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Many clinics in rural western Kenya lack access to safe water and hand-washing facilities. To address this problem, in 2005 a programme was initiated to install water stations for hand washing and drinking water in 109 health facilities, train health workers on water treatment and hygiene, and motivate clients to adopt these practices. In 2008, we evaluated this intervention’s impact by conducting observations at facilities, and interviewing staff and clients about water treatment and hygiene. Of 30 randomly selected facilities, 97% had water stations in use. Chlorine residuals were detectable in at least one container at 59% of facilities. Of 164 interviewed staff, 79% knew the recommended water-treatment procedure. Of 298 clients, 45% had received training on water treatment at a facility; of these, 68% knew the recommended water-treatment procedure. Use of water stations, water treatment, and client training were sustained in some facilities for up to 3 years.
The evaluation was a cross-sectional survey of 30 randomly selected health facilities, including dispensaries (the lowest level and first line of contact with the healthcare system, providing mainly preventive and minor curative ambulatory services), health centres (which provide preventive and curative health services, usually with some capacity for inpatient care) and hospitals (which provide a wider range of inpatient and outpatient services). It consisted of three components: an assessment of the presence and use of drinking-water and hand-washing containers in health facilities, a survey of health facility staff, and exit interviews of clinic clients. We selected a random sample of 30/109 facilities, stratifying proportionally by type of facility (hospital, health centre, dispensary). The 30 facilities were located in seven different districts in Nyanza Province. We attempted to interview all patient care staff present at each health facility on the day of the evaluation. To determine the sample size for the client survey, we assumed reported WaterGuard utilization of 10%, a margin of error of ± 5%, and a design effect of 2, which resulted in an estimated 276 clients. We attempted to conduct exit interviews with 10 clients at each of the 30 health facilities. We made surprise visits to all of the selected health facilities. The charge nurses, who had worked with the implementing organization and were familiar with the project, gave permission for evaluation activities at the time of the visit and responded to questions about the facility and use of the intervention. At each health facility, a data collection form was completed that included observations of the hand-washing and drinking-water stations, the presence of WaterGuard and soap, and general sanitary conditions. A water station was defined as ‘in use’ if it was stationed in a location where staff or patients could use it; all stations were also examined to see if water was present. In addition, we tested water in hand-washing and drinking-water stations for free chlorine residuals using the N,N-diethyl-p-phenylene diamine (DPD) method (Hach Co., USA). We interviewed all clinical staff available at dispensaries and health centres on the day of the visit. At hospitals, only outpatient Maternal and Child Health (MCH) staff were interviewed, as MCH clinics were the principal implementation site for the intervention. Staff were interviewed about their hand-washing and water-treatment knowledge and practices, and client teaching activities. Due to the low number of clients visiting smaller facilities and the limited opening hours of most facilities, it was necessary to choose a convenience sample of clients in order to reach our target of 10 client interviews per facility. As mothers had been the main target of the intervention, we chose to interview women whenever possible. If the number of clients at the facility was low, we included men in our sample population, in order to reach the target. The clients were interviewed about their knowledge and practices of hand washing, water treatment and storage, and the content of the training they had received at the health facility, if any. The Institutional Review Board (IRB) at CDC determined that this activity was an evaluation of proven public health practice and IRB regulations did not apply; the Kenyan Ministry of Health approved and supported the activity, which took place in its facilities. Oral informed consent was obtained from all participants and personal identifiers were permanently removed from databases. Data from the evaluation were entered into EpiData v. 3.1 (EpiData Association, Denmark). Statistical analysis was performed using Epi Info v. 3.5.1 (CDC, USA). We calculated frequencies, median values and ranges, and stratified the interviews and observations according to type of facility.
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