title: Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala.
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.
authors: Division of Epidemiology, University of California, Berkeley, CA 94720-7360, USA. benarnold@berkeley.edu
authors: Benjamin
authors: B
authors: Arnold
authors: Byron
authors: B
authors: Arana
authors: Daniel
authors: D
authors: Mäusezahl
authors: Alan
authors: A
authors: Hubbard
authors: John M
authors: JM
authors: Colford
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D003967:Diarrhea / Q000453:epidemiology / Q000517:prevention & control*; D005260:Female; D005500:Follow-Up Studies; D005618:Fresh Water; D006128:Growth / Q000502:physiology; D006166:Guatemala / Q000453:epidemiology; D006235:Hand Disinfection; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D006920:Hygiene / Q000193:education / Q000592:standards*; D016013:Likelihood Functions; D008297:Male; D012141:Respiratory Tract Infections / Q000453:epidemiology / Q000517:prevention & control*; D012423:Rural Health; D012915:Soaps
chemical_list: D012915:Soaps