Impact of the integration of water treatment and handwashing incentives with antenatal services on hygiene practices of pregnant women in Malawi

Knowledge and Behavioral Practice of Mothers About Childhood Diarrhea in Arar City, Saudi Arabia

BACKGROUND

Diarrhea is the second most significant cause of child morbidity and mortality, especially in developing countries. The World Health Organization (WHO) advises that mothers and other caregivers be able to recognize the symptoms of dehydration. Therefore, this study aimed to assess the knowledge and behavioral practices regarding diarrhea among mothers in Arar City, Saudi Arabia.

METHODS

This cross-sectional survey used an anonymous online questionnaire distributed among mothers of children aged one to five years in Arar City. The snowball convenient sampling method was used to recruit the participants. Information on knowledge and behavioral practices regarding diarrhea was obtained from the mothers of children through an electronic questionnaire. The Chi-square test and Fisher's exact test were used to evaluate the relationship between studied variables, as appropriate with statistical significance at P<0.05.

RESULTS

A total of 479 mothers participated in this survey. Of these, 421 were included in the analysis. Most mothers fall within the age range of 20-40 years (71.1%). A large sector of the studied mothers had high education (72.4%) and was a housewife (40.4%). Most children were above one year old (77.7%). Most participants (69.6%) fell into the moderate knowledge category and 56.3% had moderate behavioral practice scores. Maternal education was significantly associated with knowledge. Furthermore, maternal education and behavioral practice levels were significantly correlated (P < 0.01).

CONCLUSION

The findings highlight the importance of targeted education programs and community-based interventions to improve mothers' knowledge and promote appropriate behavioral practices related to childhood diarrhea that ultimately will lead to improved health outcomes for children globally.

Adoption of Point-of-Use Chlorination for Household Drinking Water Treatment: A Systematic Review

BACKGROUND

Centralized chlorination of urban piped water supplies has historically contributed to major reductions in waterborne illness. In locations without effective centralized water treatment, point-of-use (POU) chlorination for households is widely promoted to improve drinking water quality and health. Realizing these health benefits requires correct, consistent, and sustained product use, but real-world evaluations have often observed low levels of use. To our knowledge, no prior reviews exist on adoption of chlorine POU products.

OBJECTIVES

Our objectives were to identify which indicators of adoption are most often used in chlorine POU studies, summarize levels of adoption observed, understand how adoption changes over time, and determine how adoption is affected by frequency of contact between participants and study staff.

METHODS

We conducted a systematic review of household POU chlorination interventions or programs from 1990 through 2021 that reported a quantitative measure of adoption, were conducted in low- and middle-income countries, included data collection at households, and reported the intervention start date.

RESULTS

We identified 36 studies of household drinking water chlorination products that met prespecified eligibility criteria and extracted data from 46 chlorine intervention groups with a variety of chlorine POU products and locations. There was no consensus definition of adoption of household water treatment; the most common indicator was the proportion of household stored water samples with free chlorine residual > 0.1  or   0.2 mg / L . Among studies that reported either free or total chlorine-confirmed adoption of chlorine POU products, use was highly variable (across all chlorine intervention groups at the last time point measured in each study; range: 1.5%-100%; sample size-weighted median = 47 % ; unweighted median = 58 % ). The median follow-up duration among intervention groups was 3 months. On average, adoption declined over time and was positively associated with frequency of contact between respondents and study staff.

DISCUSSION

Although prior research has shown that POU chlorine products improve health when correctly and consistently used, a reliance on individual adoption for effective treatment is unlikely to lead to the widespread public health benefits historically associated with pressurized, centralized treatment of piped water supplies. https://doi.org/10.1289/EHP10839.

COVID-19 and handwashing: Implications for water use in Sub-Saharan Africa

Because the main modes of transmission of the COVID-19 virus are respiration and contact, WHO recommends frequent washing of hands with soap under running water for at least 20 s. This article investigates how the level of concern about COVID-19 affects the likelihood of washing hands frequently in sub-Saharan Africa. We discuss the implication of the findings for water-scarce environment. The study makes use of a unique survey dataset from 12 sub-Saharan African countries collected in April 2020 (first round) and May 2020 (second round) and employs an extended ordered probit model with endogenous covariate. The results show that the level of concern about the spread of the virus increases the likelihood of washing hands with soap under running water for a minimum of 20 s at least five times a day. The increase in the probability of handwashing due to concern about COVID-19, ranges from 3% for Benin to 6.3% for South Africa. The results also show heterogeneous effects across gender- and age-groups, locality and various water sources. However, in Africa, the sustainability of the handwashing protocol could be threatened by the severe water scarcity that exists in the region. To sustain frequent handwashing, sub-Saharan Africa needs an effective strategy for water management and supply.

The impact of supply-side and demand-side interventions on use of antenatal and maternal services in western Kenya: a qualitative study

Background

Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products.

Methods

To explore pregnant mothers’ experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants’ perceptions and experiences.

Results

FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education.

Conclusions

Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.

Formative research to scale up a handwashing with soap and water treatment intervention for household members of diarrhea patients in health facilities in Dhaka, Bangladesh (CHoBI7 program)

BACKGROUND

During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease.

METHODS

We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery.

RESULTS

The intervention program was modified based on formative research findings. Pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs.

CONCLUSIONS

Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.

Diffusion of Handwashing Knowledge and Water Treatment Practices From Mothers in an Antenatal Hygiene Promotion Program to Nonpregnant Friends and Relatives, Machinga District, Malawi

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases in low- and middle-income countries. Integrating water treatment and hygiene products into antenatal clinic care can motivate water treatment and handwashing among pregnant women. Free water hygiene kits (water storage containers, sodium hypochlorite water treatment solution, and soap) and refills of water treatment solution and soap were integrated into antenatal care and delivery services in Machinga District, Malawi, resulting in improved water treatment and hygiene practices in the home and increased maternal health service use. To determine whether water treatment and hygiene practices diffused from maternal health program participants to friends and relatives households in the same communities, we assessed the practices of 106 nonpregnant friends and relatives of these new mothers at baseline and 1-year follow-up. At follow-up, friends and relatives were more likely than at baseline to have water treatment products observable in the home (33.3% vs. 1.2%, p < 0.00001) and detectable free chlorine residual in their water, confirming water treatment (35.7% vs. 1.4%; p < 0.00001). Qualitative data from in-depth interviews also suggested that program participants helped motivate adoption of water treatment and hygiene behaviors among their friends and relatives.

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

Many health care facilities (HCFs) and households in low-and-middle-income countries have inadequate access to water for hygiene and consumption. To address these problems, handwashing and drinking water stations were installed in 53 HCFs with prevention-of-mother-to-child-transmission of HIV programs in Kenya in 2005, and hygiene education was provided to health workers and clinic clients. To assess this program, we selected a random sample of 30 HCFs, observed the percentage of handwashing and drinking water stations that were functional and in use, and after that interviewed health providers and clients about hygiene and water treatment. Results indicated that, six years after implementation, 80.0% of HCFs had at least one functional handwashing station and 83.3% had at least one functional drinking water station. In addition, 60% of HCFs had soap at ≥ one handwashing stations, and 23.3% had ≥ one container with detectable free chlorine. Of 299 clients (mothers with ≥ one child under five), 57.2% demonstrated proper water treatment knowledge, 93.3% reported ever using water treatment products, 16.4% had detectable chlorine residual in stored water, and 89.0% demonstrated proper handwashing technique. Six years after program implementation, although most HCFs had water stations and most clients could demonstrate proper handwashing technique, water stored in most clinics and homes was not treated.

Safe Water and Hygiene Integration with Human Immunodeficiency Virus and Antenatal Services: Leveraging Opportunities for Public Health Interventions and Improved Service Uptake

Integrating public health interventions with antenatal clinic (ANC) visits may motivate women to attend ANC, thereby improving maternal and neonatal health, particularly for human immunodeficiency virus (HIV)-infected persons. In 2009, in an integrated ANC/Preventing Mother-to-Child Transmission program, we provided free hygiene kits (safe storage containers, WaterGuard water treatment solution, soap, and oral rehydration salts) to women at their first ANC visit and refills at subsequent visits. To increase fathers' participation, we required partners' presence for women to receive hygiene kits. We surveyed pregnant women at baseline and at 12-month follow-up to assess ANC service utilization, HIV counseling and testing (HCT), test drinking water for residual chlorine, and observe handwashing. We conducted in-depth interviews with pregnant women, partners, and health workers. We enrolled 106 participants; 97 (92%) were found at follow-up. During the program, 99% of pregnant women and their partners received HCT, and 99% mutually disclosed. Fifty-six percent of respondents had ≥ 4 ANC visits and 90% delivered at health facilities. From baseline to follow-up, the percentage of women who knew how to use WaterGuard (23% versus 80%, P < 0.0001), had residual chlorine in stored water (0% versus 73%, P < 0.0001), had confirmed WaterGuard use (0% versus 70%, P < 0.0003), and demonstrated proper handwashing technique (21% versus 64% P < 0.0001) increased. Program participants showed significant improvements in water treatment and hygiene, and high use of ANC services and HCT. This evaluation suggests that integration of hygiene kits, refills, and HIV testing during ANC is feasible and may help improve household hygiene and increase use of health services.

Integrating Household Water Treatment, Hand Washing, and Insecticide-Treated Bed Nets Into Pediatric HIV Care in Mombasa, Kenya: Impact on Diarrhea and Malaria Risk

Introduction:

In developing countries, HIV-infected children are at higher risk of morbidity and mortality from opportunistic infections than HIV-uninfected children. To address this problem, the Healthy Living Initiative (HLI) in Mombasa, Kenya distributed basic care packages (BCPs) containing improved water storage vessels, water treatment solution, soap, and insecticide-treated bed nets to prevent diarrhea and malaria in children, and had community health workers (CHWs) make bimonthly home visits to encourage adherence to HLI interventions and antiretroviral (ARV) medicine use.

Methods:

To evaluate HLI, we enrolled 500 HIV-infected children from Bomu Hospital. In the implementation phase, from February to August 2011, we conducted surveys of caregivers, then provided free BCPs. In the evaluation phase, from September 2011 to August 2012, CHWs recorded observations of BCP use during home visits. We abstracted hospital data to compare diarrhea and malaria episodes, and pharmacy data on ARVs dispensed, between the 12-month preimplementation baseline phase (February 2010–January 2011) and the evaluation phase.

Results:

The retention rate of children in HLI was 78.4%. In a multivariable logistic regression model adjusting for demographic characteristics, number of CHW home visits, distance to clinic, orphan status, and number of ARVs dispensed, children in HLI had 71% lower risk of diarrhea (relative risk 0.29, P < 0.001) and 87% lower risk of malaria (relative risk 0.13, P = 0.001) during the evaluation phase than the baseline phase; there was no independent association between ARV use and illness.

Conclusions:

HIV-infected children in HLI were less likely to experience diarrhea and malaria during the evaluation phase than the baseline phase.

Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use

AbstractReducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.

Can incentives reduce the barriers to use of antenatal care and delivery services in Kenya?: Results of a qualitative inquiry

A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.

Integrating Water Treatment into Antenatal Care: Impact on Use of Maternal Health Services and Household Water Treatment by Mothers-Rural Uganda, 2013

To increase maternal health service use and household water treatment (HWT), free water treatment kits were provided at first antenatal care (ANC) visits and free water treatment sachet refills were provided at follow-up ANC visits, delivery, and postnatal visits in 46 health facilities in rural Uganda. We evaluated the impact by surveying 226 women in the initiative (intervention group) and 207 women who received ANC before the initiative began (comparison group). There was no differences in the percentages of intervention and comparison group women with ≥ 4 ANC visits; however, a higher percentage of intervention group women reported treating their drinking water (31.7% versus 19.7%, P = 0.01), and had free chlorine residual in stored water (13.5% versus 3.4%, P = 0.02) than comparison group women. The intervention did not appear to motivate increased maternal health service use, but demonstrated improvements in HWT.

Randomized Controlled Trial of Hospital-Based Hygiene and Water Treatment Intervention (CHoBI7) to Reduce Cholera

The risk for cholera infection is >100 times higher for household contacts of cholera patients during the week after the index patient seeks hospital care than it is for the general population. To initiate a standard of care for this high-risk population, we developed Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7), which promotes hand washing with soap and treatment of water. To test CHoBI7, we conducted a randomized controlled trial among 219 intervention household contacts of 82 cholera patients and 220 control contacts of 83 cholera patients in Dhaka, Bangladesh, during 2013-2014. Intervention contacts had significantly fewer symptomatic Vibrio cholerae infections than did control contacts and 47% fewer overall V. cholerae infections. Intervention households had no stored drinking water with V. cholerae and 14 times higher odds of hand washing with soap at key events during structured observation on surveillance days 5, 6, or 7. CHoBI7 presents a promising approach for controlling cholera among highly susceptible household contacts of cholera patients.

Sustained Uptake of a Hospital-Based Handwashing with Soap and Water Treatment Intervention (Cholera-Hospital-Based Intervention for 7 Days [CHoBI7]): A Randomized Controlled Trial

Diarrhea is the second leading cause of death in children under 5 years of age globally. The time patients and caregivers spend at a health facility for severe diarrhea presents the opportunity to deliver water, sanitation, and hygiene (WASH) interventions. We recently developed Cholera-Hospital-Based Intervention for 7 days (CHoBI7), a 1-week hospital-based handwashing with soap and water treatment intervention, for household members of cholera patients. To investigate if this intervention could lead to sustained WASH practices, we conducted a follow-up evaluation of 196 intervention household members and 205 control household members enrolled in a randomized controlled trial of the CHoBI7 intervention 6 to 12 months post-intervention. Compared with the control arm, the intervention arm had four times higher odds of household members' handwashing with soap at a key time during 5-hour structured observation (odds ratio [OR]: 4.71, 95% confidence interval [CI]: 2.61, 8.49) (18% versus 50%) and a 41% reduction in households in the World Health Organization very high-risk category for stored drinking water (OR: 0.38, 95% CI: 0.15, 0.96) (58% versus 34%) 6 to 12 months post-intervention. Furthemore, 71% of observed handwashing with soap events in the intervention arm involved the preparation and use of soapy water, which was promoted during the intervention, compared to 9% of control households. These findings demonstrate that the hospital-based CHoBI7 intervention can lead to significant increases in handwashing with soap practices and improved stored drinking water quality 6 to 12 months post-intervention.

Interventions to improve water quality for preventing diarrhoea

BACKGROUND

Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. In these settings, many infectious agents associated with diarrhoea are spread through water contaminated with faeces.In remote and low-income settings, source-based water quality improvement includes providing protected groundwater (springs, wells, and bore holes), or harvested rainwater as an alternative to surface sources (rivers and lakes). Point-of-use water quality improvement interventions include boiling, chlorination, flocculation, filtration, or solar disinfection, mainly conducted at home.

OBJECTIVES

To assess the effectiveness of interventions to improve water quality for preventing diarrhoea.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register (11 November 2014), CENTRAL (the Cochrane Library, 7 November 2014), MEDLINE (1966 to 10 November 2014), EMBASE (1974 to 10 November 2014), and LILACS (1982 to 7 November 2014). We also handsearched relevant conference proceedings, contacted researchers and organizations working in the field, and checked references from identified studies through 11 November 2014.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-RCTs, and controlled before-and-after studies (CBA) comparing interventions aimed at improving the microbiological quality of drinking water with no intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used meta-analyses to estimate pooled measures of effect, where appropriate, and investigated potential sources of heterogeneity using subgroup analyses. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Forty-five cluster-RCTs, two quasi-RCTs, and eight CBA studies, including over 84,000 participants, met the inclusion criteria. Most included studies were conducted in low- or middle-income countries (LMICs) (50 studies) with unimproved water sources (30 studies) and unimproved or unclear sanitation (34 studies). The primary outcome in most studies was self-reported diarrhoea, which is at high risk of bias due to the lack of blinding in over 80% of the included studies. Source-based water quality improvementsThere is currently insufficient evidence to know if source-based improvements such as protected wells, communal tap stands, or chlorination/filtration of community sources consistently reduce diarrhoea (one cluster-RCT, five CBA studies, very low quality evidence). We found no studies evaluating reliable piped-in water supplies delivered to households. Point-of-use water quality interventionsOn average, distributing water disinfection products for use at the household level may reduce diarrhoea by around one quarter (Home chlorination products: RR 0.77, 95% CI 0.65 to 0.91; 14 trials, 30,746 participants, low quality evidence; flocculation and disinfection sachets: RR 0.69, 95% CI 0.58 to 0.82, four trials, 11,788 participants, moderate quality evidence). However, there was substantial heterogeneity in the size of the effect estimates between individual studies.Point-of-use filtration systems probably reduce diarrhoea by around a half (RR 0.48, 95% CI 0.38 to 0.59, 18 trials, 15,582 participants, moderate quality evidence). Important reductions in diarrhoea episodes were shown with ceramic filters, biosand systems and LifeStraw® filters; (Ceramic: RR 0.39, 95% CI 0.28 to 0.53; eight trials, 5763 participants, moderate quality evidence; Biosand: RR 0.47, 95% CI 0.39 to 0.57; four trials, 5504 participants, moderate quality evidence; LifeStraw®: RR 0.69, 95% CI 0.51 to 0.93; three trials, 3259 participants, low quality evidence). Plumbed in filters have only been evaluated in high-income settings (RR 0.81, 95% CI 0.71 to 0.94, three trials, 1056 participants, fixed effects model).In low-income settings, solar water disinfection (SODIS) by distribution of plastic bottles with instructions to leave filled bottles in direct sunlight for at least six hours before drinking probably reduces diarrhoea by around a third (RR 0.62, 95% CI 0.42 to 0.94; four trials, 3460 participants, moderate quality evidence).In subgroup analyses, larger effects were seen in trials with higher adherence, and trials that provided a safe storage container. In most cases, the reduction in diarrhoea shown in the studies was evident in settings with improved and unimproved water sources and sanitation.

AUTHORS' CONCLUSIONS

Interventions that address the microbial contamination of water at the point-of-use may be important interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections. The average estimates of effect for each individual point-of-use intervention generally show important effects. Comparisons between these estimates do not provide evidence of superiority of one intervention over another, as such comparisons are confounded by the study setting, design, and population.Further studies assessing the effects of household connections and chlorination at the point of delivery will help improve our knowledge base. As evidence suggests effectiveness improves with adherence, studies assessing programmatic approaches to optimising coverage and long-term utilization of these interventions among vulnerable populations could also help strategies to improve health outcomes.

Acceptability and use of portable drinking water and hand washing stations in health care facilities and their impact on patient hygiene practices, Western kenya

Many health care facilities (HCF) in developing countries lack access to reliable hand washing stations and safe drinking water. To address this problem, we installed portable, low-cost hand washing stations (HWS) and drinking water stations (DWS), and trained healthcare workers (HCW) on hand hygiene, safe drinking water, and patient education techniques at 200 rural HCFs lacking a reliable water supply in western Kenya. We performed a survey at baseline and a follow-up evaluation at 15 months to assess the impact of the intervention at a random sample of 40 HCFs and 391 households nearest to these HCFs. From baseline to follow-up, there was a statistically significant increase in the percentage of dispensaries with access to HWSs with soap (42% vs. 77%, p<0.01) and access to safe drinking water (6% vs. 55%, p<0.01). Female heads of household in the HCF catchment area exhibited statistically significant increases from baseline to follow-up in the ability to state target times for hand washing (10% vs. 35%, p<0.01), perform all four hand washing steps correctly (32% vs. 43%, p = 0.01), and report treatment of stored drinking water using any method (73% vs. 92%, p<0.01); the percentage of households with detectable free residual chlorine in stored drinking water did not change (6%, vs. 8%, p = 0.14). The installation of low-cost, low-maintenance, locally-available, portable hand washing and drinking water stations in rural HCFs without access to 24-hour piped water helped assure that health workers had a place to wash their hands and provide safe drinking water. This HCF intervention may have also contributed to the improvement of hand hygiene and reported safe drinking water behaviors among households nearest to HCFs.

Sustainability and scale-up of household water treatment and safe storage practices: Enablers and barriers to effective implementation

Household water treatment and safe storage (HWTS) provides a solution, when employed correctly and consistently, for managing water safety at home. However, despite years of promotion by non-governmental organizations (NGOs), governments and others, boiling is the only method to achieve scale. Many HWTS programs have reported strong initial uptake and use that then decreases over time. This study maps out enablers and barriers to sustaining and scaling up HWTS practices. Interviews were carried out with 79 practitioners who had experience with HWTS programs in over 25 countries. A total of 47 enablers and barriers important to sustaining and scaling up HWTS practices were identified. These were grouped into six domains: user guidance on HWTS products; resource availability; standards, certification and regulations; integration and collaboration; user preferences; and market strategies. Collectively, the six domains cover the major aspects of moving products from development to the consumers. It is important that each domain is considered in all programs that aim to sustain and scale-up HWTS practices. Our findings can assist governments, NGOs, and other organizations involved in HWTS to approach programs more effectively and efficiently.

Improved health among people living with HIV/AIDS who received packages of proven preventive health interventions, Amhara, Ethiopia

In 2009, basic care packages (BCP) containing health products were distributed to HIV-infected persons in Ethiopia who were clients of antiretroviral therapy clinics. To measure health impact, we enrolled clients from an intervention hospital and comparison hospital, and then conducted a baseline survey, and 7 bi-weekly home visits. We enrolled 405 intervention group clients and 344 comparison clients. Intervention clients were more likely than comparison clients to have detectable chlorine in stored water (40% vs. 1%, p<0.001), soap (51% vs. 36%, p<0.001), and a BCP water container (65% vs. 0%, p<0.001) at every home visit. Intervention clients were less likely than comparison clients to report illness (44% vs. 67%, p<0.001) or health facility visits for illness (74% vs. 95%, p<0.001), and had lower median illness scores (1.0 vs. 3.0, p<0.05). Participation in the BCP program appeared to improve reported health outcomes.

Long-term impact of integration of household water treatment and hygiene promotion with antenatal services on maternal water treatment and hygiene practices in Malawi

A clinic-based program to integrate antenatal services with distribution of hygiene kits including safe water storage containers, water treatment solution (brand name WaterGuard), soap, and hygiene education, was implemented in Malawi in 2007 and evaluated in 2010. We surveyed 389 participants at baseline in 2007, and found and surveyed 232 (60%) participants to assess water treatment, test stored drinking water for residual chlorine (an objective measure of treatment), and observe handwashing technique at follow-up in 2010. Program participants were more likely to know correct water treatment procedures (67% versus 36%; P < 0.0001), treat drinking water with WaterGuard (24% versus 2%; P < 0.0001), purchase and use WaterGuard (21% versus 1%; P < 0.001), and demonstrate correct handwashing technique (50% versus 21%; P < 0.001) at the three-year follow-up survey than at baseline. This antenatal-clinic-based program may have contributed to sustained water treatment and proper handwashing technique among program participants.

Impact of a hygiene curriculum and the installation of simple handwashing and drinking water stations in rural Kenyan primary schools on student health and hygiene practices

School-based hygiene and water treatment programs increase student knowledge, improve hygiene, and decrease absenteeism, however health impact studies of these programs are lacking. We collected baseline information from students in 42 schools in Kenya. We then instituted a curriculum on safe water and hand hygiene and installed water stations in half ("intervention schools"). One year later, we implemented the intervention in remaining schools. Through biweekly student household visits and two annual surveys, we compared the effect of the intervention on hygiene practices and reported student illness. We saw improvement in proper handwashing techniques after the school program was introduced. We observed a decrease in the median percentage of students with acute respiratory illness among those exposed to the program; no decrease in acute diarrhea was seen. Students in this school program exhibited sustained improvement in hygiene knowledge and a decreased risk of respiratory infections after the intervention.

Water treatment and handwashing behaviors among non-pregnant friends and relatives of participants in an antenatal hygiene promotion program in Malawi

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases. To integrate hygiene improvement with antenatal care, free hygiene kits (water storage containers, water treatment solution, soap) and educational messages were distributed to pregnant women at antenatal clinics in Malawi. We assessed water treatment and hygiene practices of 275 non-pregnant friends and relatives of the hygiene kit recipients at baseline and follow-up nine months later to measure program impact on non-participants in the same communities. At follow-up, friends and relatives who did not receive kits or education were more likely than at baseline to purchase and use water treatment solution (25% versus 1%; P < 0.0001) and demonstrate correct handwashing practices (60% versus 18%; P < 0.0001). This antenatal clinic-based program resulted in improved water treatment and hygiene behaviors among non-pregnant friends and relatives living in the same communities as hygiene kit recipients, suggesting that program benefits extended beyond direct beneficiaries.

Addressing Inequities in Access to Health Products through the Use of Social Marketing, Community Mobilization, and Local Entrepreneurs in Rural Western Kenya

While social marketing can increase uptake of health products in developing countries, providing equitable access is challenging. We conducted a 2-year evaluation of uptake of WaterGuard, insecticide-treated bednets (ITNs), and micronutrient Sprinkles in Western Kenya. Sixty villages were randomly assigned to intervention and comparison groups. Following a baseline survey (BL), a multifaceted intervention comprising social marketing of these products, home visits by product vendors from a local women’s group (Safe Water and AIDS Project, or SWAP), product promotions, and modeling of water treatment and safe storage in was implemented in intervention villages. Comparison villages received only social marketing of WaterGuard and ITNs. We surveyed again at one year (FU1), implemented the intervention in comparison villages, and surveyed again at two years (FU2). At BL, <3% of households had been visited by a SWAP vendor. At FU1, more intervention than comparison households had been visited by a SWAP vendor (39% versus 9%, P<0.0001), and purchased WaterGuard (14% versus 2%, P<0.0001), Sprinkles (36% versus 6%, P<0.0001), or ITNs (3% versus 1%, P<0.04) from that vendor. During FU2, 47% and 41% of original intervention and comparison households, respectively, reported ever receiving a SWAP vendor visit (P=0.16); >90% those reported ever purchasing a product from the vendor. WaterGuard (P=0.02) and ITNs (P=0.005) were purchased less frequently by lower-SES than higher-SES households; Sprinkles, the least expensive product, was purchased equally across all quintiles.

Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya

BACKGROUND

Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenya's Homa Bay district, 1 using community workers to support nurses and 1 using nurses.

METHODS

Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability.

RESULTS

Between April 2009 and March 2010, 39 158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease).

CONCLUSIONS

Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery.

Hygiene behaviour and health attitudes in African countries

PURPOSE OF REVIEW

In African countries, the biggest killers of young children are respiratory infections and diarrhoeal disease, and both are preventable via hand washing. Regular tooth brushing, at least twice a day, is one of the most effective methods for the control and prevention of dental caries and periodontal diseases. Both these oral diseases are infectious diseases (caused by bacteria) and thus can be controlled by proper oral hygiene. This review aims to provide updated research related to hygiene behaviours in African countries in three areas: children, community and healthcare setting.

RECENT FINDINGS

Suboptimal hygiene knowledge and behaviour (hand washing, hand washing with soap and oral hygiene) were found among African children, contributing to diarrhoeal diseases, helminth infections, dental caries, periodontal diseases and other communicable diseases. Several promising intervention studies have been done to increase hygiene behaviours among children and adolescents and may need to be scaled up. Community studies found faecal contamination on hands to be common and to be associated with various ill-health conditions. Several innovative interventions to improve hand hygiene behaviours in the community setting show promising results. Healthcare-associated infections due to lack of hand hygiene are common in Africa and interventions need to be developed and implemented.

SUMMARY

Hand and oral hygiene are suboptimal in both community and healthcare settings. Several promising hygiene intervention strategies have been found effective and may be scaled up in African countries.

Understanding why women adopt and sustain home water treatment: insights from the Malawi antenatal care program

In many settings in Africa, social marketing has proven more successful in generating brand recognition for chlorine water treatment products than in promoting their use. To promote household use of one such product in Malawi, WaterGuard, the Ministry of Health (MOH) and Population Services International (PSI) distributed free hygiene kits that included WaterGuard to pregnant women attending antenatal clinics in 2007. Follow-up surveys documented a sustained increase in WaterGuard use three years after the initial intervention. In 2010, PATH (www.path.org) conducted qualitative research on the factors motivating women to adopt, sustain, or discontinue use. To provide context, interviews were also conducted with their friends, relatives, and husbands. Interviews revealed that sustained use of WaterGuard does not necessarily imply consistent use. Most respondents reported switching back and forth between WaterGuard and stock chlorine distributed for free by the government, and many treated water seasonally rather than year-round. Qualitative findings suggest that two program strategies strongly influenced women's decisions to adopt, purchase, and continue using WaterGuard. First, positive, ongoing contacts with health care workers, especially during home visits, raised awareness of the need to treat water, encouraged trial use, and supported continuing use. Second, an extended free trial of the product overcame initial cost barriers and allowed women and their families to experience the health benefits of WaterGuard, appreciate its value and relevance to their lives, and get used to its taste. Social support-from like-minded relatives, friends, neighbors, health care workers, husbands, and children-was also a critical factor that promoted consistent, ongoing use of WaterGuard. The findings confirm the importance of interpersonal communication in prompting adoption of household water treatment and suggest that consumers assess the perceived value of a product, not simply its cost. Further research is planned to investigate questions raised about patterns of ongoing use.