Hand washing education in Quezalguaque, Nicaragua

Presentation Transcript

APHA 136th Annual Conference,

San Diego, CA – October 29, 2008

Denise Burke MPH, *Courtney Cawthon MPH,

Casey Rebholz MPH, Karen Sherk MPH

(*Presenting author)

Presenter Disclosures

Courtney Cawthon

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

No relationships to disclose

Learning Objective

To understand the design, monitoring and evaluation of a community hygiene intervention

Background

Boston University Masters Practicum 2006
Brookline Sister City Project:

Quezalguaque General Health Survey
Demographics, health services access and utilization, common health issues

Source: http://www.mapsofworld.com/nicaragua

Source: Mayor’s office, Quezalguaque, Nicaragua

Setting

Many households don’t have electricity
Wells are main source of water
Sinks and latrines are often shared
55% had no school or not completed primary school
Most live in close proximity to livestock

Photos courtesy of Christine Yennaco, BUSPH ‘08

Disease Burden

Worldwide

A child dies every 30 seconds from diarrhea
ARI is the cause of 30-50% of child visits
67% of child mortality

In Nicaragua

Diarrhea is a leading cause of mortality
Quezalguaque Ministry of Health:

54% of health center visits
ARI the leading complaint in 2006-07

Disease Transmission Model

Wagner and Lanois, 1958; PAHO

Specific Aims

Decrease frequency of diarrhea
Decrease frequency of ARI
Increase hand washing at 3 key times:

After defecation or using the latrine
After changing /cleaning a child who has defecated
Before preparing and serving food

Qualitative evaluation

(June 2-15, 2007)

Key informant interviews

Focus Groups

Results

Price is a barrier to purchasing hand soap

Interest in home visits

Prevention vs. Treatment

Formative Phase

Photo courtesy of Brookline Sister City Project

Source: Mayor’s office, Quezalguaque, Nicaragua

Intervention

Charlas – informal educational workshops

Local project assistants
Once a month in each intervention community
Lesson plans by BUSPH grad student
Health center support

Free hand soap (CP, Central America)
Home visits focused on

education

Colgate-Palmolive Co.

Enrollment and Data collection

Enrollment (July 9-25, 2007)

Children ≤ 5 years with a caregiver ≥ 18 years
Photos, symptom diaries

Baseline survey
Direct observations

Photo courtesy of Christine Yennaco, BUSPH ‘08

Monitoring

Final Evaluation(January 2008)

Repeat baseline survey
Repeat direct observations

Results

108 caregivers/149 children (94% retention)
97% female caregivers
Average age:

Caregiver: 28 years (range 18-59)
Children: 2.6 years

Households

1.4 children < 6 yr
5.3 people
1.6 adults employed

Results

Disease prevention knowledge
Hand washing behavior at key times
Health outcomes

Photo courtesy of Christine Yennaco, BUSPH ‘08

Disease Prevention Knowledge

Table 1. Comparison of Knowledge of Hand Washing with Soap and Water to Prevent Disease,
and Importance of Key Activities for Hand Washing, at follow-up

Hand Washing Behavior

Table 2. Frequency of "Always" or "Almost Always" Washing Hands with Soap and Water with Key Activities, at follow-up

*Among those with children wearing diapers, n=51

Health Outcomes

Table 3. Comparison of overall disease burden of ARI and diarrhea at follow up

*P-values only significant for diarrheal measures

Discussion

Heightened awareness of symptoms can lead to increased reporting
Added emphasis of education materials on diarrhea
Intervention techniques: not closely evaluated
Direct observations: unsuccessful

Limitations

Communal sinks, location of sink and soap
Self-report subject to bias
Selection of study communities was not at random
Demographic factors

High unemployment rate
Large families in close quarters
Low educational attainment
Persistent need for food

Conclusions

The intervention successfully increased knowledge
To achieve more impact on health outcomes, need to address logistical barriers

Thanks to our Funders

APHA International Section & Colgate-Palmolive

Acknowledgements

Advisors Dr. Jim Wolff and Sarah Johnson, for their constant encouragement and guidance.
Boston University MPH Candidates Nicole Daley, Julie O’Donnell, Christine Yennaco, Yuko Rodriguez, Dana Greeson and Ana Morales, who all contributed long hours and creative ideas to this project
Special thanks to Colgate Palmolive-Central America, for their generous donation of hand soap.
Most importantly, Brookline Sister City in Brookline, MA and Quezalguaque, Nicaragua, for letting us be a part of their wonderful work.

Bibliography

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