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

Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

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.

A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia

Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.

Chlorination for low-cost household water disinfection - A critical review and status in three Latin American countries

Chlorination has historically provided microbiologically safe drinking water in public water supplies. Likewise, chlorine has also been introduced as a low-cost disinfection method in rural and marginalized communities, both at community and household level, as well as during emergencies. Although this practice is common and well established for use as a household water treatment technology in the Global South, several challenges in effective and efficient implementation still need to be addressed. Here, we explored these issues by a literature review and narrowed them to the status of three Latin American countries (Mexico, Colombia, and Brazil). Overall, it was found that although guidance on household-based chlorination includes information on health risks and hygiene, this may not create enough incentive for the user to adapt the method satisfactorily. Physicochemical quality of the water influences chlorination efficiency and it is found that variations in quality are rarely considered when recommending chlorine doses during implementation. These are far more often based on a few measurements of turbidity, thereby not considering dissolved organic matter, or seasonal and day-to-day variations. Other factors such as user preferences, chlorine product quality and availability also represent potential barriers to the sustainable use of chlorination. For chlorination to become a sustainable household water treatment, more focus should therefore be given to local conditions prior to the intervention, as well as support and maintenance of behavioural changes during and after the intervention.

Design, delivery, and determinants of uptake: findings from a food hygiene behavior change intervention in rural Bangladesh

BACKGROUND

Microbial food contamination, although a known contributor to diarrheal disease and highly prevalent in low-income settings, has received relatively little attention in nutrition programs. Therefore, to address the critical pathway from food contamination to infection to child undernutrition, we adapted and integrated an innovative food hygiene intervention into a large-scale nutrition-sensitive agriculture trial in rural Bangladesh. In this article, we describe the intervention, analyze participation and uptake of the promoted food hygiene behaviors among intervention households, and examine the underlying determinants of behavior adoption.

METHODS

The food hygiene intervention employed emotional drivers, engaging group activities, and household visits to improve six feeding and food hygiene behaviors. The program centered on an 'ideal family' competition. Households' attendance in each food hygiene session was documented. Uptake of promoted behaviors was assessed by project staff on seven 'ideal family' indicators using direct observations of practices and spot checks of household hygiene conditions during household visits. We used descriptive analysis and mixed-effect logistic regression to examine changes in household food hygiene practices and to identify determinants of uptake.

RESULTS

Participation in the food hygiene intervention was high with more than 75% attendance at each session. Hygiene behavior practices increased from pre-intervention with success varying by behavior. Safe storage and fresh preparation or reheating of leftover foods were frequently practiced, while handwashing and cleaning of utensils was practiced by fewer participants. In total, 496 of 1275 participating households (39%) adopted at least 5 of 7 selected practices in all three assessment rounds and were awarded 'ideal family' titles at the end of the intervention. Being an 'ideal family' winner was associated with high participation in intervention activities [adjusted odds ratio (AOR): 11.4, 95% CI: 5.2-24.9], highest household wealth [AOR: 2.3, 95% CI: 1.4-3.6] and secondary education of participating women [AOR: 2.2, 95% CI: 1.4-3.4].

CONCLUSION

This intervention is an example of successful integration of a behavior change food hygiene component into an existing large-scale trial and achieved satisfactory coverage. Future analysis will show if the intervention was able to sustain improved behaviors over time and decrease food contamination and infection.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

BACKGROUND

Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum.

METHODS

Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours.

RESULTS

Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge.

CONCLUSIONS

Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Engineering and characterization of gymnosperm sapwood toward enabling the design of water filtration devices

Naturally-occurring membranes in the xylem tissue of gymnosperm sapwood enable its use as an abundantly-available material to construct filters, with potential to facilitate access to safe drinking water in resource-constrained settings. However, the material’s behavior as a filter is poorly understood, and challenges such as short shelf life have not been addressed. Here, we characterize the operational attributes of xylem filters and show that the material exhibits a highly non-linear dependence of flow resistance on thickness upon drying, and a tendency for self-blocking. We develop guidelines for the design and fabrication of xylem filters, demonstrate gravity-operated filters with shelf life >2 years, and show that the filters can provide >3 log removal of E. coli, MS-2 phage, and rotavirus from synthetic test waters and coliform bacteria from contaminated spring, tap, and ground waters. Through interviews and workshops in India, we use a user-centric approach to design a prototype filtration device with daily- to weekly-replaceable xylem filters, and uncover indicators of social acceptance of xylem as a natural water filter. Our work enhances the understanding of xylem as a filtration material, and opens opportunities for engineering a diverse range of low-cost, biodegradable xylem-based filtration products on a global scale.

Gymnosperm sapwood is an abundantly available material to construct water filters but the material’s behaviour as a filter is poorly understood and challenges such as short shelf live have not been addressed. Here, the authors develop guidelines for the design and fabrication of xylem filters and demonstrate gravity-operated filters with a shelf life of more than two years for the removal of contaminants from spring, tap and ground water.

Risk Factors Associated with Feeding Children under 2 Years in Rural Malawi-A Formative Study

Diarrhoeal disease remains one of the leading causes of morbidity and mortality in the under-five population, particularly in low income settings such as sub-Saharan Africa. Despite significant progress in sanitation and water access, faecal-oral infections persist in these populations. Therefore, a better understanding of these transmission pathways, and how potential risk factors can be reduced within low income contexts is needed. This study, conducted in Southern Malawi from June to October 2017, used a mixed methods approach to collect data from household surveys (n = 323), checklists (n = 31), structured observations (n = 80), and microbiological food samples (n = 20). Results showed that food prepared for immediate consumption (primarily porridge for children) posed a low health risk. Poor hygiene practices increased the risk of contamination from shared family meals. Faecal and nosocomial bacteria were associated with poor hand hygiene and unhygienic eating conditions. Leftover food storage and inadequate pre-consumption heating increased the risk of contamination. Improvements in food hygiene and hand hygiene practices at critical points could reduce the risk of diarrhoeal disease for children under 2 years but must consider the contextual structural barriers to improved practice like access to handwashing facilities, soap, food and water storage.

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.

Targeting health subsidies through a nonprice mechanism: A randomized controlled trial in Kenya

Free provision of preventive health products can markedly increase access in low-income countries. A cost concern about free provision is that some recipients may not use the product, wasting resources (overinclusion). Yet, charging a price to screen out nonusers may screen out poor people who need and would use the product (overexclusion). We report on a randomized controlled trial of a screening mechanism that combines the free provision of chlorine solution for water treatment with a small nonmonetary cost (household vouchers that need to be redeemed monthly in order). Relative to a nonvoucher free distribution program, this mechanism reduces the quantity of chlorine procured by 60 percentage points, but reduces the share of households whose stored water tests positive for chlorine residual by only one percentage point, substantially improving the trade-off between overinclusion and overexclusion.

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.

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review

BACKGROUND

Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

METHODS

We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

RESULTS

We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

CONCLUSIONS

Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

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.