Evaluation of SaTo pans as a new latrine technology in Kisumu County healthcare facilities, Kenya

OBJECTIVES

Innovations to improve public sanitation facilities, especially in healthcare facilities (HCFs) in low-income countries, are limited. SaTo pans represent novel, largely untested, modifications to reduce odour and flies and improve acceptability of HCF sanitation facilities. We conducted a pilot project to evaluate acceptability, cleanliness, flies and odour within latrines in 37 HCFs in Kisumu, Kenya, randomised into intervention (SaTo pan modifications) and control arms by sub-county and HCF level.

METHODS

At baseline (pre-intervention) and endline (>3 months after completion of SaTo pan installations in latrines in intervention HCFs), we surveyed users, cleaners and in-charges, observed odour and cleanliness, and assessed flies using fly tape. Unadjusted difference-in-difference analysis compared changes from baseline to endline in patient-reported acceptability and observed latrine conditions between intervention and control HCFs. A secondary assessment compared patient-reported acceptability following use of SaTo pan versus non-SaTo pan latrines within intervention HCFs.

RESULTS

Patient-reported acceptability of latrines was higher following the intervention (baseline: 87%, endline: 96%, p = 0.05). However, patient-reported acceptability was also high in the control arm (79%, 86%, p = 0.34), and the between-arm difference-in-difference was not significant. Enumerator-observed odour declined in intervention latrines (32%-14%) compared with controls (36%-51%, difference-in-difference ratio: 0.32, 95% confidence interval: 0.12-0.84), but changes in flies, puddling of urine and visible faeces did not differ between arms. In the secondary assessment, fewer intervention than control latrines had patient-reported flies (0% vs. 26%) and odour (18% vs. 50%), and reported satisfaction was greater. Most cleaners reported dropholes and floors were easier to clean in intervention versus controls; limited challenges with water for flushing were reported.

CONCLUSIONS

Our results suggest SaTo pans may be acceptable by cleaners and users and reduce odour in HCF sanitation facilities, though challenges exist and further evaluation with larger sample sizes is needed.

An Assessment of Household Knowledge and Practices during a Cholera Epidemic- Dar es Salaam, Tanzania, 2016

From August 15, 2015 to March 5, 2016, Tanzania reported 16,521 cholera cases and 251 deaths, with 4,596 cases and 44 deaths in its largest city, Dar es Salaam. To evaluate outbreak response efforts, we conducted a household survey with drinking water testing in the five most affected wards in Dar es Salaam. We interviewed 641 households 6 months after the beginning of the outbreak. Although most respondents knew that cholera causes diarrhea (90%) and would seek care if suspecting cholera (95%), only 45% were aware of the current outbreak in the area and only 5% would use oral rehydration salts (ORS) if ill. Of 200 (31%) respondents reporting no regular water treatment, 46% believed treatment was unnecessary and 18% believed treatment was too expensive. Fecal contamination was found in 45% of water samples and was associated with water availability (P = 0.047). Only 11% of samples had detectable free chlorine residual, which was associated with water availability (P = 0.025), reported current water treatment (P = 0.006), and observed free chlorine product in the household (P = 0.015). The provision of accessible, adequately chlorinated water supply, and implementation of social mobilization campaigns advocating household water treatment and use of ORS should be prioritized to address gaps in cholera prevention and treatment activities.

Impact Of Supply- and Demand-Side Interventions Integrated with Antenatal Care on Use of Maternal Health Services-Western Kenya, 2013‒2014

We evaluated whether antenatal supply-side and demand-side interventions in 10 public health care facilities (HCFs) increased the percentage of women who had four or more antenatal care (ANC4+) visits and HCF deliveries from baseline to follow-up compared with women in 10 public control HCFs in Kenya. We compared maternal registry data during baseline and follow-up periods between public intervention and public control HCFs; we added seven private intervention HCFs and five private control HCFs to evaluate an unanticipated pilot insurance program that enabled women to use private intervention HCFs. From baseline to follow-up, ANC4+ visits and HCF deliveries in public intervention HCFs were 1.64 and 1.19 times greater, respectively, than in public control HCFs. Health care facility deliveries were 1.5 times higher in private intervention HCFs than public intervention HCFs. Results suggested that the combined antenatal and insurance interventions motivated increased ANC4+ visits and HCF deliveries. Women appeared to prefer private HCFs for delivery.

A Cluster Randomized Trial of the Impact of Education through Listening (a Novel Behavior Change Technique) on Household Water Treatment with Chlorine in Vihiga District, Kenya, 2010-2011

Despite multiple studies demonstrating the effectiveness of household water treatment with chlorine in disinfecting water and preventing diarrhea, social marketing of this intervention in low- and middle-income countries has resulted in only modest uptake. In a cluster randomized trial in Vihiga district, western Kenya, we compared uptake of household water treatment with chlorine among six villages served by community vendors trained in standard social marketing plus education through listening (ETL), an innovative behavior change method, and six villages served by community vendors trained in standard social marketing only. Water treatment uptake, water quality, and childhood diarrhea were measured over 6 months and compared between the two groups of villages. During the 6-month period, we found no association between ETL exposure and reported and confirmed household water treatment with chlorine. In both groups (ETL and comparison), reported use of water treatment was low and did not change during our 6-month follow-up. However, persons confirmed to have chlorinated water had improved bacteriologic water quality. Study findings suggest that ETL implementation was suboptimal, which, along with unexpected changes in the supply and price of chlorine, may have prevented an accurate assessment of the potential impact of ETL on water treatment behavior. Taken together, these observations exemplify the complexities of habits, practices, attitudes, and external factors that can create challenging conditions for implementing behavioral interventions. As a consequence, in this trial, ETL had no measurable impact on water treatment behavior.

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.

"Ethics When You Least Expect It": A Modular Approach to Short Course Data Ethics Instruction

Data science skills are rapidly becoming a necessity in modern science. In response to this need, institutions and organizations around the world are developing research data science curricula to teach the programming and computational skills that are needed to build and maintain data infrastructures and maximize the use of available data. To date, however, few of these courses have included an explicit ethics component, and developing such components can be challenging. This paper describes a novel approach to teaching data ethics on short courses developed for the CODATA-RDA Schools for Research Data Science. The ethics content of these schools is centred on the concept of open and responsible (data) science citizenship that draws on virtue ethics to promote ethics of practice. Despite having little formal teaching time, this concept of citizenship is made central to the course by distributing ethics content across technical modules. Ethics instruction consists of a wide range of techniques, including stand-alone lectures, group discussions and mini-exercises linked to technical modules. This multi-level approach enables students to develop an understanding both of "responsible and open (data) science citizenship", and of how such responsibilities are implemented in daily research practices within their home environment. This approach successfully locates ethics within daily data science practice, and allows students to see how small actions build into larger ethical concerns. This emphasises that ethics are not something "removed from daily research" or the remit of data generators/end users, but rather are a vital concern for all data scientists.

Use, Acceptability, Performance, and Health Impact of Hollow Fiber Ultrafilters for Water Treatment in Rural Kenyan Households, 2009-2011

Diarrheal illness remains a leading cause of morbidity and mortality in children < 5 years in developing countries, and contaminated water contributes to diarrhea risk. To address this problem, a novel hollow fiber ultrafilter (HFU) was developed for household water treatment. To test its impact on water quality and infant health, we conducted a cluster-randomized longitudinal evaluation in 10 intervention and 10 comparison villages in Kenya, attempting to enroll all households with infants (< 12 months old). We conducted a baseline survey, distributed HFUs to intervention households, made biweekly home visits for 1 year to assess water treatment practices and diarrhea in infants, and tested water samples from both groups every 2 months for Escherichia coli. We enrolled 92 infants from intervention households and 74 from comparison households. During the 1-year study period, 45.7% of intervention households and 97.3% of comparison households had at least one stored water sample test positive for E. coli. Compared with comparison households, the odds of E. coli contamination in stored water was lower for intervention households (odds ratio [OR]: 0.42, 95% CI: 0.24, 0.74), but there was no difference in the odds of reported diarrhea in infants, adjusting for covariates (OR: 1.19, 95% CI: 0.74, 1.90). Although nearly all water samples obtained from unprotected sources and filtered by the HFU were free of E. coli contamination, HFUs alone were not effective at reducing diarrhea in infants.

Making Data and Workflows Findable for Machines

Research data currently face a huge increase of data objects with an increasing variety of types (data types, formats) and variety of workflows by which objects need to be managed across their lifecycle by data infrastructures. Researchers desire to shorten the workflows from data generation to analysis and publication, and the full workflow needs to become transparent to multiple stakeholders, including research administrators and funders. This poses challenges for research infrastructures and user-oriented data services in terms of not only making data and workflows findable, accessible, interoperable and reusable, but also doing so in a way that leverages machine support for better efficiency. One primary need to be addressed is that of findability, and achieving better findability has benefits for other aspects of data and workflow management. In this article, we describe how machine capabilities can be extended to make workflows more findable, in particular by leveraging the Digital Object Architecture, common object operations and machine learning techniques.

E. coli recovery from antimicrobial hand towels used in rural households in Kenya

An antimicrobial towel designed for repeated use was developed to prevent recontamination of washed hands after drying. This field trial in Kenya found that nearly all antimicrobial hand towels and untreated control towels were contaminated with E. coli after household use. The antimicrobial towel did not inactivate E. coli.

Evaluation of a Water and Hygiene Project in Health-Care Facilities in Siaya County, Kenya, 2016

To address water and hygiene infrastructure deficiencies in health-care facilities (HCFs) in Siaya County, Kenya, portable water stations, soap, and water treatment products were provided to 109 HCFs in 2005. In 2011 and again in 2016, we interviewed staff in 26 randomly selected HCFs, observed water sources, water stations, and tested source and stored water for chlorine residual and Escherichia coli. Of 26 HCFs, 22 (85%) had improved water supplies, and 22 (85%) had functioning handwashing and drinking water stations, but < 50% provided soap or water treatment. Thirteen (50%) of 26 source water samples yielded E. coli; 24 (92%) of 26 stored water samples yielded no E. coli, including nine with residual chlorine and nine untreated samples from sources yielding no E. coli. Eleven years after implementation, 85% of HCFs continued to use water stations that protected water from recontamination. Sustainable provision of soap and water treatment products could optimize intervention use.

Evaluation of the impact of antimicrobial hand towels on hand contamination with Escherichia coli among mothers in Kisumu County, Kenya, 2011-2012

Poor hand hygiene contributes to diarrhea in developing countries. Handwashing with soap reduces diarrhea risk, but drying hands on contaminated towels can compromise the benefits of handwashing. In response to the challenge of keeping hands clean, an antimicrobial hand towel was developed and shown to be promising in the laboratory, but has not been adequately tested in the field. We evaluated the effectiveness of an antimicrobial towel in two randomized, double-blinded crossover trials among mothers with children<5 years old in 125 households in western Kenya. In trial 1, we randomly assigned mothers to use either the treated towel or an identical untreated (placebo) towel and made surprise home visits at random times once a week for three weeks. At each visit, we tested hands for Escherichia coli using sterile hand rinses, then switched towel types in the two groups and repeated three weekly rounds of E. coli testing. In crossover trial 2, we compared E. coli contamination of maternal hands immediately following three different handwashing/drying procedures: soap and water + treated towel, water only + treated towel, and soap and water + air dry. There was no statistically significant difference in the level of E. coli contamination on maternal hands by type of towel used during trial 1 (odds ratio for treated vs untreated towel: 1.14, 95% confidence interval 0.83-1.56). In trial 2, there were no significant differences in E. coli contamination of maternal hands by handwashing/drying procedure. In these trials, use of antimicrobial hand towels did not prevent E. coli contamination of mothers' hands in Kenyan households during random testing and offered no advantages over standard handwashing and drying practices. Handwashing with soap and clean water and drying with clean towels are recommended.

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.

Evaluation of Student Handwashing Practices During a School-Based Hygiene Program in Rural Western Kenya, 2007

Unsafe drinking water and inadequate handwashing facilities in primary schools increase the risk of absenteeism due to diarrhea and respiratory infections. To mitigate these risks, we provided 28 schools in rural Western Kenya with handwashing and drinking water stations (containers with lids and taps on metal stands), bleach for water treatment, soap for handwashing, and educational materials. We observed the use of the water stations and assessed teachers' attitudes toward the intervention. Of 151 total handwashing stations, 69 (59%) were observed to have soap and water and treated drinking water 4 months after implementation; observations of pupils showed an increase in handwashing behavior in water stations located < 10 m, as compared with those >10 m, from latrines ( p < .02). In focus groups, teachers reported improved cleanliness and decreased illness in pupils. Teacher training and installation of water stations resulted in observed improvements in pupils' hygiene, particularly when water stations were located <10 m from latrines.

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.

Teacher perspectives on implementing and sustaining a handwashing promotion intervention in Western Kenyan primary schools

School-based handwashing programs are challenging to establish and sustain, especially in low-resource settings. This qualitative study described teacher perspectives associated with implementing and sustaining a handwashing program in primary schools participating in the Nyando Integrated Child Health and Education (NICHE) project. Structured key informant interviews were conducted with teachers. Prevalent concepts and themes were grouped into themes and topic areas using an iterative, open coding approach. Forty-one teacher respondents reported favorable expectations and benefits of handwashing programs. The importance of available resources (e.g., reliable water) was cited as a primary concern. Other challenges included time and personal or institutional financial commitment necessary to ensure program sustainability. Handwashing programs in low-income, rural schools, where infrastructure is lacking and "student ambassadors" extend the intervention to the surrounding community, hold great promise to improve community health. Teachers must have adequate support and resources to implement and sustain the programs.

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.

Cholera epidemic associated with consumption of unsafe drinking water and street-vended water--Eastern Freetown, Sierra Leone, 2012

During 2012, Sierra Leone experienced a cholera epidemic with 22,815 reported cases and 296 deaths. We conducted a matched case-control study to assess risk factors, enrolling 49 cases and 98 controls. Stool specimens were analyzed by culture, polymerase chain reaction (PCR), and pulsed-field gel electrophoresis (PFGE). Conditional logistic regression found that consuming unsafe water (matched odds ratio [mOR]: 3.4; 95% confidence interval [CI]: 1.1, 11.0), street-vended water (mOR: 9.4; 95% CI: 2.0, 43.7), and crab (mOR: 3.3; 95% CI: 1.03, 10.6) were significant risk factors for cholera infection. Of 30 stool specimens, 13 (43%) showed PCR evidence of toxigenic Vibrio cholerae O1. Six specimens yielded isolates of V. cholerae O1, El Tor; PFGE identified a pattern previously observed in seven countries. We recommended ensuring the quality of improved water sources, promoting household chlorination, and educating street vendors on water handling practices.

Evaluation of a rapid cholera response activity--Nyanza Province, Kenya, 2008

BACKGROUND

In response to recurrent cholera outbreaks in Nyanza Province, Kenya, a local nongovernmental organization assisted the Ministry of Health by providing cholera education activities to some cholera-affected communities. We evaluated the impact on cholera prevention knowledge and practices.

METHODS

In November-December 2008, we conducted a cross-sectional household survey and tested stored water for chlorine in 6 cholera-affected enumeration areas (intervention-EAs) where response activities had occurred between March-September 2008, and 6 comparison-EAs with no known reports of cholera outbreaks or response activities.

RESULTS

We enrolled 358 individuals from intervention-EAs and 365 from comparison-EAs. Overall, >80% knew cholera symptoms and over 60% knew that water treatment prevented diarrhea; <20% had chlorine residual in stored water. More intervention-EA respondents than comparison-EA respondents recalled a cholera outbreak in their community (52% vs 19%, P < .0001), and of those, 51% versus 39%, respectively, had attended a cholera response event. Detectable chlorine residuals in stored water were found in a higher percentage of intervention-EA and comparison-EA event attendees (21% and 25%, respectively) than nonattendees (17% and 8%, respectively).

CONCLUSIONS

There was a gap between knowledge and practice of water treatment as a cholera preventive measure. Cholera event attendance may have modestly motivated increased household water treatment.

The challenge of promoting interventions to prevent disease in impoverished populations in rural western Kenya

Poverty is a critical social determinant of health. A particular approach toward mitigating inequitable access to health services in Kenya has been through a community-based distribution program implemented by the Safe Water and AIDS Project (SWAP) that has achieved modest uptake of public health interventions. To explore reasons for modest uptake, we asked program participants about child health problems, daily tasks, household expenditures, and services needed by their communities. Respondents identified child health problems consistent with health data and reported daily tasks, expenses, and needed services that were more related to basic needs of life other than health. These findings highlight the challenges of implementing potentially self-sustaining preventive interventions at scale in poor populations in the developing world.

Enhancing a safe water intervention with student-created visual aids to promote handwashing behavior in Kenyan primary schools

The Nyando Integrated Child Health Education (NICHE) project was a collaborative effort by the U.S. Centers for Disease Control and local partners to assess the effectiveness of multiple interventions for improving child survival in western Kenya. To increase handwashing in schools, NICHE trained teachers and installed handwashing stations with treated water and soap in 51 primary schools. This cluster-randomized trial evaluated an additional educational strategy (a poster contest themed, "Handwashing with Soap") to improve handwashing behavior in 23 NICHE primary schools. Pupils were engaged in the poster development. Pupil handwashing behavior was observed unobtrusively at baseline and after four months. Intervention schools displayed a significant increase in the number of handwashing stations and proportion of teacher-supervised stations over the study period. No significant between-group differences of intervention in handwashing frequency, soap availability, or visibility of handwashing stations was observed. Despite finding a limited effect beyond the NICHE intervention, the trial appeared to promote sustainability across some measures.

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.

Selling Sprinkles micronutrient powder reduces anemia, iron deficiency, and vitamin A deficiency in young children in Western Kenya: a cluster-randomized controlled trial

BACKGROUND

Although the efficacy of micronutrient powders [MNPs; eg, Sprinkles MNP (Sprinkles Global Health Initiative)] in the reduction of anemia has been established, the effectiveness of these powders in real-world programs has seldom been assessed.

OBJECTIVE

In this study, we evaluated the effect of community-based marketing and distribution of Sprinkles MNP on childhood rates of anemia and iron and vitamin A deficiency.

DESIGN

In a cluster-randomized trial in children aged 6-35 mo in Western Kenya, 60 villages were randomly assigned to either intervention or control groups. Community vendors marketed and sold sachets of Sprinkles MNP in intervention villages. Biweekly household visits monitored the use of Sprinkles MNP. Hemoglobin, ferritin, retinol binding protein, malaria, and anthropometric measures were assessed at baseline (n = 1063) and 12 mo of follow-up (n = 862). Data were analyzed by using an intention-to-treat analysis and generalized linear mixed models.

RESULTS

On average, 33% of households in intervention villages purchased Sprinkles MNP; the average weekly intake per child was 0.9 sachets (∼11.3 mg Fe and ∼328 μg vitamin A). Compared with control subjects, intervention children had greater improvements in hemoglobin concentrations (increase of 0.9 compared with 0.6 g/dL, respectively; P = 0.02), iron deficiency (decrease of 19.3% compared with 5.3%, respectively; P = 0.001), and vitamin A deficiency (decrease of 7.5% compared with an increase of 2.5%, respectively; P = 0.01). Results adjusted for age, sex, socioeconomic status, and maternal education showed a significant association between the hemoglobin, iron, and vitamin A concentrations of children and the number of Sprinkles MNP sachets the children consumed. The prevalence of malaria, wasting, and stunting did not change significantly in either group.

CONCLUSION

Even with relatively low and infrequent use, Sprinkles MNP sales through community vendors were associated with decreased rates of anemia and iron and vitamin A deficiency in children in a resource-poor setting. This trial was registered at clinicaltrials.gov as NCT01088958.

Risk factors early in the 2010 cholera epidemic, Haiti

During the early weeks of the cholera outbreak that began in Haiti in October 2010, we conducted a case-control study to identify risk factors. Drinking treated water was strongly protective against illness. Our results highlight the effectiveness of safe water in cholera control.

Cholera prevention training materials for community health workers, Haiti, 2010–2011

Stopping the spread of the cholera epidemic in Haiti required engaging community health workers (CHWs) in prevention and treatment activities. The Centers for Disease Control and Prevention collaborated with the Haitian Ministry of Public Health and Population to develop CHW educational materials, train >1,100 CHWs, and evaluate training efforts.

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.

Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers

Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings.

Epidemic cholera in a crowded urban environment, Port-au-Prince, Haiti

We conducted a case-control study to investigate factors associated with epidemic cholera. Water treatment and handwashing may have been protective, highlighting the need for personal hygiene for cholera prevention in contaminated urban environments. We also found a diverse diet, a possible proxy for improved nutrition, was protective against cholera.

Microbiologic effectiveness of boiling and safe water storage in South Sulawesi, Indonesia

In Indonesia, where diarrhea remains a major cause of mortality among children <5 years, the government promotes boiling of drinking water. We assessed the impact of boiling on water quality in South Sulawesi. We surveyed randomly selected households with at least one child <5 years old in two rural districts and tested source and stored water samples for Escherichia coli contamination. Among 242 households, 96% of source and 51% of stored water samples yielded E. coli. Unboiled water samples, obtained from 15% of households, were more likely to yield E. coli than boiled samples [prevalence ratios (PR) = 2.0, 95% confidence interval (CI) 1.7-2.5]. Water stored in wide-mouthed (PR = 1.4, 95% CI = 1.1-1.8) or uncovered (PR = 1.8, 95% CI = 1.3-2.4) containers, or observed to be touched by the respondent's hands (PR = 1.6, 95% CI = 1.3-2.1) was more likely to yield E. coli. A multivariable model showed that households that did not boil water were more likely to have contaminated stored water than households that did boil water (PR = 1.9, 95% CI = 1.5-2.3). Although this study demonstrated the effectiveness of boiling in reducing contamination, overall impact on water quality was suboptimal. Future studies are needed to identify factors behind the success of boiling water in Indonesia to inform efforts to scale up other effective water treatment practices.

Aetiology of diarrhoea among persons with HIV and their family members in rural Uganda: a community-based study

OBJECTIVES

To identify pathogens associated with diarrhoea in HIV-infected persons and their HIV-uninfected family members.

DESIGN

Prospective cohort study.

SETTING

Rural community in eastern Uganda.

SUBJECTS

Eight hundred and seventy nine HIV-infected adults (74% females and median age 35 years (IQR, 29-41) and 2771 HIV-uninfected family members (51% females and median age 11 years (IQR 6-16) were included.

MAIN OUTCOME MEASURES

Using microscopy and culture, stools were tested for parasites, bacteria and bacterial-antimicrobial-susceptibility. Logistic regression models, adjusting for age, CD4 cells, season, household clustering and use of safe-water system were used for relationships between pathogens, diarrhoea and HIV.

RESULTS

Persons with HIV had similar pathogens in diarrhoeal (69%) and nondiarrhoeal stools (57%). Most diarrhoea was not associated with identifiable aetiology; the population attributable risk of diarrhoea for known diarrhoea pathogens was 32%. Enteric bacteria (19%), enteropathogenic or enterotoxigenic E. coli (8%), Aeromonas species (7%), Strongyloides stercoralis (8%) and Cryptosporidium parvum (5%). HIV-infected, stools had more Cryptosporidium parvum than HIV-uninfected (OR 2.64, 95% CI 1.43-4.87). Most bacteria were resistant to commonly used antimicrobials irrespective of HIV status.

CONCLUSIONS

Irrespective of HIV-status, aetiologies of majority of their diarrhoea in Uganda cannot be identified by microscopy and culture. Bacterial pathogens isolated have high resistance to common antimicrobials. Empiric treatment should be tailored to local bacterial-resistance patterns.

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

Access to safe drinking water and improved hygiene are important for reducing morbidity and mortality from diarrhea. We surveyed 330 pregnant women who participated in an antenatal clinic-based intervention in Malawi that promoted water treatment and hygiene through distribution of water storage containers, sodium hypochlorite water treatment solution, soap, and educational messages. Program participants were more likely to know correct water treatment procedures (62% versus 27%, P < 0.0001), chlorinate drinking water (61% versus 1%, P < 0.0001), demonstrate correct handwashing practices (68% versus 22%, P < 0.0001), and purchase water treatment solution after free distribution (32% versus 1%, P < 0.0001). Among participants, 72% had at least three antenatal visits, 76% delivered in a health facility, and 54% had a postnatal check. This antenatal-clinic-based program is an effective new strategy for promoting water treatment and hygiene behaviors among pregnant women. Participants had high use of antenatal, delivery, and postnatal services, which could improve maternal and child health.

Monitoring the marketing, distribution, and use of Sprinkles micronutrient powders in rural western Kenya

BACKGROUND

In 2007, the US Centers for Disease Control and Prevention partnered with local Kenyan institutions to implement the Nyando Integrated Child Health and Education Project, an effectiveness study that used social marketing and a community-based distribution program to promote the sale of Sprinkles and other health products.

OBJECTIVE

To describe monitoring of wholesale sales, household demand, promotional strategies, and perceived factors influencing Sprinkles sales among vendors.

METHODS

Ongoing quantitative and qualitative monitoring of Sprinkles sales began in May 2007 in 30 intervention villages. Data sources included baseline and follow-up cross-sectional surveys; office records of Sprinkles sales to vendors; biweekly household monitoring of Sprinkles use; and qualitative data collection, including vendor focus groups and key informant interviews.

RESULTS

A total of 550 children aged 6 to 35 months were enrolled at baseline, and 451 were available at 12-month follow-up. During this period, nearly 160,000 sachets were sold wholesale to vendors, with variability in sales influenced by the social, political, and economic context. Vendors living closer to the wholesale office purchased more Sprinkles, so a second office was opened closer to remote vendors. On average, 33% of households purchased Sprinkles during household monitoring visits. Training sessions and community launches were important for community support and raising awareness about Sprinkles. Vendor incentives motivated vendors to sell Sprinkles, and consumer incentives promoted purchases.

CONCLUSIONS

Sprinkles program monitoring in Kenya was critically important for understanding sales and distribution trends and vendor perceptions. Understanding these trends led to strategic changes to the intervention over time.

Utilization of a basic care and prevention package by HIV-infected persons in Uganda

Opportunistic infections are the leading cause of mortality among HIV-infected people. Several simple interventions prevent illness, prolong life, or prevent HIV transmission from HIV-infected people in Africa. These include: cotrimoxazole prophylaxis; insecticide-treated bed nets; supplies for household water treatment and safe storage; materials promoting family voluntary counselling and testing (VCT); and condoms. We provided these interventions to adults and children with HIV who were members of the AIDS Support Organization in Uganda. To evaluate use of this basic care and prevention package, we surveyed a representative sample of 112 clients of TASO in their homes. Among respondents, 95% reported taking cotrimoxazole everyday, 89% said they had slept under a bednet the night before, 65% reported current treatment of household drinking water, 89% of sexually active respondents reported using condoms, and 96% reported family use of VCT. Household observations verified that use of cotrimoxazole, bednets, and water treatment products were consistent with reported use. This evaluation suggests successful distribution and use of basic care and prevention services at an AIDS organization in Uganda.

Disinfection by-product formation and mitigation strategies in point-of-use chlorination of turbid and non-turbid waters in western Kenya

Over 1.1 billion people in the world lack access to improved drinking water. Diarrheal and other waterborne diseases cause an estimated 2.2 million deaths per year. The Safe Water System (SWS) is a proven household water treatment intervention that reduces diarrheal disease incidence in users in developing countries. Because the SWS recommends the addition of sodium hypochlorite to unfiltered water sources, concerns have been raised about the potential long-term health effects of disinfection by-products to SWS users. This study investigated the production of trihalomethanes (THMs) in water treated with sodium hypochlorite from six sources used for drinking water in western Kenya. The turbidity values of these sources ranged from 4.23 NTU to 305 NTU. THM concentrations were analysed at 1, 8, and 24 hours after addition of sodium hypochlorite. No sample exceeded the World Health Organization (WHO) guideline values for any of the four THMs: chloroform, bromodichloromethane, dibromochloromethane, or bromoform. In addition, no sample exceeded the WHO additive total THM guideline value. These results clearly show that point-of-use chlorination of a variety of realistic source waters used for drinking did not lead to THM concentrations that pose a significant health risk to SWS users.

The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006

Safe drinking water and hygiene are essential to reducing Kenya's diarrhoeal disease burden. A school-based safe water and hygiene intervention in Kenya was evaluated to assess its impact on students' knowledge and parents' adoption of safe water and hygiene practices. We surveyed 390 students from nine schools and their parents at baseline and conducted a final evaluation of 363 students and their parents. From baseline to final evaluation, improvement was seen in students' knowledge of correct water treatment procedure (21-65%, P<0.01) and knowing when to wash their hands. At final evaluation, 14% of parents reported currently treating their water, compared with 6% at baseline (P<0.01). From 2004 to 2005, school absenteeism in the September-November term decreased in nine project schools by 35% and increased in nine neighbouring comparison schools by 5%. This novel programme shows promise for reducing school absenteeism and promoting water and hygiene interventions in the home.

Cost and financial sustainability of a household-based water treatment and storage intervention in Zambia

Providing safe water to >1 billion people in need is a major challenge. To address this need, the Safe Water System (SWS) - household water treatment with dilute bleach, safe water storage, and behavior change - has been implemented in >20 countries. To assess the potential sustainability of the SWS, we analyzed costs in Zambia of "Clorin" brand product sold in bottles sufficient for a month of water treatment at a price of $0.09. We analyzed production, marketing, distribution, and overhead costs of Clorin before and after sales reached nationwide scale, and analyzed Clorin sales revenue. The average cost per bottle of Clorin production, marketing and distribution at start-up in 1999 was $1.88 but decreased by 82% to $0.33 in 2003, when >1.7 million bottles were sold. The financial loss per bottle decreased from $1.72 in 1999 to $0.24 in 2003. Net program costs in 2003 were $428,984, or only $0.04 per person-month of protection. A sensitivity analysis showed that if the bottle price increased to $0.18, the project would be self-sustaining at maximum capacity. This analysis demonstrated that efficiencies in the SWS supply chain can be achieved through social marketing. Even with a subsidy, overall program costs per beneficiary are low.

Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention

To prevent diarrhea in rural Western Kenya, we implemented the Safe Water System (water treatment with bleach, safe storage, and behavior-change communications) in 2000. We implemented a pilot project in a school in May 2003. Teachers taught students about safe water and hygiene. Safe water storage vessels were placed between classrooms. Two large water tanks for handwashing were positioned by the kitchen and latrines. The vessels were filled daily with water, which was treated with bleach and monitored for free chlorine residuals. Daily student care logs at the local clinic were reviewed. Clinic visits for diarrhea peaked during the January through March period in 2002 at 130 and in 2003 at 71, but in 2004, after project implementation, only 13 diarrhea episodes were recorded. The project saved the school about 5.49 dollars per student per year. The project has been expanded to 70 schools, and an evaluation is planned.

Cost-effectiveness of home-based chlorination and safe water storage in reducing diarrhea among HIV-affected households in rural Uganda

Safe water systems (SWSs) have been shown to reduce diarrhea and death. We examined the cost-effectiveness of SWS for HIV-affected households using health outcomes and costs from a randomized controlled trial in Tororo, Uganda. SWS was part of a home-based health care package that included rapid diarrhea diagnosis and treatment of 196 households with relatively good water and sanitation coverage. SWS use averted 37 diarrhea episodes and 310 diarrhea-days, representing 0.155 disability-adjusted life year (DALY) gained per 100 person-years, but did not alter mortality. Net program costs were 5.21 dollars/episode averted, 0.62 dollars/diarrhea-day averted, and 1,252 dollars/DALY gained. If mortality reduction had equaled another SWS trial in Kenya, the cost would have been 11 dollars/DALY gained. The high SWS cost per DALY gained was probably caused by a lack of mortality benefit in a trial designed to rapidly treat diarrhea. SWS is an effective intervention whose cost-effectiveness is sensitive to diarrhea-related mortality, diarrhea incidence, and effective clinical management.