200505 Evaluating the sustainability and impact of a three-year point-of-use water treatment and handwashing intervention in rural Guatemala

Monday, November 9, 2009: 8:50 AM

Benjamin Arnold, MPH , Division of Epidemiology, University of California, Berkeley, Berkeley, CA
Byron Arana, MD, PhD , Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
Daniel Maeusezahl, PhD , Swiss Tropical Institute, Department of Public Health and Epidemiology, University of Basel, Basel, Switzerland
Alan Hubbard, PhD , School of Public Health, University of California, Berkeley, Berkeley, CA
John Colford, MD PhD , Division of Epidemiology, University of California, Berkeley, Berkeley, CA
Background: The promotion of point-of-use water treatment and handwashing with soap has led to large reductions in child diarrhea in randomized efficacy trials. We know little about the sustainability of behavior change and health benefits after the conclusion of intervention activities.

Methods: We present an extension of previously published design (propensity score matching) and analysis (targeted maximum likelihood estimation) methods to evaluate the sustainability and health impacts of a pre-existing (non-randomized) intervention (a three-year, combined point-of-use water treatment and handwashing campaign in rural Guatemala). Six months after the intervention, we conducted a cross-sectional cohort study in 30 villages (15 intervention, 15 control) that included 600 households and 929 children under five years old.

Results: The design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics. The intervention was associated with modest gains in confirmed water treatment behavior (risk difference=0.05, 95%CI 0.02-0.09). We found, however, no differences between the intervention and control villages in self-reported handwashing behavior, spot-check hygiene conditions, the prevalence of either child diarrhea or clinical acute lower respiratory infections, or child growth.

Conclusions: To our knowledge this is the first post-intervention follow-up study of a combined point-of-use water treatment and handwashing behavior change intervention, and the first post-intervention follow-up of either intervention type to include child health measurement. Our findings highlight the difficulty of sustaining behavior-based point-of-use water treatment and handwashing outside of intensive efficacy trials.

Learning Objectives:
1. Describe new methods to measure intervention sustainability using pre-existing interventions. 2. Illustrate the new method with a case study from a household water treatment intervention in rural Guatemala. 3. Summarize key outcomes and identify challenges to the sustainability of behavior-based water treatment interventions.

Keywords: Water, Sustainability

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a co-investigator on the study and have been involved in all steps of the research. Some previously published, related papers include: Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis. 2005 Jan;5(1):42-52. Colford JM Jr., Wade TJ, Sandhu SK, Wright CC, Lee S, Shaw S, Fox K, Burns S, Benker A, Brookhart MA, van der Laan M, Levy D. A randomized controlled trial of in-home drinking water intervention for the reduction of gastrointestinal illness. Am J Epidemiol. 2005 Mar 1;161(5):472-82. Colford JM Jr, Saha SR, Wade TJ, Wright CC, Vu M, Charles S, Jensen P, Hubbard A, Levy DA, Eisenberg JN. A pilot randomized, controlled trial of an in-home drinking water intervention among HIV + persons. J Water Health. 2005 Jun;3(2):173-84.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.