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. Copyright © 2010 by The American Society of Tropical Medicine and Hygiene. We conducted a baseline cross-sectional survey of pregnant women receiving care at 15 antenatal clinics in Blantyre and Salima districts where the program was implemented. Pregnant women received hygiene kits after completion of the baseline. We performed a follow-up survey of the same women after 9 months. To determine whether hygiene behaviors diffused to other persons, we asked pregnant women to identify non-pregnant relatives or friends with children < 5 years of age and included one for each pregnant woman in the evaluation; these results are presented elsewhere. Using a formula for comparing two correlated proportions, we calculated a minimum sample size of 338, assuming 7% overall use of WaterGuard at baseline based on a previous national survey, 100% increase in use in response to the intervention based on prior experience with water treatment interventions, and a proportion discordant equal to 20%, based on a type I error of 5% and a power of 80% (PASS 2008 v 8.06).9,11,12 A target sample size of 400 was set to account for loss to follow-up. We enrolled 400 pregnant women in April–May 2007 by selecting a weighted sample of pregnant women from each health facility proportional to the average monthly antenatal clinic attendance. We approached every third woman waiting to receive antenatal services for survey enrollment to complete enrollment from each health facility in 1 week. We used standardized questionnaires at baseline to collect data on demographic and socioeconomic characteristics; water sources; and water storage, treatment, and hygiene practices. Participants were interviewed by trained staff in the health facilities before program implementation occurred. We then made observations in the participants' homes regarding water storage and treatment practices, presence of soap, and demonstration of handwashing procedure. We tested stored drinking water for residual chlorine using the N,N-diethyl-p-phenylenediamine (DPD) colorimetric method using Hach Free and Total Chlorine kits (Hach Co., Loveland, CO) as an objective measure of WaterGuard use. In February–March 2008, trained enumerators conducted follow-up interviews and home observations of all participants during surprise visits to assess whether their practices had changed as a result of the program using a questionnaire that was identical to the baseline questionnaire except for additional questions on the hygiene kit program. After completion of the baseline survey and home observations, participants received hygiene kits and instructions for their use. Participants were told that they would receive refills of WaterGuard and soap on up to three return antenatal visits. In preparation for program implementation, PSI conducted a training of health facility staff members on patient communication, hand hygiene techniques, and appropriate water storage, handling, and treatment with WaterGuard. Antenatal clinic staff members were instructed to incorporate these water treatments and hand hygiene educational messages into antenatal clinic activities. Health Surveillance Assistants (Ministry of Health employees who provide community health services, hereafter referred to as HSAs) were encouraged to reinforce hygiene kit use by demonstrating correct use of WaterGuard and handwashing during periodic home visits; each HSA was encouraged to visit at least five women in the program per month. Finally, PSI ensured that social marketing and WaterGuard reached target communities through increased radio advertisements, billboards, and distribution of WaterGuard to commercial sales outlets in the program area. We solicited cost information from each of the key stakeholders responsible for program implementation: Ministry of Health, United Nations Children's Fund (Malawi), and PSI (Malawi). Costs included health facility personnel training and time, commodities (hygiene kits components and refills), product distribution, and increased social marketing in the targeted health facilities' catchment areas during the program period. Health facility personnel time was estimated on the basis of a survey of health facility staff involved in program implementation. The Centers for Disease Control and Prevention (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 oversight. Oral informed consent was obtained from all survey participants and personal identifiers were permanently removed from the database. Data from baseline and follow-up surveys were entered into a Microsoft (Redmond, WA) Access 2003 database and analyzed using SAS software version 9.2 (Cary, NC) and SUDAAN version 10.0.1 (Research Triangle Park, NC). To classify respondents by socioeconomic status, we used principal component analysis methodology in which household assets were assigned values based on a scoring factor as described by Filmer and Pritchett.13 Asset indicators included ownership of consumer durables, observed characteristics of the household dwelling, and land ownership. Asset values were summed for each participant to create a household asset score.13 Respondents were placed in socioeconomic quintiles based on their asset score relative to their district's survey population. Comparisons between the two districts on baseline demographics and perinatal outcomes were done using the Wald F-test accounting for clustering by health facility by the Taylor series method of variance estimation (SUDAAN). The primary outcomes of interest included confirmed WaterGuard use (defined as presence of a WaterGuard bottle in the home and detectable residual chlorine in stored water) and lathering hands completely with soap during a handwashing demonstration. Baseline and follow-up data were summarized and compared using McNemar's test for paired proportions adjusting for clustering by health facility.14 For a few instances where the adjustment to McNemar's test was not feasible, an exact test of a binomial proportion was used when necessary. To assess factors associated with confirmed use of WaterGuard, purchase of WaterGuard, and correct handwashing demonstration at follow-up among the subset of participants who did not exhibit these behaviors at baseline, bivariate odds ratios (OR) were estimated by a logistic regression model adjusting for district. The Taylor series method of variance estimation was used to account for stratification by district and clustering by health facility (SUDAAN).