***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: The impact of improved water , sanitation , and hygiene ( WASH ) access on mitigating illness is well documented , although impact of school-based WASH on school-aged children has not been rigorously explored . We conducted a cluster-r and omized trial in Nyanza Province , Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary -school pupils . Two study population s were used : schools with a nearby dry season water source and those without . Pupils attending ' water-available ' schools that received hygiene promotion and water treatment ( HP&WT ) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools . Those pupils in schools that received only the HP&WT showed similar results . Pupils in ' water-scarce ' schools that received a water-supply improvement , HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness . Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea BACKGROUND The promotion of household water treatment and h and washing with soap has led to large reductions in child diarrhoea in r and omized efficacy trials . Currently , we know little about the health effectiveness of behaviour-based water and hygiene interventions after the conclusion of intervention activities . METHODS We present an extension of previously published design ( propensity score matching ) and analysis ( targeted maximum likelihood estimation ) methods to evaluate the behavioural and health impacts of a pre-existing but non-r and omized intervention ( a 3-year ,  combined household water treatment and h and washing campaign in rural Guatemala ) . Six months after the intervention , we conducted a cross-sectional cohort study in 30 villages ( 15 intervention and 15 control ) that included 600 households , and 929 children < 5 years of age . RESULTS The study design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics . The intervention led to modest gains in confirmed water treatment behaviour [ risk difference = 0.05 , 95 % confidence interval ( CI ) 0.02 - 0.09 ] . We found , however , no difference between the intervention and control villages in self-reported h and washing behaviour , spot-check hygiene conditions , or the prevalence of child diarrhoea , clinical acute lower respiratory infections or child growth . CONCLUSIONS To our knowledge this is the first post-intervention follow-up study of a combined household water treatment and h and washing behaviour change intervention , and the first post-intervention follow-up of either intervention type to include child health measurement . The lack of child health impacts is consistent with unsustained behaviour adoption . Our findings highlight the difficulty of implementing behaviour-based household water treatment and h and washing outside of intensive efficacy trials Background H and hygiene is considered as an important means of infection control . We explored whether guided h and hygiene together with transmission-limiting behaviour reduces infection episodes and lost days of work in a common work environment in an open cluster-r and omized 3-arm intervention trial . Methods A total of 21 clusters ( 683 persons ) were r and omized to implement h and hygiene with soap and water ( 257 persons ) , with alcohol-based h and rub ( 202 persons ) , or to serve as a control ( 224 persons ) . Participants in both intervention arms also received st and ardized instructions on how to limit the transmission of infections . The intervention period ( 16 months ) included the emergence of the 2009 influenza p and emic and the subsequent national h and hygiene campaign influencing also the control arm . Results In the total follow-up period there was a 6.7 % reduction of infection episodes in the soap- and water arm ( p = 0.04 ) . Before the onset of the anti-p and emic campaign , a statistically significant ( p = 0.002 ) difference in the mean occurrence of infection episodes was observed between the control ( 6.0 per year ) and the soap- and -water arm ( 5.0 per year ) but not between the control and the alcohol-rub arm ( 5.6 per year ) . Neither intervention had a decreasing effect on absence from work . Conclusions We conclude that intensified h and hygiene using water and soap together with behavioural recommendations can reduce the occurrence of self-reported acute illnesses in common work environment . Surprisingly , the occurrence of reported sick leaves also increased in the soap- and water-arm . Trial Registration Clinical Trials.gov : NCT00981877 Source of funding The Finnish Work Environment Fund and the National Institute for Health and Welfare Elementary school-age children are particularly vulnerable to infections . While h and washing is the best method of preventing infections , many elementary schools are housed in buildings that have barriers to effective h and hygiene . The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to h and washing in reducing absenteeism secondary to infectious illness .  Two-hundred and fifty-three elementary school children were r and omized by classroom into an experimental or control group . With a crossover design , all children participated in both groups , with a one-week washout period between phases . A 45-minute “ Germ Unit ” was taught to all children as they started the experimental phase and a st and ard unit on h and hygiene was taught as they started the control phase . Sixty-nine children were absent due to illness while in the control group . Thirty-nine children became ill while in the experimental group . Alcohol gel as an adjunct to h and washing was shown to be effective in reducing absenteeism due to infectious illness by 43 % H and washing is thought to be effective for the prevention of transmission of diarrhoea pathogens . However it is not conclusive that h and washing with soap is more effective at reducing contamination with bacteria associated with diarrhoea than using water only . In this study 20 volunteers contaminated their h and s deliberately by touching door h and les and railings in public spaces . They were then allocated at r and om to ( 1 ) h and washing with water , ( 2 ) h and washing with non-antibacterial soap and ( 3 ) no h and washing . Each volunteer underwent this procedure 24 times , yielding 480 sample s overall . Bacteria of potential faecal origin ( mostly Enterococcus and Enterobacter spp . ) were found after no h and washing in 44 % of sample s. H and washing with water alone reduced the presence of bacteria to 23 % ( p < 0.001 ) . H and washing with plain soap and water  reduced the presence of bacteria to 8 % ( comparison of both h and washing arms : p < 0.001 ) . The effect did not appear to depend on the bacteria species . H and washing with non-antibacterial soap and water is more effective for the removal of bacteria of potential faecal origin from h and s than h and washing with water alone and should therefore be more useful for the prevention of transmission of diarrhoeal diseases Background Day care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections , which can be prevented with adequate h and hygiene ( HH ) . Based on previous studies on environmental and sociocognitive determinants of caregivers ’ compliance with HH guidelines in day care centers ( DCCs ) , an intervention has been developed aim ing to improve caregivers ’ and children ’s HH compliance and decrease infections among children attending DCCs . The aim of this paper is to describe the design of a cluster r and omized controlled trial to evaluate the effectiveness of this intervention . Methods / design The intervention will be evaluated in a two-arm cluster r and omized controlled trial among 71 DCCs in the Netherl and s. In total , 36 DCCs will receive the intervention consisting of four components : 1 ) HH products ( dispensers and refills for paper towels , soap , alcohol-based h and sanitizer , and h and cream ) ; 2 ) training to educate about the Dutch national HH guidelines ; 3 ) two team training sessions aim ed at goal setting and formulating specific HH improvement activities ; and 4 ) reminders and cues to action ( posters/stickers ) . Intervention DCCs will be compared to 35 control DCCs continuing usual practice . The primary outcome measure will be observed HH compliance of caregivers and children , measured at baseline and one , three , and six months after start of the intervention . The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in  600 children attending DCCs , monitored over six months by parents using a calendar to mark the days their child has diarrhea and /or a cold . Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance . Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs . Discussion This is one of the first DCC intervention studies to assess HH compliance of both caregivers and children , as well as the incidence of gastrointestinal and respiratory infections in children , as outcome measures . When an effect of the intervention on improving HH compliance and /or reducing incidence of infections is shown , (inter)national dissemination of the intervention in other DCCs may be considered . Trial registration Netherl and s trial registry : OBJECTIVES Improving school water , sanitation and hygiene ( WASH ) conditions reduces pupil absence and illness . However , these benefits may depend on the conditions of the latrines and availability of consumables . We sought to determine whether a low-cost , policy-relevant , environmental-level latrine cleaning intervention could improve latrine cleanliness , increase its use and reduce absenteeism . METHODS In a three-arm , cluster-r and omized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project .  Latrine conditions and use were also assessed using structured observation . Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls , as did h and washing with soap . We found no difference in latrine use and absence across arms . CONCLUSIONS The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received . Improving latrine conditions is important for the dignity and well-being of pupils , and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly Introduction Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development . Water quality , sanitation , h and washing and nutritional interventions can independently reduce enteric infections and growth faltering . There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children . The objective of the WASH Benefits study is to help fill this knowledge gap . Methods and analysis WASH Benefits includes two cluster-r and omised trials to assess improvements in water quality , sanitation , h and washing and child nutrition — alone and in combination — to rural households with pregnant women in Kenya and Bangladesh . Geographically matched clusters ( groups of household compounds in Bangladesh and villages in Kenya ) will be r and omised to one of six intervention arms or control . Intervention arms include water quality , sanitation , h and washing , nutrition , combined water+sanitation+h and washing ( WSH ) and WSH+nutrition . The studies will enrol newborn children ( N=5760 in Bangladesh and N=8000 in Kenya ) and measure outcomes at 12 and 24 months after intervention delivery . Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea . Secondary outcomes include stunting prevalence , markers of environmental enteropathy and child development scores ( verbal , motor and personal/social ) . We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests . Ethics and dissemination Study protocol s have been review ed and approved by human subjects review boards at the University of California , Berkeley , Stanford University , the International Centre for Diarrheal Disease Research , Bangladesh , the Kenya Medical Research Institute , and Innovations for Poverty Action . Independent data safety monitoring boards in each country oversee the trials . This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California , Berkeley . Registration Trial registration identifiers ( http://www . clinical trials.gov ) : NCT01590095 ( Bangladesh ) , NCT01704105 ( Kenya ) OBJECTIVE To evaluate a simple low cost method for measuring h and contamination as an objective assessment of h and washing practice s. METHOD As part of a larger r and omized controlled trial of h and washing promotion with soap conducted in squatter settlements of Karachi , Pakistan , a r and omly selected subset of 52 mothers in households receiving soap and h and washing promotion and 28 mothers in control households directly pressed three fingers of their right h and onto MacConkey agar plates on weekly unannounced visits from April to September 2002 , and monthly from October 2002 to March 2003 . The MacConkey plates were incubated at 44 degrees C for 24 h , and evaluated for growth of thermotolerant coliform bacteria . RESULTS The proportion of sample s that had detectable thermotolerant coliforms ( 50 % ) was similar in households that received soap and control households ( 52 % , P = 0.40 ) . In the week after evaluation of the mothers ' h and s , the proportion of households that reported diarrhoea was similar regardless of whether or not the mother had thermotolerant coliforms detected by direct finger imprint ( 18 
    Output:
    
Authors ' conclusions H and washing promotion probably reduces diarrhoea episodes in both child day‐care centres in high‐income countries and among communities living in LMICs by about 30 % .
However , less is known about how to help people maintain h and washing habits in the longer term .