Intervention Study to Improve Maternal Handwashing

Infectious diseases, such as umbilical cord infection, pneumonia, and sepsis, are responsible for about a quarter of neonatal deaths. Contaminated hands likely play a role in transmitting pathogens to a neonate, therefore handwashing with soap has the potential to interrupt transmission and improve neonatal health. The primary objective of this study is to develop and evaluate a scalable, cost-effective handwashing promotion program to improve handwashing behavior among mothers and caregivers of neonates. The investigators will first conduct a qualitative study to assess the feasibility and acceptability of a set of interventions. The investigators propose to evaluate the impact of the intervention components, designed as three progressively intense interventions, using a randomized controlled trial with elements of a stepped wedge design. The study will be conducted in Meru County, Kenya, enrolling a total of 800 pregnant women who seek non-emergency antenatal care at a government health facility during a 1 year period. Clinic based health care workers and community health volunteers will disseminate the intervention using an interactive storytelling approach. The focus of the interactions between the health care workers and volunteers and the participant will be on addressing barriers to handwashing through interactive question and answer sessions, rather than a didactic, educational session. The investigators will assess the impact of interventions on observed maternal and caregiver handwashing behavior and estimate the cost effectiveness for each intervention.

• Clinic (Behavioral): Pregnant women will receive handwashing promotion from a trained facility-based health care worker during her regular antenatal visit at a healthcare clinic. To the extent feasible, everyone accompanying the pregnant woman will be invited to take part in the behavior change communication session. The participant will be provided with several bars of soap to take home and she will be encouraged to maintain a designated place for washing hands (with soap and water) at the home. A poster indicating the key events for handwashing with soap will be posted at the clinic and smaller posters will be given to the participant to post in her home. A system will be established to send regular SMS messages to the participant promote handwashing with soap during the neonatal period.
• Clinic + home (Behavioral): Women will receive all components of the clinic-based handwashing promotion in addition to handwashing promotion during 3-4 home visits before their expected delivery date and during the neonatal period from a community health volunteer. All household members present will be invited to join in the session, with emphasis on including all caregivers of the neonate.
• Clinic + home + handwashing device (Behavioral): Women will receive all components of the clinic + home-based handwashing promotion intervention in addition to one handwashing device (i.e. tap and basin to use as a handwashing station) during the first home visit by the community health volunteer. The community health volunteer will work with the woman and her family to identify the location where the neonate will be most of the time in order to position the handwashing station as close to the neonate as possible.

Primary outcomes

• Frequency of washing hands with soap at potential pathogen transmission events by mothers of neonate [1 week post-natal]: Direct observation of handwashing behavior of mothers at times when pathogens may be transmitted from the mother to the neonate
• Frequency of washing hands with soap at potential pathogen transmission events by mothers of neonate [2 weeks post-natal]: Direct observation of handwashing behavior of mothers at times when pathogens may be transmitted from the mother to the neonate

Secondary outcomes

• Frequency of washing hands with soap at potential pathogen transmission events by caregivers of neonate (other than mother) [1 week post-natal]: Direct observation of handwashing behavior of caregivers (other than mother) at times when pathogens may be transmitted from the caregiver to the neonate
• Number of participants with soap and water present at a handwashing station [1 week post-natal]: Observed presence of soap and/or water at a handwashing station
• Cost-effectiveness [1 month post-partum]: Approximate cost of the intervention per participant
• Frequency of washing hands with soap at potential pathogen transmission events by caregivers of neonate (other than mother) [2 weeks post-natal]: Direct observation of handwashing behavior of caregivers (other than mother) at times when pathogens may be transmitted from the caregiver to the neonate
• Number of participants with soap and water present at a handwashing station [2 weeks post-natal]: Observed presence of soap and/or water at a handwashing station

Sex: Female

Inclusion Criteria:

* Pregnant women
* Seeking routine (non-emergency) care at a participating antenatal care clinic during the study period
* Between 30 and 36 weeks pregnant (calculated based on last known menstrual period) when they seek antenatal care
* Live within 30 minutes or 1-2 km one-way travel from the clinic
* Plan to remain in the study area for at least one month post-partum
* Willing to allow the field worker to visit her home following the antenatal care visit on the day of enrollment to conduct baseline assessments at the household
* Sought antenatal care from a qualified medical provider for the first time at or after 28 weeks gestation

Exclusion Criteria:

* Excluded if another member of their household or compound/homestead enrolled in this study
* Excluded if enrolled in the formative research for this study

• Pavani K. Ram, M.D., Principal investigator, State University of New York at Buffalo