Does a school-based intervention to engage parents change opportunity for handwashing with soap at home? Practical experience from the Mikono Safi trial in Northwestern Tanzania

BackgroundSchool-based de-worming is advocated as a strategy for reducing the burden of soil-transmitted helminth (STH) infections among children. However, re-infection tends to occur rapidly, suggesting that comprehensive water, sanitation, and hygiene (WASH) improvements may be needed to prevent this. We qualitatively assessed the influence of parental engagement activities on parents’ motivation to improve WASH infrastructure and hygiene practices at home in the context of a school-based de-worming programme.MethodologyWe conducted a longitudinal qualitative study nested within the Mikono Safi trial, designed to assess the effect of a WASH intervention on STH infection prevalence in children. Meetings were organized for parents/guardians at schools where they were given information about STH infection, the role of WASH in STH infection prevention, and actionable steps they could take at home. During the meetings, parents/guardians received information about their own child’s STH infection status. Twenty purposively selected households were visited and interviewed 3 times over a period of about 8-months. We employed thematic analysis; findings are reported following the Capability-Opportunity-Motivation and Behaviour (COM-B) framework.Principal findingsThe engagement strategy improved parents’/guardians’ knowledge and skills about handwashing with soap and its benefits. Parents/guardians reported that the sessions had motivated them to improve WASH infrastructure at home. Of 20 households included in this study, 17 renovated or built new latrines and 18 installed handwashing facilities. However, only 8 households established and maintained handwashing stations with both soap and water at 8 months.ConclusionsThe engagement of parents/guardians in a school-based WASH education intervention as part of the Mikono Safi trial resulted in increased knowledge and motivation about handwashing and sanitation. This led to improvements in sanitation facilities and handwashing opportunities at home. However, long-term success in provision of water and soap was limited, indicating that sustained engagement may be required to encourage households to ensure these materials are consistently available at home.     

Assessment of a national voucher scheme to deliver insecticide-treated mosquito nets to pregnant women

Background

The benefits of a health-related intervention may be compromised by the challenges of delivering the intervention on a large scale. We analyzed the process involved in the Tanzania National Voucher Scheme, a system for delivering insecticide-treated mosquito nets to pregnant women. We aimed to identify potential ways to equitably improve overall coverage of the intervention.

Methods

We defined five steps in the process. We collected data from a multistage cluster survey of nationally representative households conducted in 2007 across 21 districts in Tanzania. Using these data, we multiplied the rate of success of each step cumulatively to estimate the overall success of the system.

Results

The rate of coverage for use of insecticide-treated nets among pregnant women was 23% (95% confidence interval [CI] 19%–27%). We observed large differences in coverage by socio-economic status, from 7% (95% CI 4%–13%) among participants in the poorest households to 48% (95% CI 38%–59%) among those in the richest households. The rate of success of each step in the process was high (60%–98%). However, the cumulative rate of success for the process as a whole was low (30%). The largest and most inequitable reduction in coverage occurred in the step involving treatment of nets with insecticide.

Interpretation

The cumulative effect of modest attrition at several steps in the process substantially diminished the overall rate of coverage for all women, but most markedly among the poorest participants. Analysis of the process suggests that delivery of nets treated with long-lasting insecticide rather than untreated nets packaged with an insecticide-treatment kit could result in an improvement in coverage of 22 percentage points, from 30% to 52%.Systems designed to deliver health-related interventions on a large scale re quire a number of operational steps to reach targeted groups. Some people will not be reached at each step because of attrition, which creates a staircase effect of diminishing effectiveness at the population level.^1,2 This cumulative effect may be further pronounced among people in poor households, because they may be more likely than those in wealthier households to drop out at each step.³We investigated the impact of reductions in coverage on the effectiveness of a national multistep system in Tanzania to deliver insecticide-treated mosquito nets to pregnant women. The use of such nets has been shown to reduce childhood mortality by 17% across different African settings.⁴ When used by pregnant women, these nets have been associated with a reduction of 38% in the incidence of maternal malaria parasitemia, of 47% in the incidence of severe malarial anemia and of 28% in the prevalence of infants with low birth weights.⁵All socio-economic groups are susceptible to malaria.⁶ However, there can be large socio-economic inequities in knowledge of the risks associated with infection, in access to prevention and treatment, and in ability to pay for prevention and treatment.⁷ Over the last 10 years, political commitment to achieve high and equitable coverage for the delivery of insecticide-treated nets has grown. Many countries in sub-Saharan Africa have committed to the target set at a meeting in Abuja, Nigeria, in 2000 to increase coverage among children and pregnant women to at least 60%, a target recently increased to 80% by 2010.⁸ However, progress has been slow: coverage among children under five years of age in malaria-endemic regions of Africa was estimated to be less than 20% in 2007.⁹Since 2006, Tanzania has implemented a discount voucher system on a national level to deliver insecticide-treated nets to pregnant women. Although relatively simple, the process involves a sequence of five steps that include the woman attending an antenatal clinic, obtaining a voucher there, using the voucher to buy a mosquito net packaged with insecticide, treating the net with the insecticide and, finally, using the net. Each step depends on the success of the previous one. At each point, a pregnant woman may drop out of the process and end up unprotected. If we assume hypothetically that 90% of women are reached at each step, the coverage would be only 59% (100 × 0.9 × 0.9 × 0.9 × 0.9 × 0.9 = 59). Furthermore, there are likely to be socio- economic differences that give rise to an “equity gap” at each step.We conducted this study to analyze the processes involved in the Tanzanian discount voucher system. Using survey data collected as part of the program for monitoring and evaluating the system, we calculated the cumulative success of the system for different socio-economic groups. We also explored opportunities to improve the system.