The provision of drinking water and hand washing stations with a hygiene education program in 17 rural primary schools in western Kenya resulted in statistically significant increases in water treatment and hand washing knowledge and an ability to demonstrate proper handwashing technique among 4th
grade students. Students' knowledge appeared to translate to their households, for their primary caregivers also exhibited statistically significant increases in knowledge of water treatment using locally-available products and ability to demonstrate proper hand washing procedure. In addition, confirmed use of water treatment products in stored drinking water in students' households showed a statistically significant increase that was sustained over a period of 13 months. The magnitude of these changes exceeded that of an earlier school program in the same region.7
There are several possible explanations for the observed increases in water treatment knowledge and practices. First, schools are known to be effective venues to teach new educational material, as indicated by the finding that schools became the main information source about water treatment cited by both students and their caregivers. These findings were consistent with results of a previous study in Kenya.7
The transmission of these water treatment messages from schools to pupils and their caregivers may also have heightened awareness of the same messages delivered by other sources. For example, the increased recognition of local organizations as sources of water treatment messages was likely a result of the involvement of CARE in the school program, and the increased identification of mass media as an information source may have resulted from greater awareness of advertising for PuR and WaterGuard among caregivers who had been sensitized by their schoolchildren. Second, by giving all students an instructional comic book and three free sachets of PuR®
to try at home, this program may have helped ensure the successful diffusion of an innovation—water treatment—into student's homes. Our surveys demonstrated that nearly 90% of primary caregivers had seen the comic books and that their children demonstrated to them how to use PuR®
. Furthermore, 42% of primary caregivers reported that they had purchased PuR®
after using the three sample PuR®
sachets. These findings suggest that the five characteristics identified by research into diffusion of innovations as essential for successful adoption of innovations in populations had been met.14
These characteristics include relative advantage
of the product over locally-available alternatives (boiling), compatibility
with perceived needs (clarifying very turbid water, which cannot be accomplished effectively with other point-of-use water treatment methods such as chlorination, solar disinfection, or ceramic filtration), low complexity
(relatively easy to use), trialability
(the free sachets enabled caregivers to try the product), and observable results
(clarification of water). Finally, behavior change messages were delivered from multiple sources, which included social networks (friends, family, and neighbors), community organizations (schools), and mass media (mainly radio). In addition, involvement of Ministry of Education officials added the sanction of health authorities to the mix of different levels of influence involved in behavior change efforts. The use of multiple levels of influence has been shown to enhance initiation and maintenance of behavior change when compared with a single level of influence.15–17
It is likely that water treatment at the household level by both products was underestimated in this study. For both products, reported water treatment was substantially higher than confirmed treatment. All source water in study households had organic content that increased chlorine demand, which would effectively eliminate free chlorine residuals in a matter of hours.18,19
It was also possible that estimates of WaterGuard or PuR®
use were incorrect because the DPD test cannot distinguish between the two products. This is unlikely, however, because all respondents indicated which of the two products they were currently using. The mechanism of disinfection is the same in both products and both have been proven to be effective, therefore the more important outcome is that households treat their water with one of the products.
Although the magnitude of the increase in the use of both PuR®
(0.6% to 7.3% of the population) and WaterGuard (6–13%) was similar from baseline to follow-up, the higher level of use of WaterGuard compared with PuR®
likely reflected the substantially (40-fold) lower cost of WaterGuard. The level of use of PuR®
in this study exceeded that encountered in 2 other studies of adoption of the product.20,21
Two possible explanations for this finding include the population's dependence on highly turbid water sources, which would make PuR®
an attractive option for water treatment, and the distribution of 3 free sachets with the comic books, which gave families a chance to try the product before purchasing. Overall use of both products remained relatively low, however, indicating that more work is needed to scale up use. On the other hand, although there were some differences in confirmed water treatment by quintile, these differences were not statistically significant, which suggests that use of water treatment products was relatively equitable. A similar finding by educational level of the mother was another indicator of equity of use.
As with water treatment behaviors, improvements in demonstrations of proper hand washing procedure were noted among both students and their caregivers. Although objective measures of handwashing behavior remain elusive, in this evaluation, hand washing demonstrations provided a measure of change in practical knowledge of the behavior and, as such, served as a proxy of behavior change among students and households. Similar improvements in the ability to demonstrate proper hand washing technique have been observed after school-based7
educational programs in Kenya.
An evaluation of student absentee records in participant schools suggested that there was a significant decrease in absentee rates, a finding that was consistent with at least two other studies.7,22
This apparent health impact was sustained over 2 school years; its plausibility is supported by a documented decrease in diarrheal diseases reported at a school that adopted a similar intervention.6
The results observed in this evaluation were achieved in a high-risk, impoverished population with lack of access to an improved water supply and poor hygienic and sanitary conditions. Although previous studies have documented a lower degree of utilization of socially marketed water treatment products in poorer populations,20,23
in this evaluation, performance of the target behaviors increased and persisted over a period of at least 13 months. Despite this finding, substantial barriers to use of WaterGuard and PuR®
were identified and over 80% of households were not observed to be treating their water. It is clear that additional research on behavior change is needed.
There were several important limitations to this evaluation. First, repeated interviews with the same respondents may have influenced their practices and biased the results.24,25
Second, because of limited resources, we were unable to include a control group in this evaluation as a basis for assessing changes in the intervention group. However, because no other water, sanitation, or hygiene programs took place in project communities over the course of this evaluation, we believe that the findings resulted from the school-based program described in this paper. Furthermore, a similar magnitude effect on absentee rates was observed in another study that did use a comparison group.7
Finally, the findings of this evaluation are not generalizable because we used a convenience sample of schools and communities chosen because of their dependence on markedly turbid surface water sources.
Results of this evaluation suggest that this school-based intervention is a promising method for motivating behavior change among students and their caregivers, particularly when behavior change messages are coordinated from different levels of influence. Changes in water treatment and handwashing behaviors were documented after 3 months and sustained over the succeeding year. Sustainability over a longer period remains to be documented. Further research into factors associated with sustained impact is warranted.