***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND More than 95 % of neonatal deaths occur in developing countries , approximately 50 % at home . Few data are available on the impact of h and -washing practice s by birth attendants or caretakers on  neonatal mortality . OBJECTIVE To evaluate the relationship between birth attendant and maternal h and -washing practice s and  neonatal mortality  in rural Nepal . DESIGN Observational prospect i ve cohort study . SETTING Sarlahi District in rural southern Nepal . PARTICIPANTS Newborn infants were originally enrolled in a community-based trial assessing the effect of skin and /or umbilical cord cleansing with chlorhexidine on neonatal mortality in southern Nepal . A total of 23,662 newborns were enrolled and observed through 28 days of life . MAIN EXPOSURES Question naires were administered to mothers on days 1 and 14 after delivery to identify care practice s and risk factors for mortality and infection . Three h and -washing categories were defined : ( 1 ) birth attendant h and washing with soap and water before assisting with delivery , ( 2 ) maternal h and washing with soap and water or antiseptic before h and ling the baby , and ( 3 ) combined birth attendant and maternal h and washing . OUTCOME MEASURES Mortality within the neonatal period . RESULTS Birth attendant h and washing was related to a statistically significant lower mortality rate among neonates ( adjusted relative risk [ RR ] = 0.81 ; 95 % confidence interval [ CI ] , 0.66 - 0.99 ) , as was maternal h and washing ( adjusted RR = 0.56 ; 95 % CI , 0.38 - 0.82 ) . There was a 41 % lower mortality rate among neonates exposed to both h and -washing practice s ( adjusted RR = 0.59 ; 95 % CI , 0.37 - 0.94 ) . CONCLUSIONS Birth attendant and maternal h and washing with soap and water were associated with significantly lower rates of neonatal mortality . Measures to improve or promote birth attendant and maternal h and washing could improve neonatal survival rates Measuring h and contamination at critical times , such as eating , can be challenging . We examined whether h and contamination measured at r and om , such as on arrival ( initial ) , predicts contamination at critical times . Mothers of young children in Bangladesh rinsed both h and s in 200 mL of Ringer 's solution . We compared results of serial sample s with respect to fecal coliform counts . Among 39 mothers , the geometric mean of fecal coliforms was 307 colony-forming units (cfu)/100 mL at initial collection and 3,001 cfu/100 mL during critical times ( P = 0.0006 ) . There was no correlation between initial and critical time fecal coliform counts ( R = 0.13 , P = 0.43 ) . The mean difference between initial and critical time counts was 3.5 ( st and ard deviation = 1.4 ) on the log base-10 scale . Contamination of the same subjects ' h and s varied substantially within a few hours . Because h and contamination measured at r and om can not reliably predict h and contamination at times of potential pathogen transmission , single r and om h and rinses are not valid proxy measures for h and washing behavior OBJECTIVES To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing  diarrhoea  and the additional benefit of promoting h and washing with soap . METHODS The study was conducted in squatter settlements of Karachi , Pakistan , where diarrhoea is a leading cause of childhood death . Interventions were r and omly assigned to 47 neighbourhoods . Households in 10 neighbourhoods received diluted bleach and a water vessel ; nine neighbourhoods received soap and were encouraged to wash h and s ; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel ; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash h and s ; and nine neighbourhoods were followed as controls . Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea . RESULTS Study participants in control neighbourhoods had diarrhoea on 5.2 % of days . Compared to controls , participants living in intervention neighbourhoods had a lower prevalence of diarrhoea : 55 % ( 95 % CI 17 % , 80 % ) lower in bleach and water vessel neighbourhoods , 51 % ( 95 % CI 12 % , 76 % ) lower in h and washing promotion with soap neighbourhoods , 64 % lower ( 95 % CI 29 % , 90 % ) in disinfectant-disinfectant neighbourhoods , and 55 % ( 95 % CI 18 % , 80 % ) lower in disinfectant-disinfectant plus h and washing with soap neighbourhoods . CONCLUSIONS With an intense community-based intervention and supplies provided free of cost , each of the home-based interventions significantly reduced diarrhoea . There was no benefit by combining h and washing promotion with water treatment Intensive h and washing promotion can reduce  diarrheal and respiratory disease incidence . To determine whether less intensive , more scalable interventions can improve health , we evaluated a school-based h and washing program . We r and omized 87 Chinese schools to usual practice s : st and ard intervention ( h and washing program ) or exp and ed intervention ( h and washing program , soap for school sinks , and peer hygiene monitors )  . We compared student absence rates , adjusting for cluster design . In control schools , children experienced a median 2.0 episodes ( median 2.6 days ) of absence per 100 student-weeks . In st and ard intervention schools , there were a median 1.2 episodes ( P = 0.08 ) and 1.9 days ( P = 0.14 ) of absence per 100 student-weeks . Children in exp and ed intervention schools experienced a median 1.2 episodes ( P = 0.03 ) and 1.2 days ( P = 0.03 ) of absence per 100 student-weeks . Provision of a large-scale h and washing promotion program and soap was associated with significantly reduced absenteeism . Similar programs could improve the health of children worldwide We tested the efficacy of a simple , visual cue to increase h and washing with soap and water .  Automated towel dispensers in 8 public bathrooms were set to present a towel either with or without activation by users . We set the 2 modes to operate alternately for 10 weeks . Wireless sensors were used to record entry into bathrooms . Towel and soap consumption rates were checked weekly . There were 97,351 h and -washing opportunities across all restrooms . Towel use was 22.6 % higher ( P=.05 ) and soap use was 13.3 % higher ( P=.003 ) when the dispenser presented the towel without user activation than when activation was required . Results showed that a visual cue can increase h and -washing compliance in public facilities BACKGROUND Diarrhoea and respiratory infections are the two biggest causes of child death globally . H and washing with soap could substantially reduce diarrhoea and respiratory infections , but prevalence of adequate h and washing is low . We tested whether a scalable village-level intervention based on emotional drivers of behaviour , rather than knowledge , could improve h and washing behaviour in rural India . METHODS The study was done in Chittoor district in southern And hra Pradesh , India , between May 24 , 2011 , and Sept 10 , 2012 . Eligible villages had a population of 700 - 2000 people , a state-run primary school for children aged 8 - 13 years , and a preschool for children younger than 5 years . 14 villages ( clusters ) were selected , stratified by population size ( < 1200 vs > 1200 ) , and r and omly assigned in a 1:1 ratio to intervention or control ( no intervention ) . Clusters were enrolled by the study manager . R and om allocation was done by the study statistician using a r and om number generator . The intervention included community and school-based events incorporating an animated film , skits , and public pledging ceremonies . Outcomes were measured by direct observation in 20 - 25 households per village at baseline and at three follow-up visits ( 6 weeks , 6 months , and 12 months after the intervention ) . Observers had no connection with the intervention and observers and participant households were told that the study was about domestic water use to reduce the risk of bias . No other masking was possible . The primary outcome was the proportion of h and washing with soap at key events ( after defecation , after cleaning a child 's bottom , before food preparation , and before eating ) at all follow-up visits . The control villages received a shortened version of the intervention before the final follow-up round . Outcome data are presented as village-level means . FINDINGS H and washing with soap at key events was rare at baseline in both the intervention and control groups ( 1 % [ SD 1 ] vs 2 % [ 1 ] ) . At 6 weeks ' follow-up , h and washing with soap at key events was more common in the intervention group than in the control group ( 19 % [ SD 21 ] vs 4 % [ 2 ] ; difference 15 % , p=0·005 ) . At the 6-month follow-up visit , the proportion h and washing with soap was 37 % ( SD 7 ) in the intervention group versus 6 % ( 3 ) in the control group ( difference 31 % ; p=0·02 ) . At the 12-month follow-up visit , after the control villages had received the shortened intervention , the proportion h and washing with soap was 29 % ( SD 9 ) in the intervention group and 29 % ( 13 ) in the control group . INTERPRETATION This study shows that substantial increases in h and washing with soap can be achieved using a scalable intervention based on emotional drivers . FUNDING Wellcome Trust , SHARE We conducted a cluster-r and omized trial to assess the impact of a school-based water treatment , hygiene , and sanitation program on reducing infection with soil-transmitted helminths ( STHs ) after school-based deworming . We assessed infection with STHs at baseline and then at two follow-up rounds 8 and 10 months after deworming . Forty government primary schools in Nyanza Province , Kenya were r and omly selected and assigned to intervention or control arms . The intervention reduced reinfection prevalence ( odds ratio [ OR ] 0.56 , 95 % confidence interval [ CI ] 0.31 - 1.00 ) and egg count ( rate ratio [ RR ] 0.34 , CI 0.15 - 0.75 ) of Ascaris lumbricoides . We found no evidence of significant intervention effects on the overall prevalence and intensity of Trichuris trichiura , hookworm , or Schistosoma mansoni reinfection . Provision of school-based sanitation , water quality , and hygiene improvements may reduce reinfection of STHs after school-based deworming , but the magnitude of the effects may be sex- and helminth species-specific BACKGROUND Soil-transmitted helminths are among the most prevalent sources of human infections globally . We determined the effect of an educational package at rural schools in Linxiang City District , Hunan province , China , where these worms are prevalent . The intervention aim ed to increase knowledge about soil-transmitted helminths , induce behavioral change , and reduce the rate of infection . METHODS We conducted a single-blind , unmatched , cluster-r and omized intervention trial involving 1718 children , 9 to 10 years of age , in 38 schools over the course of 1 school year . Schools were r and omly assigned to the health-education package , which included a cartoon video , or to a control package , which involved only the display of a health-education poster . Infection rates , knowledge about soil-transmitted helminths ( as assessed with the use of a question naire ) , and h and -washing behavior were assessed before and after the intervention . Albendazole was administered in all the participants at baseline and in all the children who were found to be positive for infection with soil-transmitted helminths at the follow-up assessment at the end of the school year . RESULTS At the follow-up assessment , the mean score for the knowledge of helminths , calculated as a percentage of a total of 43 points on a question naire , was 90 % higher in the intervention group than in the control group ( 63.3 vs. 33.4 , P<0.001 ) , the percentage of children who washed their h and s after using the toilet was nearly twice as high in the intervention group ( 98.9 % , vs. 54.2 % in the control group ; P<0.001 ) , and the incidence of infection with soil-transmitted helminths was 50 % lower in the intervention group than in the control group ( 4.1 % vs. 8.4 % , P<0.001 ) . No adverse events were observed immediately ( within 15 minutes ) after albendazole treatment . CONCLUSIONS The health-education package increased students ' knowledge about soil-transmitted helminths and led to a change in behavior and a reduced incidence of infection within 1 school year . ( Funded by UBS Optimus Foundation , Zurich , Switzerl and ; Australian New Zeal and Clinical Trials Registry number , ACTRN12610000048088 . ) Confounding should always be addressed in studies concerned with causality . When present , it results in a biased estimate of the effect of exposure on disease . The bias can 
    Output:
    
Our results show that h and washing after contact with excreta is poorly practice d globally , despite the likely positive health benefits