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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 3 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.
We conducted cross-sectional surveys of a sample of pregnant women at their first ANC visit and 1 year later at eight rural health facilities in Machinga district in which the program was first initiated (Figure 2). The CHAI data analyst abstracted maternal health and HCT service use data from antenatal and HCT registries at all 15 health facilities in Machinga district for 2008 quarter 2 (the year preceding program implementation) and all 12 subsequent quarters from 2009 to 2011. Timeline for implementation and evaluation of water hygiene kit (WHK) intervention into prevention of mother to child transmission program, Machinga District, Malawi, 2008–2012. This figure appears in color at www.ajtmh.org. Machinga is a rural district in the Southern region of Malawi with an economically impoverished population of approximately 370,000 and an overall HIV prevalence of 15.1%, well above the national average of 10.1%.5 Evaluation participants were limited to those attending ANC for the first time during their current pregnancy. We aimed to enroll all eligible pregnant women at the eight health facilities initially participating in the program during the week of March 15–22, 2010. We selected a sample of pregnant women from each of these facilities proportional to at least 10% of their average monthly ANC attendance. Participants were enrolled in a continuous fashion until the correct number for each clinic was obtained. Prior to enrollment, enumerators read a consent form explaining the purpose of the evaluation, and women gave verbal consent to participate. Women were eligible to participate if this was the first ANC visit for this pregnancy, and they were accompanied by their husband or partner. If a woman’s partner was not present because of divorce, death, or travel, she could participate if she could present a note from the village headman verifying her partner’s status. Our resulting total sample size of 106 pregnant women provided 80% power to detect a 12% difference from baseline to follow-up, assuming a 20% proportion of discordant pairs. The baseline survey took place in March 2010. We used standardized questionnaires to interview participants at their first ANC visit on demographic and socioeconomic characteristics, water sources, and water storage, treatment, and hygiene practices. We then visited participants’ homes to observe water storage and treatment practices, presence of soap, and demonstration of handwashing procedure. We tested stored drinking water for free chlorine residual (FCR) using the N,N-diethyl-phenylenediamine colorimetric method using Hach Free and Total Chlorine kits (Hach Co., Loveland, CO) as an objective measure of WaterGuard use. Enrollees received their hygiene kits after completing the baseline survey. Distribution of hygiene kits began in Machinga in September 2009 and continued through December 2011, at which time CHAI handed the program over to the Ministry of Health. Participants were offered HCT together with their partner, and told that they would receive a WHK at that visit, and up to five refills of WaterGuard and soap: at three return ANC visits, delivery and 6-week post-natal check. In preparation for program implementation, Population Services International, the non-governmental organization that marketed WaterGuard, trained health facility staff, consisting of ANC nurses and Health Surveillance Assistants (Ministry of Health employees who provide community health services, hereafter referred to as HSAs) on patient communication, handwashing techniques, and appropriate water storage, handling, and treatment with WaterGuard. Antenatal clinic nurses were asked to incorporate these topics into ANC educational activities. Health Surveillance Assistants were encouraged to reinforce hygiene kit use by demonstrating correct WaterGuard use and handwashing technique during periodic home visits. In March 2011 we visited program participants enrolled at baseline to conduct follow-up interviews and make observations. The questionnaire was identical to the baseline questionnaire except for additional questions on the hygiene kit program and use of ANC and HIV testing services. Before initiation of the program, CHAI collected data from quarter 2, 2008 for specific ANC and HIV indicators from Machinga district in all 15 health facilities providing ANC and HIV care. Clinton Health Access Initiative then abstracted data on ANC, maternity, and HIV services received by pregnant women during all 12 subsequent quarters, including the study period March 2010–March 2011, from registries at the same 15 health facilities, which included the eight facilities participating in the evaluation. The registry data from 2008 and from the 12 subsequent quarters that included the study period were compared with the Malawi Demographic and Health Survey (DHS) data, collected in 2010.5 In May 2011, we conducted in-depth interviews and focus group discussions (FGDs) with a convenience sample of program participants to determine factors influencing use of PMTCT and ANC services, and water treatment and handwashing practices. To provide context, interviews were also conducted with partners of program participants and health providers (mostly nurses). Focus group discussions and in-depth interview topic guides were developed and modified to adapt to local linguistic and cultural nuances. Topic guides included use of ANC and delivery services, and water treatment and hygiene practices. Local research assistants conducted the in-depth interviews and FGDs, which each took about 45 minutes, in Chichewa, the local language. Verbatim field notes were taken during the in-depth interviews and FGDs, and were then transcribed and translated into English for analysis. Data from both baseline and follow-up surveys were entered into a Microsoft Access 2007 database (Microsoft, Redmond, WA) and analyzed using SAS 9.3 (SAS Institute, Cary, NC). Antenatal clinic and delivery service use were examined descriptively and compared with Malawi DHS data for 2010.5 Human immunodeficiency virus service use data were also analyzed descriptively. Baseline and follow-up data were summarized and compared using McNemar’s test for paired proportions. When McNemar’s test was not feasible, an exact test of a binomial proportion was used. While we were unable to statistically adjust for any correlation within health facility subjects, we performed stratified analysis for the eight health facilities and determined that these results supported the overall results. Therefore we present the overall estimates, for all clinics for primary outcomes of interest. Outcomes of interest included knowledge of water treatment procedures with WaterGuard, detectable FCR in stored drinking water, confirmed use of WaterGuard (defined as presence of a bottle of WaterGuard and detectable FCR in stored water), reported purchase and confirmed use of WaterGuard, and use of proper handwashing technique (lathering hands completely with soap during a handwashing demonstration). Data from district maternal health and CHAI PMTCT registries were examined descriptively. For this paper, major themes were identified from in-depth interviews and FGDs and are presented using illustrative quotes. The CDC Human Subjects Contact determined that, because this activity consisted of an evaluation of a proven public health practice, it was exempt from human subjects research review (protocol 6082). The Malawi Ministry of Health authorized the evaluation and provided CHAI with a letter of approval for the comprehensive and integrated PMTCT pilot program in Machinga. Verbal informed consent was obtained from all survey participants and personal identifiers were permanently removed from the database.
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