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IJE Advance Access published online on July 2, 2009
International Journal of Epidemiology, doi:10.1093/ije/dyp241
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Published by Oxford University Press on behalf of the International Epidemiological Association. © The Author 2009; all rights reserved.
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala

Benjamin Arnold1,*, Byron Arana2, Daniel Mäusezahl3, Alan Hubbard4 and John M Colford, Jr1

1Division of Epidemiology, University of California, Berkeley, CA, USA.
2Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
3Swiss Tropical Institute, Department of Public Health and Epidemiology, University of Basel, Basel, Switzerland.
4Division of Biostatistics, University of California, Berkeley, CA, USA.

*Corresponding author. Division of Epidemiology, University of California, 50 University Hall, Berkeley, CA 94720-7360, USA. E-mail: benarnold{at}berkeley.edu


  Abstract

Background The promotion of household water treatment and handwashing with soap has led to large reductions in child diarrhoea in randomized efficacy trials. Currently, we know little about the health effectiveness of behaviour-based water and hygiene interventions 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 behavioural and health impacts of a pre-existing but non-randomized intervention (a 3-year, combined household 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 and 15 control) that included 600 households, and 929 children <5 years of age.

Results The study design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics. The intervention led to modest gains in confirmed water treatment behaviour [risk difference = 0.05, 95% confidence interval (CI) 0.02–0.09]. We found, however, no difference between the intervention and control villages in self-reported handwashing behaviour, spot-check hygiene conditions, or the prevalence of child diarrhoea, clinical acute lower respiratory infections or child growth.

Conclusions To our knowledge this is the first post-intervention follow-up study of a combined household water treatment and handwashing behaviour change intervention, and the first post-intervention follow-up of either intervention type to include child health measurement. The lack of child health impacts is consistent with unsustained behaviour adoption. Our findings highlight the difficulty of implementing behaviour-based household water treatment and handwashing outside of intensive efficacy trials.

Keywords Household water treatment, handwashing, intervention, sustainability, propensity score matching, targeted maximum likelihood, Guatemala

Accepted 2 June 2009


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