Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children

Shabina Ariff1, Ubaidullah Khan2, Ali Turab1, Imtiaz Hussain1, Atif Habib1, Tarab Mansoor1, Dania Mallick1, Zamir Suhag1, Zaid Bhatti1, Imran Ahmed1, Sajid Bashir Soofi1*, Zulfiqar A Bhutta3,4 1Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan 2Department of Pediatrics, King Edward Medical University, Lahore, Pakistan 3Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan 4Center for Global Child Health, Hospital for Sick Children, Toronto, Canada International Journal of Pediatrics & Child Care Open Access Research Article


Background
Elimination of waterborne illnesses alone can add up to two years to the life expectancy at birth in Pakistan (1).As many as 6 million children under the age of five die annually, quarter of these deaths are attributable to environmental factors and 0.6 million die due to diarrheal illnesses (2)(3)(4).Approximately 79% of these deaths are concentrated in Africa and South Asia [2] Unsafe water, sanitation, and hygiene are rendered as the most critical global risk factors for diarrhoea and related illnesses [5].Globally, over 1.1 billion people lack of access to safe drinking water and are at risk of becoming infected with water-related pathogens [6] In Pakistan, only 49% of rural population has access to improved drinking water source (tube well, bore hole) and 91% do not treat drinking water in any way prior to consumption [7].These numbers reflect the need to restructure our efforts, strategies, and interventions if we are to narrow the gap towards reaching the Sustainable Development Goals 2030.Construction of water supply schemes and treatment plants as well as sanitation and waste management requires significant resources and planning.However household treatment methods such as chlorination, filtration, flocculation and solar disinfection have emerged as effective and inexpensive alternative in places where access to safe piped water is not available.and heating [14,15].SODIS is proven efficacious by laboratory improving the quality of water [15][16][17].Its use is advocated in developing countries to improve health in settings where safe drinking water is not available.Despite the efforts only a few field studies assessed its health impact and evidence on acceptance, regular use, and scalability of the method is scarce and inconclusive [18][19][20][21][22][23].
Unfortunately there are no local studies to validate regional outcomes, especially in context to its acceptability in the rural community where majority of the population resides.Our study attempted to evaluate, and measure the health outcomes of solar water disinfection (SODIS) and its acceptability in Faisalabad and Toba Tek Singh districts of Punjab province Pakistan.

Material and Methods
We carried out an impact assessment of solar water disinfection (SODIS) program through a cross-sectional survey in two districts (Faisalabad, Toba Tek Singh) Punjab, Pakistan At present there are ~ 100,000 LHWs that provide an essential link between the formal health system and the communities.They provide antenatal care, postnatal visits for the mother and newborn, immunization services, and health education on hygiene and sanitation.

Implementation of Intervention
Faisalabad served as the intervention district where SODIS was implemented along with community mobilization and awareness messages on diarrheal disease prevention and hygiene.Community mobilization involved formation of village health committees (VHCs) and Self-help Groups (SHGs) through LHWs / CHWs and key influential people to create sensitization on SODIS.Regular monthly meetings were held for advocacy of SODIS as a simple method of water purification by CHW.Brochures and pamphlet with pictorials in local language were used for this purpose.
Toba Tek Singh was selected as anon-intervention district.Faisalabad stands in the rolling flat plains of northeast Punjab and is a major industrial centre in the heart of Pakistan with a population that is a blend of agrarian and industrial urban populace.The population of Faisalabad city is 1.23 million Toba Tek Singh is a neighboring district with a population of 1.39 million.

Data Collection
To exclude any possible bias the data collection was carried out by an independent team of data collectors living in the same locality who were not involved in any of the project activities .There were 5 teams of data collectors, each team comprising of 3 data collectors and one male supervisor.The data collectors received a 3 day class room training on the content of the questionnaire and its administration prior to the initiation of the survey.
The cross sectional survey was conducted from May -June, 2011 after one year of the intervention implementation.The target population was mothers with children under five years of age.All mothers whose children had diarrhoea in the two weeks prior to the date of the interview and in the last 24 hours were enrolled A verbal consent was sought prior to the administration of data collection questionnaire.
The questionnaire sought information on health, hygiene, water management habits, knowledge, practices and perceptions about diarrheal illnesses, water sterilization, and disinfection practices including SODIS methods.
Diarrhoea was defined as per WHO 'the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual)'.A new episode of diarrhea was considered if there was a 3 day asymptomatic period between consecutive 2 episodes.Dysentery was defined as presence of blood /mucus in stools.

Sampling Frame
The WHO's "30 x 7" cluster sampling method was adopted.The catchment population of one LHW served as a cluster.Typically a LHW's catchment area is comprised of approximately of 150 to 200 households.Thirty clusters were randomly selected from both intervention and control areas.Systematic sampling technique was used to select households from each selected cluster.In case the response from selected household could not be attained (no child less than 5 years, or temporarily not at home due to family vacation or any emergency) substitution of sampled household was allowed by selecting subsequent household using the "next nearest household" approach.Household with women having at least one child less than five years of age was selection criteria.If there was more than one eligible woman in a household, then only one of them was selected randomly.

Ethical Clearance
The study was approved by Ethical Review Committee of Aga Khan University.Informed consent was sought from each respondent before inclusion into the study.Confidentiality of data was maintained throughout the study and was only accessible to the senior project staff.Participants in the study were allocated unique ID number for identification.

Quality Assurance
The quality of data was ensured through review meetings and supervisory field visits.A random 5% of interviews were also attended by the study supervisor.The purpose of these visits was to ensure if correct interview procedure and probing techniques were being applied by the interviewers.Daily progress report was generated by the data management unit and the supervisor conducted daily debriefing meetings for problems pertaining to interviews and operations.Random field visits were undertaken by study investigators to ensure quality and adequacy of collected data.
through Lady Health Workers in reduction of diarrheal episodes in under five children.Int J Pediatr Child Care 1(1): 10.

Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children
Copyright: © 2016 Soofi et al.

Statistical Methods and Analysis
For data entry, the entry screens were developed in Microsoft visual FoxPro version 7.0.The data entry screens employed range and logical checks to identify and manage erroneous values.All the data were dual entered.The statistical analysis was performed by using SPSS version 19.Frequency and percentages were reported for categorical variables and mean and standard deviations for quantitative variables.Proportions were tested by using chi-square across the control and intervention arm.Independent sample t-test was used to calculate the mean difference between the two arms for quantitative variables with a level of significance at 5%.Differences in the diarrhoea frequency between the intervention and control groups were determined through the risk rate as well as through the difference between the risk rates as a function of safe/unsafe water consumption.
Bivariate analyses of factors associated with diarrheal prevalence were tested using binary logistic regression.Variables with p value <0.25 in the bivariate analysis were considered for inclusion in the multivariable logistic regression model.A parsimonious model building strategy was used to select variables with statistical significance on multivariable analysis.
Unadjusted and adjusted odds ratios were presented.

Results
Total 2,792 household participated in the study; 1,391 interviews were conducted in the intervention and 1,401 in the control arm.Demographic, socioeconomic characteristics and wash practices of the population are described in Table 1.The base line household characteristics and demographics were comparable in both areas.Majority of household in both areas used electric motor pumps to access underground water for drinking purposes similarly, toilet facility and waste disposal scenario at both the areas was dominated by pour flush and connected sewer.Almost 93% respondents in intervention and 87% in control arms reported that their under 5 children washed hands more than three times a day.Similarly the use of soap for hand washing was significantly high but comparable in the intervention (98.5%) and control areas (92.9% p <0.0001).However the proportion of household who reported Lady Health Worker (LHW) as the main source of information on health and hygiene practices was substantially higher in the intervention area (88.9) compared to control (29.4).

Knowledge attitude practices regarding drinking water, Diarrheal disease and SODIS
Table 2 describes the knowledge attitude and practices of the study population with regards to drinking water quality, diarrheal illnesses and SODIS.High proportion of respondents in the intervention (89%) and control areas (79%, p value < 0.0001) were aware of the hazards of unsafe water and considered it to be a major risk factor for diarrhoea.Similarly most of the respondents in the intervention (90%) and control area (78%) had knowledge of the harmful outcomes of germs/bacteria in drinking water.Almost 91%respondentsin the intervention area had heard about SODIS method to treat water in the intervention area and LHWs were the main source of information 98%.Whereas only 1% of the households in the control area heard of the intervention 82% mothers in the intervention area reported using SODIS method of water purification and > 80 % used it regularly.Almost 89% of respondents were aware of the correct placement of water and exposure time (6hours) for SODIS and 81 percent were aware of the mechanism of disinfection being solar power.Majority of the population (97%) interviewed in the intervention arm considered SODIS as an effective method to treat water for drinking The top hurdles cited for non-adherence to SODIS were prolonged process time for purification (45%) and non-availability of PET bottles (38%).
High proportion of respondents (96%) believed SODIS was beneficial to their households.more than half (59%) of the participants of intervention arm reported reduction in the diarrheal episodes following SODIS treatment of water whereas 49% reported improvement in general health of children.Majority of the household heads (96.8%) advocated the use of SODIS for household drinking water.

LHW's, SODIS intervention coverage
The LHW coverage for the intervention (100%) and control areas (99%) was comparable table 3. Similarly 48% households in both the areas reported the LHW's visiting the household

Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children
Copyright: © 2016 Soofi et al.

Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children
Copyright: © 2016 Soofi et al.
* represent the multiple response, ǂ Proportions were compared using Chi-square test & Ψ Mean difference compared using Independent sample t-test atleast once a week.81% percent of respondent reported having received information on health, hygiene and immunization practices in the intervention area vs. 26% percent in the nonintervention area.In the intervention area 81% respondents reported LHW's while 18% mentioned Television as the source for receiving information regarding SODIS in past 1 month.

Impact of SODIS on diarrhoea in past two weeks
Table 4 reflects that there was a significant impact of SODIS intervention on diarrheal illness in the intervention compared to non-intervention area.Diarrhoea prevalence was 10.1 episodes per child per year in the non-intervention area compared to 5.6 episodes per child per year (p < 0.0001) in the intervention area.
Similarly the proportion of children with dysentery reported in the intervention was half compared to non-intervention area (6.1% vs. 13.9%)

Discussion
The study focused to establish the impact of SODIS to reduce diarrheal episodes and to evaluate its uptake by the community at large.The study showed a significant impact of SODIS treatment on diarrheal episodes which is similar to studies conducted in Kenya, India and Cambodia [8,[10][11].
Impact of SODIS was measured via 'reported diarrhoea' in the last two weeks; type of diarrhoea; associated symptoms (e.g.vomiting, stomach pain); and factors influencing diarrhoea (e.g.hand washing).SODIS caused a significant reduction in the number of new cases of diarrhoea and our results are supported by a similar study conducted in Kenya for duration of four months revealing 10 percent less new cases of diarrhoea in families using SODIS when compared with those who were not [8].Another observational study also conducted in Kenya revealed a 16%

Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children
Copyright: © 2016 Soofi et al. percent reduction of diarrhoeal illnesses in children under 5 years of age utilizing SODIS over one year [12].
The effectiveness of SODIS method was well established as 97.5% of the population using.SODIS methods were convinced of its benefits.Among those who used the SODIS method, 52.9% reported decreased diarrhoea in children under five and 60.8% reported an improvement in general health of their children.
The overwhelming increase in compliance of the SODIS method may be attributed to the awareness of benefits of clean drinking water and lack of alternative safe water sources.The results overall are in consonance with the findings of Kevin G McGuigan et al (2011) [8] where SODIS was concomitant with a 50% reduction in risk of diarrheal diseases.The aetiology of diarrhoeal disease among the survey population is not certain but subjectively determined to be the result of poor hygiene and utilization of unsafe water.This is strongly depicted (p value of 0.0006) among the poorest quintile of the survey population.
Analysis with regression models revealed that the four out of the seven postulated influencing factors were significant: children have a lower risk of contracting diarrhoea when they consume high percentages of safe drinks, live in households with good hygiene, wash hands, and belongs to the richest quintile.This is paralleled with Graf J et al (2008) [11] and (2010) [14].
Based on our findings, SODIS method for purifying drinking through Lady Health Workers in reduction of diarrheal episodes in under five children.Int J Pediatr Child Care 1(1): 10. water is acceptable and effective in the developing countries.It is safe, cheap and convenient method.In order to reduce under five mortality, SODIS needs to be included as an intervention in the preventive strategies to control diarrheal illnesses.The community mobilization strategies were effective as majority of the respondents were either practicing SODIS or were willing to adopt it.

Evaluation of Solar Disinfection of water intervention delivered through Lady Health Workers in reduction of diarrheal episodes in under five children
SODIS intervention was introduced and implemented by Community Action Program (CAP), an initiative taken by the Ministry of Health Pakistan through the Lady Health Workers (LHW's) of the National Program of Family Planning and Primary Health Care from April 2010-May 2011.The LHW's are community health workers employed by the Ministry of Health.

Number of rooms in the house n (%)
through Lady Health Workers in reduction of diarrheal episodes in under five children.Int J Pediatr Child Care 1(1): 10.

Have you or other household members been given any advice regarding the importance of hand washing with soap? n (%)
* represent the multiple response, ǂ Proportions were compared using Chi-square test & Ψ Mean difference compared using Independent sample t-test

Table 2 :
Knowledge attitude practices regarding drinking water, Diarrheal disease and SODIS.

Have you noticed any benefits/changes by using SODIS treated water in your house? n (%)
* represent the multiple responses, ǂ Proportions were compared using Chi-square test & Ψ Mean difference compared Using Independent sample t-test through Lady Health Workers in reduction of diarrheal episodes in under five children.Int J Pediatr Child Care 1(1): 10.

Table 4 :
Diarrhea in last two weeks.Proportions were compared using Chi-square test &Ψ Mean difference compared using Independent sample t-test

Table 5 :
Factors influencing diarrheal prevalence and health impact of SODIS in under age of five children.*adjusted for district, wealth quintiles, number of under 5 children in the households and hand washing practices. *