This evaluation showed that the integration of water treatment and handwashing products and promotion into 15 health facilities included in Malawi's antenatal care system was an effective approach for changing hygiene behaviors among expectant mothers. Program participants exhibited statistically significant increases in a number of water treatment indicators, including water treatment with any method, awareness of WaterGuard, knowledge of proper use of WaterGuard, reported WaterGuard use in the previous 2 days, WaterGuard use in the home confirmed by the presence of residual chlorine in stored water, and WaterGuard purchase and use after exhausting their free bottles (suggesting that some women sustained water treatment behaviors). Use of the hygiene kit bucket was also observed in over 90% of homes at follow-up, and over 50% of participants reported removing water by pouring or using a tap, thereby reducing the risk of recontamination of stored water by hands or other objects.6,15
Finally, we observed increases in the presence of soap in respondents' homes and the ability of mothers to demonstrate correct handwashing procedures. Because household water treatment, safe water storage, and handwashing with soap have all been shown to reduce the risk of diarrhea by ~30–40%, we expect that participants in this program and their families experienced a positive health benefit.3–5,16–18
Additionally, maternal handwashing at the time of delivery has been associated with reduced neonatal mortality, suggesting additional protective benefits of this intervention.19
There are several explanations for the success of this program in changing maternal hygiene behaviors. First, this program involved water treatment and hand hygiene promotion both at the clinic and in the home. When asked who gave them the most confidence to use WaterGuard, the majority of women named health care providers or HSAs, which is consistent with previous research suggesting that health care personnel are trusted sources of information and health facilities are effective venues for promoting these behaviors.11
Furthermore, at least three previous studies have documented greater adoption of point-of-use water treatment in populations receiving one-on-one interventions in the home.20–22
In this study, both confirmed WaterGuard use and correct handwashing were associated with increased HSA home visits; however, because the study was not designed to assess the effect of HSA visits, this association may have been confounded by other factors. Second, the intervention used behavior change strategies at multiple levels, including mass media promotion by PSI, clinic-based education, government engagement through the Ministry of Health, and interpersonal communication by HSAs and between women.23,24
Finally, four of five characteristics that influence diffusion of innovations were present: advantage over alternatives (e.g., boiling, which is more expensive and time-consuming25,26
), compatibility with existing needs, low complexity, and trialability.27
We did not assess the fifth characteristic, observability of results.
In this evaluation, among participants who did not use WaterGuard at baseline, confirmed use of WaterGuard at follow-up was associated with rural residence, lower wealth, and lower education. These results contrasted with the tendency, found in a previous nationwide survey, for WaterGuard use in Malawi to be highest in urban, more educated, and wealthier populations, suggesting that this type of program may be particularly successful in reaching poor, uneducated, and rural populations that have greatest risk of adverse outcomes from diarrheal illness.9,28
The cost per program beneficiary, which was estimated to be US$ 5.63, was relatively low even though we did not take into account potential cost savings from water treatment or handwashing with soap. The cost of this program was comparable to the cost of an insecticide-treated bednet distribution program which, in one study, was estimated to be US$ 1.40 per person protected per year, including potential cost savings.29
Studies of the persistence of water treatment and handwashing behaviors over time are needed to assess costs per sustained program benefit.
Use of perinatal services reported in this evaluation was higher than described in the population-based 2006 Malawi Multiple Indicator Cluster Survey (MICS), including institutional delivery in Blantyre (90% versus 76%) and Salima (59% versus 44%) and postnatal checks in Blantyre (68% versus 45%) and Salima (37% versus 28%).2
Although the population surveyed in this evaluation may not be directly compared with the MICS survey population, and we do not know whether districtwide increases in use of these services occurred between 2006 and 2008, offering incentives for antenatal clinic attendance may have increased use of services, as was seen previously in Malawi with immunization services.30
This study had several limitations. First, because women from more distant areas may have been less likely to attend antenatal clinic and the program was implemented in only 15 health facilities, the program population may not be representative of the entire population in these districts. Second, participation in the evaluation may have influenced the participants' behavior. Third, the population lost to follow-up was wealthier, more educated, and more likely to live in an urban area than the follow-up evaluation population. Improvements in water treatment and hand hygiene practices among participants with similar demographics who remained in the evaluation suggest that the loss to follow-up of these women would not have significantly affected evaluation findings. Fourth, the baseline survey was conducted during the dry season, whereas the follow-up survey was conducted during the rainy season. Seasonal variation may have affected water treatment behaviors. Fifth, factors outside of this intervention could have also contributed to improved water treatment and hygiene behaviors over time in the surveyed population. Finally, because of resource limitations, this project was limited to 1 year. Because previous studies of point-of-use chlorine water treatment programs have suggested that there is attenuation in health impact over time,18
it would be particularly useful for future evaluations of this program to take place after periods of 1 or more years to measure the extent to which new hygiene behaviors were sustained.
Results of this evaluation suggest that integrated interventions offer promising opportunities for more efficient and effective health service delivery in resource-poor settings. The significant improvements in water treatment, hand hygiene, and perinatal care demonstrated in this program justify consideration of further implementation, along with program evaluation to assure that objectives are being met, in other parts of Malawi and other countries where contaminated drinking water and poor hygiene contribute to disease and death.