Related Studies

MaaChampion Gambia Cluster RCT study

The fatal threat from diarrhoea and pneumonia to young children in the world's poorer countries can be reduced by using traditional performing arts to encourage mothers to provide youngsters with safe food and water. 

The Gambia, like many other Low- and Middle-income Countries (LMICs) faces high rates of under-five deaths due to diarrhoea and pneumonia - the two highest causes of death in this age group in this country and globally.

Children transitioning from breastfeeding to eating food are at most risk, as complementary food becomes contaminated. Researchers working in The Gambia discovered that mothers’ food safety and hygiene behaviours were massively improved by a low-cost behaviour change community programs trialled in rural villages.

After six months, researchers observed that hospital admissions had reduced by 60% for diarrhoea and 30% for respiratory infection. After 32 months, the mothers continued to practice improved food safety and hygiene practices, informing and encouraging new mothers to do the same.

Led by experts from the University of Birmingham, the international research team has now published its findings in PLOS Medicine.

Lead researcher, Dr Semira Manaseki-Holland, Clinical Senior Lecturer in Public Health at the University of Birmingham, commented: “We developed a low-cost, but seemingly effective, community health intervention that if replicated in countries around the globe could save thousands, if not millions, of lives in the years ahead.

“Gambian rural villages are similar to thousands in sub-Saharan Africa and these methods can be used in many countries across Africa and Asia. We saw the food hygiene practices of Gambian mothers with weaning age children improve dramatically. Although we could not measure death rates, since diarrhoea and pneumonia are leading causes of death in young children, we can deduce that the program can result in fewer young children dying from diarrhoea and pneumonia.”

The research programme used a randomised trial across 30 Gambian villages (15 got the program and 15 instead got messages about household gardens) to identify and correct behaviour around critical points in food preparation and handling when contamination can occur.

Researchers translated food safety and hygiene information into stories and songs with a central figure called ‘MaaChampian’ - a role model mother with behaviours that mothers and families strived to achieve. Five community visits included performances and music -honouring the achievements of mothers and other community members towards becoming mentoring figures themselves.

Dr Buba Manjang, Gambian lead researcher and Director of Public Health Directorate of the Ministry of Health of the Gambia, commented: “Communities and mothers know most of the correct behaviours, but for some reason they don’t do them, even if the means are available. This research offers a low-cost, effective solution for The Gambia and other countries to use cultural performing arts in similar behavioural change interventions. This will help to reduce the fatal impact of diarrhoea and pneumonia by involving whole communities to support the mothers and improve child health.”

Historically, expensive and resource intensive water, sanitation, and hygiene (WASH) interventions were and still are the main accepted way of addressing diarrhoea and pneumonia - involving building toilets, providing safe water, creating sewage systems.  However, changing behaviour of communities is as important as these large infrastructure programs. Without involving communities and local people, these new developments can either be ignored or not adequately suit the life of people they are intended for.  Many of these programs rely on home visits to the mother informing and encouraging her to change her practices without adequately addressing the community support that she needs to do this.

This research builds on smaller scale development studies that began in Mali and Bangladesh in 2014, as well as Nepal in 2016. The latest study in Gambia developed this early work into a scalable, low-cost, easy-to-deliver locally-sourced program.

The team secured a £2 million MRC grant to run a similar community intervention to reduce diarrhoea and improve the growth of young children in urban and rural Mali. The Mali project will assess children transitioning out of breast feeding in 120 communities and villages across the country.

Peer reviewed publications 

Cost-effectiveness of a weaning food safety and hygiene programme in rural Gambia.  Siu J, Jackson LJ, Bensassi S, Manjang B, Manaseki-Holland S.Trop Med Int Health. 2021 Dec;26(12):1624-1633. doi: 10.1111/tmi.13691. Epub 2021 Oct 24.PMID: 34672047

Manaseki-Holland S, Manjang B, Manaseki-Holland S, Hemming K, Martin JT, Bradley C, Jackson L, Taal M, Gautam OP, Crowe F, Sanneh B, Ensink J, Stokes T, Cairncross S. Effects of promoting safe and hygienic weaning-food handling practices through a community-based program on childhood infections: a cluster randomised controlled trial in the rural Gambia. PLOS Medicine. 2021 Jan 11;18(1):e1003260.

Manjang B, Hemming K, Bradley C, Ensink J, Martin JT, Sowe J, Jarju A, Cairncross S, Manaseki-Holland S (corresponding author). Promoting hygienic weaning-food handling practices through a community-based programme: intervention implementation and baseline characteristics for a cluster randomised controlled trial in rural Gambia. BMJ Open. 2018 Aug 5;8:e017573. doi: 10.1136/bmjopen-2017-017573.

Policy brief

Behaviour change for water, sanitation and hygiene



Photos and videos


Funded by Islamic Development Bank, the Medical Research Council (MRC), DFID/SHARE Consortium and UNICEF Gambia Office, the programme directly addresses a number of UN Sustainable Development Goals: Good health and well-being (SDG 3); Clean water and sanitation (SDG6); and Partnerships for the Goals (SDG 17).


Communal handwashing


Research Project Team Leads:

University of Birmingham (UOB): Dr S Manaseki-Holland, Dr Sam Watson

University of Science Technique and Technology, Bamako (USTTB): Prof O Koita, Prof O Toure, Dr Cheick Sidibe, Mr Youssouf Diarra

A public health priority:

The experience of COVID-19, Ebola and cholera demonstrates the importance of improving handwashing at key moments in reducing the transmission of significant communicable diseases. Diarrhoea, is the commonest cause of morbidity, the second leading cause of post-neonatal mortality, and is greatly associated with stunting, and thus linked to achieving SDG 3 targets. Evidence, including from our team, confirms that a mother’s effective handwashing before feeding can reduce food contamination for the child and diarrhoea.

The practice of communal bowl handwashing without soap before mealtimes (C-HW) involves a group of people (two or more) rinsing their hands in one small container of water, usually without soap and without changing the water between individuals. In Africa, C-HW is culturally engrained and believed to improve family cohesion, and is often followed by eating with hands from a large plate of food. Whenever at least one participant carries pathogens on their hands, C-HW before meals is a threat to all, especially young children who often wash last and have lower immunity; e.g. in a case-control study during the 2015 cholera epidemic in Kenya, there was an odds ratio (OR)=6.5(95% CI 2.30-18.11) of cholera cases in households that practised C-HW. Similarly, in Zimbabwe or a case-control study found that shared-bowl handwashing was a significant risk for diarrhoea in children under-5 years [OR = 2.95, 95% CI (1.47-5.89)].

We have conducted several studies to understand the prevalence of the practice in Africa, its motivators and interventions targeting C-HW, and have partners in ministries of health and international NGOs who are keen to develop effective interventions. Therefore, our team are seeking funding for the next steps.

What Next

Co-developing and testing a culturally sensitive intervention package:

We have a multi-disciplinary team of intervention development experts, from the fields of social marketing, behaviour economics, public health and WASH. We wish to combine our experience and methodological toolkits to co-develop innovative solutions both at the household level and for delivery to the community.

For intervention delivery, we will leverage our experience in the Gambia (the MaaChampion project) and currently with the MRC-funded Mali 120-cluster RCT, a complex intervention for a community-level food safety, hygiene and nutrition programme, the MaaCiwara project. This Mali RCT intervention complements African performing arts (drama, songs, stories) with community leader involvement, peer education, competitions, branding and nudges.

For co-developing alternative behaviours (solutions) using soap at the household level, we have conducted a few community involvement/engagement activities, and qualitative studies and found that households were willing to participate in co-designing an intervention to address possible social or water-supply barriers, for example, washing with soap before or after C-HW in a second bowl, while community leaders promote behaviours. The exact form and nature of solutions and possible barriers will be identified through co-production/co-design with communities and stakeholders, and generic lessons identified for replication. We aim to define the mechanisms of action according to formative research such as the RANAS framework and refine our current theory of change (Logic Model) and the most appropriate behaviour change theory/s depending on the results of our interaction during co-development. At the initial stage, we have expert research and NGO partners in two distinct countries, Ghana (a large Christian population with fewer issues of security) and Mali (a Muslim-dominated country with significant security issues) and wish to develop, pilot and implement the proposed intervention in these countries at the first instance (although we remain open to the choice of country/ies).

Summary of draft publications for studies we have conducted so far

  1. Systematic Review of the literature (Funding source: none)

Research Objectives/Methods: To summarise the literature and identify effective tested interventions, we comprehensively searched through several electronic databases and grey literature sources to identify potentially eligible papers for our review. A total of 10,711 records were identified from our search. After applying our inclusion and exclusion criteria, 16 studies were short-listed, from which we extracted data and appraised their methodological rigour using the Mixed Methods Appraisal Tool.

Results: Studies were from 10 African countries, but due to the scarcity of studies and their heterogeneity, a narrative synthesis approach was used to summarise and interpret the extracted data. Five of the included studies reported prevalence, which ranged from 30.7% to 79% among the sample studied. C-HW was practised in many settings, including households, schools, and social gatherings. Six of the included studies reported the association of C-HW practice with disease transmission measured for general diarrhoea rate, cholera, Hepatitis E virus, Shigella or human cysticercosis infections. Likewise, microbial analyses found evidence that C-HW aided the spread of pathogenic bacteria from infected hands to those that had no pathogens before C-HW. Cultural/traditional beliefs or practices were highlighted as the main reasons for engaging in this practice. Other motivations included the scarcity of water and soap. However, we were unable to identify any targeted intervention specifically addressing C-HW.

Given the high prevalence of this practice throughout Africa which has the highest rate of diarrhoeal disease and food-born infections globally, the findings of this review point to the importance of implementing culturally sensitive interventions to curb this practice.

 2. Mixed methods multi-country study with WASH experts from 15 African countries (Funding source: Wellcome ISSF)

Research Objectives:  To elicit the views of development experts working in the Water, Sanitation and Hygiene (WASH) sector on what they perceived to be the prevalence of C-HW and the reasons behind its practice in Saharan Africa. 

Methods: We used online quantitative surveys and qualitative semi-structured interviewing approach to elicit the views of Save the Children and Water Aid in-country WASH experts on the practice of C-HW. The experts were drawn from all counties that these large WASH orientated NGOs operated in and experts thus worked in West Africa, Central Africa, and East and Southern Africa. A quantitative survey was done via survey monkey, followed by one or more experts per country interviewed qualitatively virtually using zoom in English, French and Portuguese. The interviews analysed i) deductively, to quantify the responses to estimate the scale of the practice from the perspective of the experts, and ii) inductively using a thematic analysis approach to identify and describe the reasons behind this practice. We used elements of the socioecological framework to guide the data analysis, presentation, and interpretation of the results.

Results: 54 experts fully completed the quantitative survey and out of this, 22 experts were interviewed from 15 countries. The WASH Experts acknowledged that C-HWC-HW is widely practised across all countries in different settings.  The practice was perceived to be more common in rural areas than in urban settings and usually during social events, such as weddings, naming ceremonies, funerals, birthdays, family gatherings and communal labour.

Factors motivating the practice included; i) traditional beliefs and practices: C-HW is seen as a symbol of togetherness, bringing a sense of unity, bonding and solidarity for community members; ii) lack of awareness and knowledge about the health risks of C-HW practice, iii) traditional hierarchy of control: men must wash hands first, then women and children, iii) education and social class: poor and uneducated more likely to wash hands together in one bowl, and iv) lack of handwashing facilities or water scarcity.

Conclusion: C-HW is widespread in Saharan Africa, and this threatens governments’ efforts in addressing Africa’s public health challenges. A multisectoral approach to the problem is needed, and we recommend that educational interventions using a behavioural change approach have the potential to make an impact at addressing the factors acting at the community level. Due to the design of this study, we could not properly establish the scale of the practice of C-HW.  Thus, future research should consider using an extensive within country survey to estimate the prevalence. 

 3. Investigating C-HW in Mali (Funding source- MRC UKRI)

Research Objectives:  To describe C-HW, its prevalence, and the motivations underlying C-HW in urban and rural communities in Mali. Below, three studies are summarised together for brevity.

Methods: We conducted three types of data collection. First, in 7 urban and rural communities, we conducted qualitative focus group discussions separately with mothers, fathers, grandmothers and community elders, and observed daily routine activities regarding handwashing, cooking and feeding/eating in 45 households/mothers. Second, during a feasibility trial (see next study), we conducted qualitative interviews with mothers and heads of households identified earlier to be practising C-HW. Third, during the large baseline study of MaaCiwara, we conducted mealtime observations of 3400 mothers/families followed by a survey of mothers regarding the practice of C-HW which will be repeated at 4 and 15 months after an intervention that includes child food safety and hygiene and maternal handwashing with soap before feeding the child.

Findings/conclusions: In the first study, CHW was widely practised in almost all households before meals. Qualitative findings from the first and second study revealed that the use of the shared container (communal bowl) to wash hands “strengthens family solidarity”. They further explained that the custom of this form of handwashing has been passed over generations and families that wash hands together in the common bowl have “fewer disagreements and disunity”. Some participants insisted that it was important to continue C-HW for improving family unity, although some participants acknowledged that it was not the most hygienic practice and a few had some alternative solutions combined with C-HW. C-HW was also practised by the order of age in the family, where the youngest are often the last to wash their hands in the common bowl, making the youngest most vulnerable to transmission of diarrhoea pathogens from elders that already rinsed into the C-HW water. Only a few participants mentioned the scarcity of soap and water as factors influencing the practice of C-HW.  Families said they were ready to explore other methods of handwashing that preserve their unity. Designing culturally acceptable interventions specifically targeting C-HW in consideration of these cultural motivations, are urgently needed. Such interventions, if co-created with communities will ensure maximum impact.

 4. The effect of soap on pathogen transmission of E.Coli and coliforms into C-HW water and on hand swabs before mealtime in households using the same water in one bowl  (Funding source: Institute for Global Innovation- University of Birmingham)

Research questions: Will adding soap and a rinse bowl during C-HW reduce hand-swab microbiological contamination compared to regular water-only single bowl use for C-HW?

Methods: We aimed to test a low cost intervention that was similar to C-HW in terms of family participation in pre-meal handwashing, thus reducing cultural barriers to behaviour change. We randomly allocated 280 households known to use C-HW in 3 villages and 2 urban Bamako communities to intervention or control groups. Intervention households were asked to wash in a usual communal bowl but with soap and rinse in a separate communal bowl of water. In the control group, C-HW was done as normally practised, with one bowl of water without soap. Water samples, and hand-swaps of the last person, before and after C-HW were tested for E.coli and coliform. Water and hand swab samples were cultured using standard techniques for E.Coli (indicator for faecal coliforms) and coliforms.

Findings/conclusions: The intervention resulted in a rate ratio reduction of 55% (95% CI: 71%, 34%) in E.Coli colony growth (indicator for faecal coliforms) from hand-swabs after washing hands with soap. Control participants with no hand-swab contamination before traditional C-HW on average had double the rate of E.Coli contamination after C-HW. 

Updated 28/02/2023


Wellcome Trust ISSF and MRC UKRI

Microplastics in drinking water and child stool

Research Project Team Leads:

University of Birmingham (UOB): Dr S Manaseki-Holland, Professor S Krause, Professor N Thomas, Professor I Lynch

University of Science Technique and Technology, Bamako (USTTB): Professor O Koita, Professor O Toure, Dr Cheick Sidibe and Dr Youssouf Diarra

A public health priority:

Micro- and nanoplastics (MnP) are omnipresent in the natural and built environment. Our groups have evidenced their presence in water, air and food, including outdoor and indoor environments. We are developing protocols for the standardised extraction and quantification of MnP from environmental samples as well as human tissues including brain, stool, spinal fluid, and blood. While there has been remarkable progress in identifying MnP pollution sources, their transport mechanisms and hotspots of accumulation and exposures, uptake in food webs and consequences for environmental functioning and health, the health effects of MnP have not been explored epidemiologically or for childhood diseases. Cellular level studies indicate multiple possible mechanistic pathways and influences on organs. MnP have been shown, for instance, to cause gut inflammation and their absorption into the body, which likely worsens the MnP impact, and increases in presence of gut inflammation. Diarrhoea can involve inflammation in the gut and therefore may be exacerbated by MnP and in particular the leaching of their additives, including endocrine disrupting substances such as Bisphenol A, phthalates, brominated flame retardants and others. There is also limited evidence that protective microbiome organisms may either be harmed or influence the biodegradation of MnP, both with competing effect on the risks of MnPs.

Based on our observational studies of the presence of plastic waste in the environment, and pilot studies investigating MnP in children’s drinking water and stool, microplastic exposure through food, water, and air is expected to be high in Mali. Common conditions such as diarrhoea will therefore exacerbate the potential harms of MnPs increasing inequalities. We plan on conducting a number of studies to provide important evidence on the potential effects of MnPs (and their additives) exposure and uptake on child health to help prioritise further research and intervention policy.

We have secured funding for and conducted a range of studies developing the required experimental analytical techniques and protocols summarised below, that now bring us into the unique position to seek additional funding for further epidemiological work.

Studies/activities led by our UOB Geography Department laboratories and Institute of Applied Health Sciences thus far: 

  1. Development of MnP extraction and identification protocols for environmental media (water, air (passive and active sampling systems), food sources, soil, plant material, animal, and human tissue (including stool)). Thus we have established analytical methods and libraries for MnP characterization.
  2. Scoping scientific review of MnP and human health outcomes with specific focus on exacerbation of inflammatory disease, currently under peer-review for journal publication.

Based on these enabling works, we conducted two preliminary studies in Mali:

  1. Mapping of plastic use/garbage in households in Urban and Rural Mali; 2 nested studies, first, funded- Institute for Global Innovation, University of Birmingham; second, funded by UKRI Medical Research Council.

Research questions: How are plastic items used in the household e.g. utensils or containers related to eating or drinking, and the extent of plastic waste in the household compounds? What are the socioeconomic variables associated with the extent of such exposure?


Study 1: As a nested study, we explored the above research questions in 280 randomly selected houses in 3 villages and 2 urban Bamako communities. A questionnaire was used to collect data on use of common plastic items in the household. Observation of the waste areas (rubbish pile/container) as well as deposits around the compound in the household was done to estimate the presence of plastic in their rubbish/household waste. The questionnaire and observational data are coded to enable a comparison between urban and rural households, or by other characteristics such as the education level.

Study 2: In a large RCT MaaCiwara study similar observations are being made about plastics disposal – data collection in progress.

Preliminary results: Study 1: 100% of the surveyed families used plastic items for kitchen or eating as well as other household use.

Studies 1 and 2: All households had plastic waste around their compounds; the measure of waste around the compound and in the waste pile/bin is currently being coded for quantification. 

  1. Identification of MnP in stools of exposure and their association with diarrhoea, growth, and development of children in Mali and first explorative analysis of exposure routes and possible indication for association with diarrhoea, growth, and development of children’ Funding source- Donald Krogstad Award for Early-Career Malian Scientists, Tulane University, and the Institute for Global Innovation, University of Birmingham, Prof. Krause’s; Dr. Sidibe, Prof Koita and Dr Manaseki-Holland/MaaCiwara research group

Research questions: What are the overall MnP particle concentrations, total mass burden, and polymer types in drinking water and stool of children aged 6-36 months across aforementioned cohort of infants in Mali? Do initial findings indicate the existence of any type of geographical gradient (regional, urban vs rural) or other participant characteristics for this exposure?

Methods: Cross-sectional random samples from children drinking water and stools (plus their background characteristics survey) chosen from the 20 children (6-36month) who were sampled in 60 urban and 60 rural communities during the baseline data collection of MaaCiwara study (a nested study within the MaaCiwara 120 cluster RCT).

For this pilot study novel methods for extraction of MnP was developed by UOB and staff from Mali trained for this and to conduct detection of MnP using two methods at UOB laboratories. Florescent microscopy was conducted for 127 stool samples and 72 water samples to identify and quantify MnP, including characterisation of their particle properties (size, form and shape). In addition, Raman spectroscopy was conducted on 116 stool and 19 water samples to identify the types of MnP polymers (e.g. Polyethylene (PE) or polyvinyl chloride (PVC) or Polypropylene (PP), etc). Characterisation of MnP additives through Pyrolisis GC-MS is currently set-up and will be conducted April-June.

Preliminary results:

•       MnP were detected in over 90% of the stool samples and most of them were classified as ‘fibres’ and some were ‘fragments.

•       Approximately 80% of the water samples were positive for MnP; both fibres and fragments were found (as shown in the figure below).

•       Several types of polymers were identified, the most abundant being Polyvinyl Chloride (PVC), Polyethylene (PE) respectively.

Figure1: Shapes of the fragments and fibres found in the water and stool samples

stool sample


 2. Development of a unique stool sample bank for future MnP extraction

Further to the baseline data collection through MaaCiwara, stool samples are being collected through short-term and long-term follow-up data collection RCT rounds in 60 urban and 60 rural communities in Mali. The RCT is also collecting a wealth of information about the households, ranging from background characteristics to observation of plastic waste in their compounds and to child health outcomes. The nearly 9000 stools samples thus banked will enable future exploration of the possible relationship between MnP exposure and diarrhoea, respiratory symptoms, growth and development child health outcomes. The USTTB Mali team also have characterised the 17 common microbiomes in Mali infants, the role of which could be examined in exposure to MnPs.

Future plans for 2023-2030 and the need for funding:

•       Finalise pilot analysis and establish what’s the range in MnP burden – does it vary - identify if any geographical gradient

We wish to assess family or child characteristics against exposure, and plot a map of geographical level findings. However, the numbers are not large enough in the pilot to enable adequate assessment against health outcomes which is also available.

•       Extend stool/MnP sample bank for analysis beyond MaaCiwara project

•       Build a MnP analysis team and Unit in Mali in order to analyse large numbers of stools being stored/frozen for future analysis. We plan this through:

-       Developing the fluorescent microscopy platform in Mali (microscope already available; needs to get the additional accessories),

-       Developing a Raman spectroscopy platform in Mali,

-       Training more young scientists on MnP sample collection, digestion, extraction, and analysis in Mali.

•       Analyse larger stool sample sizes with increased health outcomes in order to assess any relationship between MnP exposure and diarrhoea, growth, development scores and respiratory symptoms.

•       Conducting a study on the effect of microplastics on gut microbiome in children, starting with laboratory in vitro investigations, and apply this learning to the large number of MaaCiwara samples in urban and rural Mali, to enable a possible examination of the relationship of microbiomes, MnPs and child outcome.

Updated 28/02/2023


Donald Krogstad Award for Early-Career Malian Scientists and MRC UKRI