrossRef]
- George, C.M.; Monira, S.; Zohura, F.; Thomas, E.D.; Hasan, M.T.; Parvin, T.; Hasan, K.; Rashid, M.U.; Papri, N.; Islam, A.; et al. Effects of a Water, Sanitation and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 2020, 73, e2560–e2568. [Google Scholar] [CrossRef]
- Rajasingham, A.; Leso, M.; Ombeki, S.; Ayers, T.; Quick, R. Water treatment and handwashing practices in rural Kenyan health care facilities and households six years after the installation of portable water stations and hygiene training. J. Water Health 2018, 16, 263–274. [Google Scholar] [CrossRef]
- Matanock, A.; Anderson, T.; Ayers, T.; Likicho, L.; Wamimbi, R.; Lu, X.; Emeetai, T.; Kakande, C.; Mutabazi, M.; Quick, R. Integrating Water Treatment into Antenatal Care: Impact on Use of Maternal Health Services and Household Water Treatment by Mothers-Rural Uganda, 2013. Am. J. Trop. Med. Hyg. 2016, 94, 1150–1156. [Google Scholar] [CrossRef] [PubMed]
- Loharikar, A.; Russo, E.; Sheth, A.; Menon, M.; Kudzala, A.; Tauzie, B.; Masuku, H.D.; Ayers, T.; Hoekstra, R.M.; Quick, R. Long-term Impact of Integration of Household Water Treatment and Hygiene Promotion with Antenatal Services on Maternal Water Treatment and Hygiene Practices in Malawi. Am. J. Trop. Med. Hyg. 2012, 88, 267. [Google Scholar] [CrossRef]
- Nalule, Y.; Buxton, H.; Macintyre, A.; Ir, P.; Pors, P.; Samol, C.; Leang, S.; Dreibelbis, R. Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia. Int. J. Environ. Res. Public Health 2021, 18, 4416. [Google Scholar] [CrossRef]
- Rimi, N.A.; Sultana, R.; Luby, S.P.; Islam, M.S.; Uddin, M.; Hossain, M.J.; Zaman, R.U.; Nahar, N.; Gurley, E.S. Infrastructure and contamination of the physical environment in three Bangladeshi hospitals: Putting infection control into context. PLoS ONE 2014, 9, e89085. [Google Scholar] [CrossRef] [PubMed]
- Ruel, M.T.; Arimond, M. Spot-check observational method for assessing hygiene practices: Review of experience and implications for programmes. J. Health Popul. Nutr. 2002, 20, 65–76. [Google Scholar] [PubMed]
- Luby, S.P.; Halder, A.K. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Trop Med. Int. Health 2008, 13, 835–844. [Google Scholar] [CrossRef]
- Figueroa, M.E.; Kincaid, D.L. Social, cultural and behavioral correlates of household water treatment and storage. In Household Water Treatment and Safe Storage; World Health Organization: Geneva, Switzerland, 2007. [Google Scholar]
- D’Mello-Guyett, L.; Cumming, O.; Bonneville, S.; D’Hondt, R.; Mashako, M.; Nakoka, B.; Gorski, A.; Verheyen, D.; Van den Bergh, R.; Welo, P.O.; et al. Effectiveness of hygiene kit distribution to reduce cholera transmission in Kasaï-Oriental, Democratic Republic of Congo, 2018: A prospective cohort study. BMJ Open 2021, 11, e050943. [Google Scholar] [CrossRef]
- Aubourg, M.A.; Bisimwa, L.; Bisimwa, J.C.; Sanvura, P.; Williams, C.; Boroto, R.; Lunyelunye, C.; Timsifu, J.; Munyerenkana, B.; Endres, K.; et al. A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo. Int. J. Environ. Res. Public Health 2022, 19, 13424. [Google Scholar] [CrossRef] [PubMed]
- George, C.M.; Endres, K.; Sanvura, P.; Williams, C.; Boroto, R.; Lunyelunye, C.; Bisimwa, J.C.; Timsifu, J.; Munyerenkana, B.; Bengehya, J.; et al. Methods to Evaluate COVID-19 Preventive Hygiene Programs: Observed Mask Wearing, Handwashing, and Physical Distancing Behaviors in Public Indoor Spaces in Democratic Republic of the Congo. Am. J. Trop. Med. Hyg. 2022, 107, 1083. [Google Scholar] [CrossRef]
- Sun, J.; Uwishema, O.; Kassem, H.; Abbass, M.; Uweis, L.; Rai, A.; El Saleh, R.; Adanur, I.; Onyeaka, H. Ebola virus outbreak returns to the Democratic Republic of Congo: An urgent rising concern. Ann. Med. Surg. 2022, 79, 103958. [Google Scholar] [CrossRef]
- Colwell, R.R. Global Climate and Infectious Disease: The Cholera Paradigm. Science 1996, 274, 2025–2031. [Google Scholar] [CrossRef] [PubMed]
- Lipp Erin, K.; Huq, A.; Colwell Rita, R. Effects of Global Climate on Infectious Disease: The Cholera Model. Clin. Microbiol. Rev. 2002, 15, 757–770. [Google Scholar] [CrossRef] [PubMed]
- Sommer, R. The Hawthorne dogma. Psychol. Bull. 1968, 70, 592. [Google Scholar] [CrossRef]
Overall (N = 284) | Standard Arm (N = 217) | PICHA7 Arm (N = 67) | ||||
---|---|---|---|---|---|---|
% | N | % | N | % | N | |
Diarrhea patients | 39% | 110 | 40% | 87 | 34% | 23 |
Patient attendants | 61% | 174 | 60% | 130 | 66% | 44 |
Female | 69% | 197 | 69% | 149 | 72% | 48 |
Age (years, all) | 247 | 190 | 57 | |||
Mean ± SD (min–max) | 17.5 ± 16.9 (0–65) | 17.5 ± 16.7 (0–65) | 17.3 ± 17.6 (0–60) | |||
0–2 | 29% | 71 | 27% | 52 | 33% | 19 |
2–5 | 10% | 25 | 12% | 22 | 5% | 3 |
5–12 | 6% | 16 | 5% | 10 | 11% | 6 |
>12 | 55% | 135 | 56% | 106 | 51% | 29 |
Age (years, patients) | 101 | 80 | 21 | |||
Mean ± SD (min–max) | 8.85 ± 16.2 (0–63) | 9.04 ± 16.2 (0–63) | 8.14 ± 16.9 (0–58) | |||
0–2 | 53% | 54 | 49% | 39 | 71% | 15 |
2–5 | 19% | 19 | 21% | 17 | 10% | 2 |
5–12 | 7% | 7 | 9% | 7 | 0% | 0 |
>12 | 21% | 21 | 21% | 17 | 19% | 4 |
Age (years, patient attendants) | 146 | 110 | 36 | |||
Mean ± SD (min–max) | 23.4 ± 14.6 (0–65) | 23.7 ± 14.2 (0–65) | 22.6 ± 16.0 (0–60) | |||
0–2 | 12% | 17 | 12% | 13 | 11% | 4 |
2–5 | 4% | 6 | 5% | 5 | 3% | 1 |
5–12 | 6% | 9 | 3% | 3 | 17% | 6 |
>12 | 78% | 114 | 80% | 89 | 69% | 25 |
Ward Type | 256 | 197 | 59 | |||
Cholera treatment center | 20% | 53 | 24% | 47 | 10% | 6 |
Internal medicine | 4% | 10 | 4% | 8 | 3% | 2 |
Pediatrics | 40% | 101 | 34% | 68 | 56% | 33 |
Intensive care | 2% | 4 | 2% | 4 | 0% | 0 |
Other | 34% | 88 | 36% | 70 | 31% | 18 |
% | Mean ± SD (min–max) | n | N | |
---|---|---|---|---|
Spot checks conducted | 113 | |||
Health facilities observed | 27 | |||
Ward type | ||||
Cholera treatment center | 20% | 23 | ||
Internal medicine | 6% | 7 | ||
Pediatrics | 38% | 43 | ||
Intensive Care | 2% | 2 | ||
Other | 34% | 38 | ||
Functional beds | 8.2 ± 6.1 (1–25) | 926 | ||
Patients in ward | 2.0 ± 2.3 (1–16) | 225 | ||
Handwashing stations | 1.2 ± 0.86 (0–4) | 130 | ||
Functioning handwashing stations | 1.0 ± 0.79 (0–4) | 115 |
Standard Arm | PICHA7 Arm | |||||||
---|---|---|---|---|---|---|---|---|
% (n) | N | % (n) | N | |||||
Participants Handwashing with a Cleansing Agent | 1 | 2 | 3 | 1 | 2 | 3 | ||
All key events | ||||||||
All participants | 15% (21) | 19% (26) | 13% (17) | 136 | 40% (16) | 45% (18) | 15% (6) | 40 |
Patients | 14% (5) | 17% (6) | 3% (1) | 36 | 40% (2) | 60% (3) | 0% (16) | 5 |
Patient attendants | 16% (16) | 20% (20) | 16% (16) | 100 | 40% (14) | 43% (15) | 17% (6) | 35 |
All food events | ||||||||
All participants | 12% (15) | 16% (20) | 12% (15) | 128 | 35% (13) | 41% (15) | 16% (6) | 37 |
Patients | 13% (4) | 16% (5) | 0% (0) | 32 | 40% (2) | 60% (3) | 0% (0) | 5 |
Patient attendants | 11% (11) | 17% (15) | 17% (15) | 96 | 34% (11) | 38% (12) | 19% (6) | 32 |
All stool/vomit events | ||||||||
All participants | 14% (9) | 14% (9) | 6% (4) | 63 | 37% (7) | 37% (7) | 0% (0) | 19 |
Patients | 12% (2) | 12% (2) | 6% (1) | 17 | 0% (0) | 0% (0) | 0% (0) | 2 |
Patient attendants | 15% (7) | 15% (7) | 7% (3) | 46 | 41% (7) | 41% (7) | 0% (0) | 17 |
Participants Washing Both Hands with a Cleansing Agent | N | n | OR (95% CI) |
---|---|---|---|
All events | |||
All participants | 176 | 37 | 5.04 (2.01, 12.7) |
Patient attendants | 135 | 30 | 5.27 (2.01, 13.8) |
Food events | |||
All participants | 165 | 28 | 6.57 (2.23, 19.3) |
Patient attendants | 128 | 22 | 6.27 (2.06, 19.1) |
Stool/vomit events | |||
All participants | 82 | 16 | 3.42 (1.10, 10.6) |
Patient attendants | 63 | 14 | 3.68 (1.02, 13.3) |
Standard Arm (N = 517) | PICHA7 Arm (N = 139) | |||
---|---|---|---|---|
n | % | n | % | |
Water (non-chlorinated) | 35 | 7% | 40 | 29% |
Soapy water bottle | 0 | 0% | 22 | 16% |
Soapy water bottle (provided by UCB) | 5 | 1% | 6 | 4% |
Soap (bar) | 10 | 2% | 2 | 1% |
Soap (liquid) | 4 | 1% | 0 | 0% |
Soap (detergent powder) | 0 | 0% | 1 | 1% |
Hand sanitizer | 4 | 1% | 0 | 0% |
Water (chlorinated) | 13 | 3% | 2 | 1% |
Other | 1 | 0% | 0 | 0% |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Mwishingo, A.; Endres, K.; Bisimwa, L.; Sanvura, P.; Banywesize, B.M.; Bisimwa, J.-C.; Williams, C.; Perin, J.; Boroto, R.; Nsimire, G.; et al. Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program. Int. J. Environ. Res. Public Health 2024, 21, 659. https://doi.org/10.3390/ijerph21060659
Mwishingo A, Endres K, Bisimwa L, Sanvura P, Banywesize BM, Bisimwa J-C, Williams C, Perin J, Boroto R, Nsimire G, et al. Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program. International Journal of Environmental Research and Public Health. 2024; 21(6):659. https://doi.org/10.3390/ijerph21060659
Chicago/Turabian StyleMwishingo, Alain, Kelly Endres, Lucien Bisimwa, Presence Sanvura, Blessing Muderhwa Banywesize, Jean-Claude Bisimwa, Camille Williams, Jamie Perin, Raissa Boroto, Gisèle Nsimire, and et al. 2024. "Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program" International Journal of Environmental Research and Public Health 21, no. 6: 659. https://doi.org/10.3390/ijerph21060659