Socioeconomic determinants of the success of integrating household water treatment and hygiene promotion with antenatal services in Malawi

Background: Diarrhea, one of Malawi's leading causes of childhood mortality, can be mitigated by improving water quality and hygiene. We distributed free safe water storage containers, sodium hypochlorite water treatment (WaterGuard) solution, soap, and educational messages to pregnant women during antenatal clinic (ANC) visits; provided up to 3 free refills of WaterGuard and soap at subsequent ANC visits; and evaluated program impact. A national population-based survey in 2005 found lowest WaterGuard use rates among poorer, rural, less educated women.

Methods: At baseline and 9 months after implementation we interviewed 389 women about water treatment practices, tested household stored drinking water for residual chlorine, and observed handwashing procedure.

Results: Program participants were significantly more likely to know correct water treatment procedures (62% vs. 29%, p<0.0001), demonstrate correct handwashing practices (68% vs. 22%, p<0.0001), treat drinking water with WaterGuard (61% vs. 2%, p<0.0001), and (after free distribution ended) purchase and use WaterGuard (32% vs. 2%, p<0.0001) at follow-up than at baseline. WaterGuard treatment was more likely among rural (OR=2.5, 95% CI 1.1, 2.5), poor (OR=1.7, 95% CI 1.4, 2.2), and illiterate (OR=1.2, 95% CI 1.0, 1.5) women. WaterGuard purchase and use was more common among rural (OR=1.9, 95% CI 1.2, 3.0) and poor (OR=1.7, 95% CI 1.1, 2.5) women.

Conclusions: Antenatal clinic product distribution and health promotion appeared to be an effective hygiene behavior strategy for reaching rural, poor, less educated women in Malawi. Evidence of product purchase following program exit suggests that program benefits may be sustained.