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. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/). doi: 10.2166/wh.2018.149 ://iwaponline.com/jwh/article-pdf/16/2/263/240039/jwh0160263.pdf Anu Rajasingham (corresponding author) Tracy Ayers Robert Quick National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA E-mail: idb4@cdc.gov Margaret Leso Samuel Ombeki CARE International, Kisumu, Kenya


INTRODUCTION
In low-and-middle-income countries, health care facilities (HCFs) lack reliable access to water, sanitation, and hygiene (WASH) infrastructure. Data from 54 countries show that 38% of HCFs do not use an improved water supply, 19% do not have access to improved sanitation, and 35% do not have handwashing facilities (WHO ). Consequently, health workers are unable to wash their hands between patients or provide safe drinking water for administration of oral medication. These deficiencies increase the risk of health facility-acquired infections (HAI), which occur two to 20 times more frequently than in developed countries (Allegranzi & Pittet ; Nejad et al. ). The recent Ebola epidemic in West Africa has highlighted the risk to health workers of poor WASH access in HCFs (Forrester et al. ). In response to this problem, the Sustainable Development Goals include 100% coverage of HCFs with WASH infrastructure by 2030 (Joint Monitoring Program ). The Safe Water Program installed handwashing and drinking water stations, consisting of improved storage containers with a narrow mouth, lid, and spigot on a metal stand at a cost of $15 each ( Figure 1) in 53 rural HCFs with prevention-of-mother-to-child-transmission (PMTCT) programs or clinics. PMTCT programming at these HCFs included HIV counseling, testing, and treatment, and antenatal services. HCF patient load determined the number of stations installed. Dispensaries and health centers received two handwashing and four drinking water stations, while larger HCFs, such as the outpatient areas of hospitals, received four handwashing and six drinking water stations. Health workers were also given a threemonth starter supply of WaterGuard ® , a socially marketed locally available 1.2% sodium hypochlorite water treatment solution which, for US$0.25, treats 1,000 liters of water.
These health care workers also received training on proper handwashing and water treatment and were encouraged to communicate this information to their patients during PMTCT visits, as HCFs can be an important platform for teaching communities about the importance of WASH interventions (Parker ; Bennett ).
In 2010, Procter & Gamble Co. provided funding for the same program to distribute locally available sachets of P&G Purifier of Water ® (hereafter referred to as sachets), a powder that flocculates and disinfects water at a cost of US$0.10 per 10 liters treated, to all 53 HCFs (Chiller et al. ). Sufficient sachets were provided to treat all water in the clinic. Health workers were asked to use the sachets to treat water in the HCF and to distribute them to PMTCT clinic clients. Community health workers (CHWs) were also given 240 sachets per month to be used for demonstration purposes at households during home visits.
The intervention described in this paper can help mitigate the widespread problem of inadequate access of WASH infrastructure in HCFs in the short-to-medium term, but to be effective it must be acceptable, used regularly, and durable.
In 2011, six years after the program started, and within one year of when the sachets were introduced, we assessed the acceptability, performance, durability, and use of water stations, water treatment, and hygiene practices in participating HCFs and client households in the HCF catchment areas.

Evaluation design
We conducted an assessment of HCFs, a HCF staff survey, and a household survey in the HCF catchment areas. The HCF assessment was performed by a member of our team, the HCF staff survey was self-administered, and the household survey was conducted by three enumerators familiar with the area.

HCF selection
We selected a random sample of 30 of 53 total HCFs in Siaya County, Kenya with PMTCT programs or clinics. We stratified HCFs into three types, as classified by the Ministry of Health: hospitals, health centers, and dispensaries (Sreenivasan et al. ). The number of HCFs of each type selected for the evaluation was proportional to their percentage among all 53 facilities targeted by this program. Due to financial and logistical constraints, we were limited to a single day of data collection at each of 30 sites, which restricted the number of households visited.

HCF assessment
The health facility assessment included unannounced visits to HCFs and interviews with the officer in charge to detail patient load, staff trained on handwashing and water treatment, reported use of the handwashing and drinking water stations, and to make direct observations of the functionality, access, and presence of water in handwashing and drinking water stations, soap for hand washing, and water treatment products. We tested water stored in handwashing and drinking water stations for free chlorine residual (FCR) using the N,N diethyl-p-phenylene diamine (DPD) method (LaMotte Co., Chestertown, MD).
We asked health care workers to identify and accompany us to all handwashing and drinking water stations and counted all stations observed in patient care areas in dispensaries and health centers, and in outpatient departments in hospitals. We defined a handwashing station as 'functional' if it had water present in a covered designated container with a working tap. Our observations of handwashing stations included whether soap was present or not. We also defined a drinking water station as 'functional' if it had water present in a covered container with a working tap, and determined whether stored water had a detectable FCR as an objective measure of treatment.

HCF staff survey
On the day of the visit to each HCF, all health workers present were asked to complete a self-administered questionnaire. The questionnaire inquired in simple language about their knowledge of proper water treatment and handwashing behaviors and client teaching practices.

Household survey
On the day of each HCF visit, three trained enumerators were guided by local CHWs to the community neighboring each HCF to make unannounced visits to ten nearby households with children under five years old. Mothers were targeted for interviews because they were the primary caretaker of children, were all PMTCT clinic clients, and were knowledgeable on household water and hygiene practices.
Enumerators administered a questionnaire in the local language, Dholuo, that included questions about the family's size, household assets, use of the local health facility, knowledge of hand-washing procedures, use of water treatment products, presence of water treatment products in the home, and instruction received from health facility staff.
We also observed water storage containers, water treatment products, handwashing stations, maternal handwashing procedure, presence and cleanliness of a hand towel (a towel was considered clean if it appeared free of dirt or other contaminants), and tested stored water for the presence of FCR.
A water storage container was considered improved if it was covered and had a spigot or narrow opening.

Data analysis
Data were analyzed using SAS 9.4 software (SAS Institute, Cary, NC). We assessed water treatment and hand hygiene knowledge and behaviors among health facility staff descriptively (e.g., without a test for significance). We compared water storage, treatment, and handwashing variables across the three types of HCFs using design-adjusted Rao-Scott Chi Square tests. The unit of analysis for the HCFs was the health facility, but because most HCFs had more than one water station, we also used water stations as a unit of analysis to provide a more precise indication of the extent of water treatment practices.

Ethical considerations
The Institutional Review Board (IRB) of the Centers for Disease Control and Prevention determined that because this evaluation assessed a proven public health practice, it did not require IRB review. The Kenya Ministry of Health approved the assessment protocol and facilitated access to each HCF by accompanying us to each HCF. Written informed consent was obtained from participating health workers and mothers who participated. Personal identifiers were not collected.

HCF assessment
The 30 HCFs randomly selected for this evaluation included 2 hospitals, 11 health centers, and 17 dispensaries. The median number of health workers per facility was 5 (range: 1-42); 50% of health workers were female. The median number of patients seen per day in PMTCT clinics at the 30 facilities was 29 (range: 6-60) ( Table 1).
The main drinking water sources for the 30 HCFs included rainwater catchment (46.7%), borehole (20.0%), protected spring (16.7%), and piped water (6.7%). The main drinking water source was within the grounds of 23 (76.7%) HCFs and the remaining 7 (23.0%) were within a 30-minute round-trip of their water source. All facilities reported treating water for both handwashing and drinking.   (Table 4).
Of 299 clients, 80.0% said they received sachets free during a HCF visit and 11.4% reported ever purchasing the product, while 47.8% reported receiving free Water-Guard and 57.5% reported ever purchasing it; 9.7% of clients were able to indicate the correct water treatment procedure for sachets compared to 55.6% for WaterGuard.
There were several barriers to use reported by survey respondents. Of 71 survey respondents who reported that they did not use sachets, 34 (47.9%) said they used another method, 8 (11.3%) indicated it had a bad taste or smell, 7 (9.9%) said they were too busy to treat, 5 (7.0%) did not know where to purchase sachets, 5 (7.0%) had no sachets in the house, 5 (7.0%) believed their water was already safe, and 3 (4.2%) said the cost was too high. Of 50 survey respondents who said they did not use WaterGuard, the most commonly reported barriers were use of another method by 15 (30.0%), bad taste or smell by 10 (20.0%), high cost by 7 (14.0%), water is already safe by 4 (8.0%), do not know where to purchase solution by 3 (6.0%), no The lack of soap for handwashing and chlorine treatment of drinking water (despite the availability of water treatment products through free distribution or in local markets) in half or more of HCFs, increased the potential risk of HAI.
In particular, the lack of water treatment exhibited in all dispensaries is of concern, and likely reflects the poor staffing and heavy patient loads that hinder overburdened health workers from taking on other responsibilities. Although there was no comparison group in this assessment, results were similar to follow-up evaluation data from a program elsewhere in western Kenya that included baseline and follow-up data (Bennett et al. ).
The discordance in reported and confirmed use of water treatment products in HCFs had several possible explanations. One possibility is courtesy bias, which typically leads to over-reporting of desirable behaviors.
Second, a number of HCFs reported storing water until depletion, which could take up to several days, allowing residual chlorine to dissipate and resulting in an underestimate of water treatment. Third, the water used in some heath facilities was turbid, with high chlorine demand that   This simple intervention offers a short-to-medium-term approach to protect the health of patients and providers while more permanent water supply infrastructure is constructed to meet the 2030 Sustainable Development Goal objective of 100% WASH coverage in HCFs.