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We installed drinking water and handwashing stations in 17 rural schools and trained teachers to promote water treatment and hygiene to pupils. We gave schools flocculent-disinfectant powder and hypochlorite solution for water treatment. We conducted a baseline water handling survey of pupils' parents from 17 schools and tested stored water for chlorine. We trained teachers and students about hygiene, installed water stations, and distributed instructional comic books to students. We conducted follow-up surveys and chlorine testing at 3 and 13 months. From baseline to 3-month follow-up, parental awareness of the flocculent-disinfectant increased (49–91%, P < 0.0001), awareness of hypochlorite remained high (93–92%), and household use of flocculent-disinfectant (1–7%, P < 0.0001) and hypochlorite (6–13%, P < 0.0001) increased, and were maintained after 13 months. Pupil absentee rates decreased after implementation by 26%. This school-based program resulted in pupil-to-parent knowledge transfer and significant increases in household water treatment practices that were sustained over 1 year.
Diarrheal diseases cause an estimated 1.87 million deaths per year, mostly among children less than 5 years of age in the developing world.1 A major contributing factor to this burden of disease is inadequate access to safe water and sanitation infrastructure. Universal access to water and sanitation facilities will take many years and billions of dollars to achieve. There is a need, in the short to medium term, to reduce the risk of disease in vulnerable populations that will not soon benefit from infrastructure interventions.
To address this need, Cooperative for Assistance and Relief Everywhere, Inc. (CARE) Kenya has been involved since 2000 in a series of projects to implement household-based water treatment interventions in Nyanza Province, where the diarrheal disease burden is high and access to improved water supplies is poor.2 Most of these projects used the Safe Water System (SWS), an intervention that consists of water treatment with dilute sodium hypochlorite solution, safe water storage, and behavior change techniques. Evaluations of these programs in Kenya have shown that use of the SWS was feasible, acceptable, and reduced diarrheal disease risk.3–5 In 2003, Population Services International (PSI), a social marketing non-governmental organization, initiated a campaign to promote and sell the SWS solution, which was given the brand name WaterGuard; each bottle costs approximately $U.S. 0.26 and treats 1000 L of water. The social marketing program for WaterGuard, which has been continuous since 2003, consisted of mass media advertisements (predominantly by means of radio), wall paintings, and presentations at local markets where WaterGuard was being sold. In 2008, PSI sold nearly 1.7 million bottles of WaterGuard in Kenya.
Easy and widespread access to WaterGuard facilitated efforts to implement two school-based safe water and hygiene interventions in Nyanza Province. In 2003, a pilot project was implemented in a rural boarding school, providing clay pots modified with narrow mouths, ceramic lids, and taps for drinking water, plastic tanks with taps for hand washing, WaterGuard for drinking water, and soap for hand washing. An evaluation of this project in 2004 showed that diarrhea rates among the students had decreased by more than half.6 In 2005, the school-based safe water and hygiene intervention was expanded to an additional 70 public primary schools in southern Nyanza Province. An evaluation of this program in 2006 suggested that the use of water treatment and hand-washing promotion in schools resulted in a decrease in absenteeism of 35% compared with neighboring schools, and increased utilization of WaterGuard in students' households.7 The outcomes of these two projects have resulted in further expansion of the school programs in Nyanza Province.8
In 2000, the Procter and Gamble Company (Mason, OH) launched a flocculent/disinfectant product, called PuR® Purifier of Water (hereafter referred to as PuR®) which was designed for household water treatment. The treatment process involves pouring the contents of a sachet of PuR® in 10 L of water, stirring for 5 minutes, allowing the water to settle for 20 minutes, then pouring treated water through a clean cloth into a second container. In several field trials, PuR® removed organic solids from water, left a chlorine residual, and reduced the risk of diarrhea by 16–90%.9–13 In 2006, PSI, with the support of the Procter and Gamble Company, launched a PuR® social marketing campaign in Kenya, selling sachets, each of which clarifies and disinfects 10 L of water, at a retail price of 7 Kenyan Shillings (about 10 U.S. cents) each. The PuR® social marketing program, which has been continuous since 2006, includes activities similar to the WaterGuard program. In 2008, 2.4 million sachets of PuR® were sold in Kenya. After PuR® became readily available, the incorporation of PuR® into school-based water and hygiene programs became feasible.
In May 2006, a pilot program was initiated in 3 schools and it was determined that PuR® could be a practical water-quality intervention for schools with turbid surface water sources. In February 2007, this program was expanded to 17 additional schools, and an evaluation was initiated. In this report we present the results of this evaluation.
For this project, the Ministry of Health and the Ministry of Education selected schools from 17 communities whose water sources were limited to turbid earth pan water or rainwater collection. We calculated we would need a sample of 666 students based on the assumptions that 5% of students' households would be using PuR® at baseline, and that household PuR® use would increase to 15% over the course of the project, with 80% power, and 95% confidence. We visited each school and obtained a roster of students in grades 4 through 8. Next, we assigned a unique number to each student and used a random numbers table to select the sample of students. Only the first student attending a school from each household was included in the sample; all subsequently selected household members were excluded.
CARE Kenya held trainings at the beginning of May 2007, during the second school term, with two teachers and the headmaster from each of the 17 project schools. During these trainings, the school staff was taught methods of water treatment and proper hand washing. The teachers were encouraged to take these messages back to their school, instruct their pupils in these methods, and form safe water clubs with students to develop projects related to safe water and hygiene. Directly after the training, each school was given six 60 L plastic containers to store water, three for drinking water and three for hand washing. In addition, the schools were given a 3 month supply of PuR® sachets and WaterGuard. They were encouraged to use PuR® to treat drinking water and, since younger students sometimes drink from hand washing containers, WaterGuard to treat the hand washing water.
To help educate the students, the Procter and Gamble Company, Population Services International, and the Kenyan Ministry of Education collaborated in the production of a comic book entitled “Preventing Diarrheoea, Viki finds out how…”. The comic book, which described how to treat water using PuR® and WaterGuard, was distributed to all students, who were encouraged to read it, discuss it with their class, and take it home to show their parents. In addition, each book contained 3 free sachets of PuR®, which students were encouraged to take home and demonstrate to their parents.
We conducted a baseline survey in February 2007 during the first term of the Kenyan school year. Bilingual enumerators interviewed students in the local language, Dholuo, using a questionnaire that asked about school water sources and treatment, knowledge of water treatment procedures, and sanitation. Correct treatment of water with PuR® was defined as correctly identifying the following three steps: 1) number of liters of water treated with 1 sachet; 2) the correct amount of time the water needs to be stirred; and 3) the correct time to wait before consuming the water. Correct treatment with WaterGuard was defined as identifying the correct dose and the correct wait time until the water is safe to drink. The enumerators also observed students washing their hands to determine whether they used three key steps: lathering hands thoroughly with soap, rubbing between fingers, and air drying. The enumerator walked the child to the handwashing area, instructed them to wash their hands as they typically do, and observed the child's handwashing procedure. We performed follow-up surveys of the same students interviewed at baseline who were still attending school in September 2007, during the third term of the 2007 school year, and again in July 2008, during the second term of the 2008 school year. The follow-up survey instruments included questions from the baseline survey with additional questions regarding health communications in the school and water treatment attitudes and practices.
In February 2007, we visited the homes of students selected for the evaluation and conducted a baseline survey of their primary caregivers in Dholuo. The respondents were asked questions regarding household demographic and socioeconomic characteristics; water sources, storage, and treatment; and hygiene and sanitary practices. The enumerators also observed water storage vessels, caregivers' typical hand washing procedure, and tested stored drinking water for free chlorine residuals using the N, N-diethyl-phenylenediamine (DPD) colorimetric method, which has a detection limit of 0.1 mg/L of free chlorine (Free Residual Chlorine Test®, La Motte, Chestertown, MD). The presence of free chlorine residuals in stored water confirms that the water has been treated with a chlorine-containing disinfectant. Because both WaterGuard and PuR® disinfect water through the conversion of free chlorine to hypochlorous acid, it was not possible to distinguish between the two products by water testing alone. Respondents' reports of the water treatment product used plus the presence of free residual chlorine served as confirmation of water treatment with that product. In September 2007 and July 2008, we conducted follow-up surveys that used a similar instrument to the baseline, with additional questions about health communications within the household and attitudes about water treatment practices. We performed follow-up observations of water-storage vessels, hand-washing practices, and tested drinking water for residual chlorine. All questionnaires were translated from English to Dholuo, the main language in this population, and back-translated into English for quality-control purposes.
Student absentee data were collected from 16 schools; one school that was unable to locate absentee records from 2005 was excluded. Absentee data collected from 2007 and 2008 were compared with absentee data from 2005 and 2006 to determine the impact of the program on school attendance. Because the intervention was implemented during the second of 3 school terms in 2007, we compared student absentee rates for the second term from school years before (2005 and 2006) and after (2007 and 2008) implementation of the intervention.
All data were entered into MS Access data bases and analyzed in SAS Enterprise Guide 4.0. Frequencies were reported from both the student and household interviews. Changes in knowledge and practices were examined in a matched analysis using McNemar's test.
The Institutional Review Board (IRB) at Centers for Disease Control and Prevention determined that because this project was an evaluation of a proven public health practice, IRB regulations did not apply. However, informed consent was obtained from all participants in the evaluation and personal identifiers were not recorded in the data base.
At baseline, 666 students were interviewed (Table 1). The median age of the students was 12 (range 8 to 19 years); 53% were male. Of these students, 28% were enrolled in grade 4, 22% in grade 5, 17% in grade 6, 21% in grade 7, and 12% in grade 8.
In the first follow-up evaluation, we were able to locate 603 students for re-interview. In this follow-up, the median student age and proportion of students in each grade level were similar to baseline. The reasons for the loss of 63 (9%) students to follow-up included moved away, changed schools, or other.
In the second follow-up evaluation, we were able to locate 413 of the original 666 students interviewed at baseline. The median age of students and student gender remained similar to the 2 previous surveys, however the proportion of students in each grade level shifted as a result of interviewing in a new school year. The reasons for the loss of 108 students were graduation of the previous 8th grade class, moved away, or changed schools. In addition, 37 students that were in grade 4 during the previous year failed to graduate and were therefore remaining in grade 4 during the second follow-up evaluation. Of the 413 students, 9% were enrolled in grade 4, 27% in grade 5, 26% in grade 6, 23% in grade 7, and 14% in grade 8.
Awareness of PuR® was reported by 31% of students at baseline, 97% at first follow-up (P < 0.0001), and 98% at second follow-up (P = 1.0, Table 2). Of students who had heard of PuR® at baseline, fewer than 1% were able to correctly explain three key steps of the PuR® water treatment procedure; 53% of students at first follow-up and 54% at second follow-up could state the correct procedure (P < 0.0001). The most common information sources about PuR® changed from mass media (21%) and social networks (15%) at baseline to the school at first (88%) and second (91%) follow-up evaluations (Table 3).
Awareness of WaterGuard was reported by 90% of students at baseline, 97% at first follow-up (P < 0.001), and 98% at second follow-up (Table 2). Of these students, 15% could describe the correct WaterGuard treatment process at baseline, 36% at first follow-up (P < 0.0001), and 23% at second follow-up (P = 0.0011). The most common WaterGuard information sources were social networks (65%) and mass media (42%) at baseline. Although these sources were cited at similar rates at first, and second follow-up evaluations, schools increased as an information source from 14% at baseline to 83% at first and second follow-up; a number of respondents reported multiple sources (Table 3).
At baseline, 22% of students could demonstrate proper hand washing (Table 2). This percentage increased to 53% at first follow-up (P < 0.0001) and was 47% (P = 0.3046) at second follow-up.
At baseline, primary caregivers of 662 (99%) of 666 students were interviewed; four student households could not be located (Table 1). The median age of respondents was 42 years (range 13 to 91 years); 91% were female. The median number of persons per household was six (range 2 to 15). Of 662 respondents' homes, 194 (29%) had grass roofs, 473 (71%) had mud walls, and 473 (71%) had mud/earthen floors. The primary source of lighting for 390 (59%) households was tin and wick paraffin lamps (Table 4). None had electricity.
The most common household water sources used on the day of the baseline interview were earth pans (ponds [70%]), rain water (15%), and springs (8%). The water storage containers most commonly observed in participating households were traditional clay pots (78%), plastic jerrycans (20%), and containers with a narrow mouth and tap (< 1%). Of 662 respondents, 477 (72%) said that they did something to make their stored water safer. Reported water treatment options included boiling (42%), WaterGuard (40%), filtering (27%), alum (21%), and PuR® (5%).
At first follow-up, we were able to locate 644 households from the baseline survey for interview; 18 households (8%) were excluded because they had moved or refused to participate. At second follow-up, we interviewed respondents from 536 (81%) households; 108 households were unavailable for interview due to moving or not being at home for three attempts when the interviewer returned for follow-up. The number of households visited exceeded the number of students at first (603) and second (413) follow-up because, although these students may have graduated, left school, changed schools, or moved to a relative's home, the households remained in the same location and were therefore available for revisit.
At baseline, 46% of primary caregivers had heard of PuR®, which increased to 92% at the first follow-up (P < 0.0001) and 96% (0.0013) at the second follow-up (Table 5). The most frequently cited information sources for PuR® shifted from mass media (38%) and social networks (15%) at baseline to school (76%) and mass media (51%) at first and second follow-up (Table 3).
At first follow-up, 89% of respondents reported that their child brought home the educational comic book that was distributed to all students; of these respondents, 88% said their child demonstrated how to treat water with the PuR® sachets. Additionally, 42% of respondents reported buying PuR® after the free sachets were used up; the median number purchased was 3 (range 1 to 10).
Of respondents who had heard of PuR®, 8% were able to correctly explain the PuR® water treatment process at baseline, 53% at first follow-up (P < 0.0001), and 55% at second follow-up (P = 0.74 [Table 5]).
Awareness of WaterGuard was reported by 93% of respondents at baseline, 92% at first follow-up (P = 0.40), and 96% at second follow-up (Table 5). Respondents' reported use of WaterGuard increased from 53% at baseline to 59% at first follow-up (P < 0.0001) and increased further to 66% (P = 0.073) at second follow-up (Table 5). The ability of respondents to correctly describe the treatment procedure for WaterGuard increased from 35% at baseline to 57% at the first follow-up (P < 0.0001); there was no change from the first to the second follow-up.
The most common information source about WaterGuard was the mass media during all three surveys, whereas school increased from 7% at baseline to 28% at first follow-up and 29% at second follow-up (Table 5).
Water testing for the presence of free chlorine residual was completed in 99% of households at baseline, 97% at first follow-up, and 99% at second follow-up. The percentage of all respondents that reported treating their current drinking water with PuR® increased from 0.9% at baseline to 16.6% at first follow-up (P < 0.001), and 15% at second follow-up (Table 5). The percentage of all respondents that was confirmed, by the presence of residual chlorine in stored water, to be treating their water with PuR® increased from 0.6% at baseline to 7.3% at first follow-up (P < 0.001) and 6% at second follow-up.
The percentage of all respondents reporting WaterGuard use increased from 16% at baseline to 22% at first follow-up (P = 0.0006), and 23% at second follow-up (Table 5). The percentage of all respondents with confirmed WaterGuard use increased from 6% at baseline to 13% at follow-up (P < 0.0001), and 11% at second follow-up (Table 5).
Overall, when taking into account use of either PuR® or WaterGuard, reported water treatment increased from 16.9% at baseline to 38.6% at first follow-up and 38% at second follow-up. Confirmed household water treatment increased from 6.5% at baseline to 20.9% at first follow-up (P < 0.0001) and 18% at second follow-up (Table 5). The variation in confirmed treatment by socioeconomic quintile was not statistically significant, ranging from 1% (quintile 2) to 12% (quintile 5) at baseline, 17% (quintile 2) to 32% (quintile 5) at first follow-up, and 11% (quintile 1) to 23% (quintile 5) at second follow-up (Figure 2). Similarly, there was no variation in confirmed water treatment by educational level of the mother.
At second follow-up, 331 respondents who had ever reported using PuR® were not currently using the product. When asked the reasons for not currently using PuR®, 118 (35.6%) said they used other water treatment methods (of these, 103 [87.3%] were using WaterGuard), 38 (11.5%) said the product was too expensive, and 17 (5.1%) believed that they did not need it. Of 234 respondents who had ever used WaterGuard but were not currently using the product, 78 (33.3%) said they were using another treatment method (of these, 43 [61.5%] said they used PuR®), 32 (13.7%) believed they did not need it, and 27 (11.5%) said it was too expensive.
The percentage of primary caregivers who were able to demonstrate proper hand washing increased from 25% at baseline to 41% at first follow-up (P < 0.0001), and 47% at second follow-up (P = 0.19 [Table 5]).
The school water treatment and hygiene program was implemented at the beginning of the second (March–May) school term in 2007. The absentee rate for the second school term in 2007 was 26% lower than the rates during the corresponding terms in 2005 and 2006 (Figure 1). At the second follow-up evaluation in 2008, a 24% decrease in absentee rates during the second school term was maintained.
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 to 8th 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 and clinic-based5 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.
The authors thank the study participants, in both the schools and the households. They are indebted to the dedicated team of enumerators: George Godfrey Opiyo Owuor, Dorcas Awino Ngasi, Rose Anyango Onyango, Jane Abuya Omolloh, Raphael Ochieng Anyango, Paul Omondi Obadha, Odawa Wilson Odhiambo, Wellington Omondi Oduol, Alfred Ochieng Awandu, Matilda Atieno Rajoro, David Ossome Omondi Audi, George Amadi Ondurch, and David Otieno Akayi. The authors thank their study supervisors: George Omondi Ahenda, George Owuor Onyango, Gerald Ndungu, and Benjamin Oketch Odhiambo.
Financial support: The Procter and Gamble Company exclusively funded the study but did not contribute to study design, data analysis, or interpretation of results.
Authors' addresses: Elizabeth Blanton, Kathleen Wannemuehler, and Robert Quick, Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: vog.cdc@notnalbe, vog.cdc@relheumennawk, and vog.cdc@kciuqr. Sam Ombeki, Gordon Otieno Oluoch, and Alex Mwaki, CARE Kenya, Kisumu, Kenya, E-mails: ek.gro.erac.msk@ikebmo, ek.gro.erac.msk@nodrog, and ek.gro.erac.msk@xela.