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The WHO guidelines for monitoring and evaluating Schistosoma mansoni control programs are based on the Kato-Katz (KK) fecal examination method; however, there are limitations to its use, particularly in low prevalence areas. The point-of-care urine circulating cathodic antigen (POC-CCA) assay has emerged as a useful tool for mapping schistosomiasis prevalence, but its use in monitoring and evaluating control programs has not been evaluated. Before POC-CCA can be used for these programs, it must be determined how previous guidance based on the KK method can be translated to the POC-CCA assay; furthermore, its performance in different endemicity settings must be evaluated. Urine and stool specimens were collected from students attending public primary schools in western Kenya before mass treatment with praziquantel at baseline (51 schools), year 1 (45 schools), year 2 (34 schools), and year 3 (20 schools). Prevalence and infection intensity were determined by the KK method and POC-CCA assay. Changes in prevalence and intensity were compared within the strata of schools grouped according to the baseline prevalence determined by the KK method (0–10%, > 10–20%, > 20%). The prevalence determined by the POC-CCA assay was higher than that determined by the KK method at all time points for all strata. The prevalence determined by the KK method decreased from baseline to 2 and 3 years, as did infection intensity (with one exception). A corresponding decrease was not always replicated by the POC-CCA assay results. The POC-CCA assay did not perform as expected, and the concordance of results of the two tests was poor. Furthermore, there are emerging concerns regarding the specificity of the POC-CCA assay. Therefore, it is impossible to translate historical data and programmatic guidelines based on the KK method results to the POC-CCA assay.

ObjectivesGiven high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation).DesignWe conducted an unblinded 1:1 cluster-randomised controlled trial.Setting48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019.Participants2922 women were recruited to the control and 2522 to the intervention arm.InterventionsAn electronic system recorded attendance and triggered payments to the participant’s mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone.Primary outcomesPrimary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data.ResultsWe found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10).ConclusionsDemand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe.Trial registrationNCT03021070.

ObjectivesWe report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.Intervention, setting and participantsThe Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.DesignA mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.ResultsDelivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.ConclusionsThe findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.Trial registration numberNCT03021070.

To address water and hygiene infrastructure deficiencies in health-care facilities (HCFs) in Siaya County, Kenya, portable water stations, soap, and water treatment products were provided to 109 HCFs in 2005. In 2011 and again in 2016, we interviewed staff in 26 randomly selected HCFs, observed water sources, water stations, and tested source and stored water for chlorine residual and Escherichia coli. Of 26 HCFs, 22 (85%) had improved water supplies, and 22 (85%) had functioning handwashing and drinking water stations, but < 50% provided soap or water treatment. Thirteen (50%) of 26 source water samples yielded E. coli; 24 (92%) of 26 stored water samples yielded no E. coli, including nine with residual chlorine and nine untreated samples from sources yielding no E. coli. Eleven years after implementation, 85% of HCFs continued to use water stations that protected water from recontamination. Sustainable provision of soap and water treatment products could optimize intervention use.

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

There are considerable challenges to achieving the Sustainable Development Goals&rsquo, target of universal access to basic sanitation in schools. Schools require safe, clean, and sex-segregated facilities for a large number of students. Robust and affordable solutions are needed to address the economic, spatial, social, institutional, and political factors which contribute to poor sanitary conditions in informal settlements. In 2015, we undertook a randomized controlled trial to assess the feasibility of private sector sanitation delivery (PSSD) in 20 primary schools, in informal settlements of Nairobi, Kenya. Our preliminary evaluation after one year of service delivery suggested that PSSD of urine-diverting dry latrines with routine waste collection and maintenance provided a feasible, lower-cost alternative to the government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. We conducted a mixed-methods follow-up study to assess sanitation delivery over 3&ndash, 4 years and investigate prevailing drivers and barriers that may influence the scalability of PSSD. The conditions of newly constructed and rehabilitated GSD facilities diminished quickly, reverting to the conditions of existing facilities, indicating lower sustainability compared to sanitation delivered from the private sector. Barriers in financial aspects related to the ongoing implementation of PSSD emerged, particularly among public schools, and few were able to pay for continued service. Our study demonstrates that the engagement of the private sector may lead to improvements in affordable, safely managed sanitation for schools and their students. Yet, to reach a sustained scale, additional guidance is needed on how to develop these partnerships, streamline procurement and contracting processes, and incorporate appropriate financing mechanisms.

IntroductionA wealth of evidence from a range of country settings indicates that antenatal care, facility delivery and postnatal care can reduce maternal and child mortality and morbidity in high-burden settings. However, the utilisation of these services by pregnant women, particularly in low/middle-income country settings, is well below that recommended by the WHO. The Afya trial aims to assess the impact, cost-effectiveness and scalability of conditional cash transfers to promote increased utilisation of these services in rural Kenya and thus retain women in the continuum of care during pregnancy, birth and the postnatal period. This protocol describes the planned economic evaluation of the Afya trial.Methods and analysisThe economic evaluation will be conducted from the provider perspective as a within-trial analysis to evaluate the incremental costs and health outcomes of the cash transfer programme compared with the status quo. Incremental cost-effectiveness ratios will be presented along with a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Sensitivity analyses will be undertaken to explore uncertainty and to ensure that results are robust. A fiscal space assessment will explore the affordability of the intervention. In addition, an analysis of equity impact of the intervention will be conducted.Ethics and disseminationThe study has received ethics approval from the Maseno University Ethics Review Committee, REF MSU/DRPI/MUERC/00294/16. The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference.Trial registration numberNCT03021070

The provision of safely managed sanitation in informal settlements is a challenge, especially in schools that require durable, clean, sex-segregated facilities for a large number of children. In informal settlements in Nairobi, school sanitation facilities demand considerable capital costs, yet are prone to breakage and often unhygienic. The private sector may be able to provide quality facilities and services to schools at lower costs as an alternative to the sanitation that is traditionally provided by the government. We conducted a randomized trial comparing private sector service delivery (PSSD) of urine-diverting dry latrines with routine waste collection and maintenance and government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. The primary outcomes were facility maintenance, use, exposure to fecal contamination, and cost. Schools were followed for one school year. There were few differences in maintenance and pathogen exposure between PSSD and GSD toilets. Use of the PSSD toilets was 128% higher than GSD toilets, as measured with electronic motion detectors. The initial cost of private sector service delivery was USD 2053 (KES 210,000) per school, which was lower than the average cost of rehabilitating the government standard flush-type toilets (USD 9306 (KES 922,638)) and constructing new facilities (USD 114,889 (KES 1,169,668)). The private sector delivery of dry sanitation provided a feasible alternative to the delivery of sewage sanitation in Nairobi informal settlements and might elsewhere in sub-Saharan Africa.

Water, Sanitation and Hygiene (WASH) programs in schools can increase the health, dignity and comfort of students and teachers. Understanding the costs of WASH facilities and services in schools is one essential piece for policy makers to utilize when budgeting for schools and helping to make WASH programs more sustainable. In this study we collected data from NGO and government offices, local hardware shops and 89 rural primary schools across three Kenyan counties. Current expenditures on WASH, from school and external (NGO, government, parent) sources, averaged 1.83 USD per student per year. After reviewing current expenditures, estimated costs of operations and maintenance for bringing schools up to basic WASH standards, were calculated to be 3.03 USD per student per year. This includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was 18,916 USD per school, for a school of 400 students (4.92 USD per student, per year). These findings demonstrate the need for increases in allocations to schools in Kenya, and stricter guidance on how money should be spent on WASH inputs to enable all schools to provide basic WASH for all students.

In Nyanza Province, Kenya, a sustainability evaluation of 55 pilot primary schools 2.5 years after the implementation of the Safe Water System (SWS) intervention revealed that programme activities were not successfully sustained in any of the schools visited. The most common criterion met was drinking water provision. We identified six enabling environment domains: financial capacity; accountability; technical feasibility and availability; community support; school leadership and management; and student engagement. While these domains pertain to the sustaining of the SWS activities in schools, they are likely to be applicable in creating an enabling environment and serve as proxy indicators for other school water, sanitation, and hygiene initiatives as well.

Despite the known health benefits of washing hands with soap, global handwashing rates are low. In Nyanza Province, Kenya, a follow-up of 55 pilot primary schools three years after the implementation of a safe water and hygiene intervention revealed that only 2 per cent (one school) provided soap for handwashing on the day of the assessment. After identifying barriers to soap provision, SWASH+ partners piloted a handwashing intervention using powdered soap mixed with water to create soapy water in place of bar soap in 11 schools. The first six months of unannounced visits showed high uptake (10 schools). A one-year follow-up visit revealed a decrease of soapy water use (four schools). This paper discusses the soapy water intervention, initial and follow-up monitoring findings, potential sustainability drivers of handwashing programmes in rural primary schools and next steps.

To prevent diarrheal diseases in western Kenya, CARE Kenya initiated the Water, Sanitation, and Education for Health (WASEH) Project in 1998. The project targets 72 farming and fishing communities with a total population of 43 000. Although the WASEH Project facilitated construction of shallow wells and pit latrines, the water quality still needed improvement. Consequently, in 2001, CARE implemented the Safe Water System (which consists of point-of-use water treatment with sodium hypochlorite, safe storage, and behavior change techniques) within the already established WASEH infrastructure, using existing community organizations in combination with a social marketing approach that introduced affordable products. The project has resulted in adoption rates of 33.5% for chemical water treatment and 18.5% for clay pots modified for safe water storage.

1A major contributing factor to this burden of disease is inadequate access to safe water and sanitation infrastructure. Universal access to water and sanitation facilities will take many years and billions of dollars to achieve. There is a need, in the short to medium term, to reduce the risk of disease in vulnerable populations that will not soon benefit from infrastructure interventions. To address this need, Cooperative for Assistance and Relief Everywhere, Inc. (CARE) Kenya has been involved since 2000 in a series of projects to implement household-based water treatment interventions in Nyanza Province, where the diarrheal disease burden is high and access to improved water supplies is poor. 2 Most of these projects used the Safe Water System (SWS), an intervention that consists of water treatment with dilute sodium hypochlorite solution, safe water storage, and behavior change techniques. Evaluations of these programs in Kenya have shown that use of the SWS was feasible, acceptable, and reduced diarrheal disease risk. 3– 5 In 2003, Population Services International (PSI), a social marketing non-governmental organization , initiated a campaign to promote and sell the SWS solution, which was given the brand name WaterGuard; each bottle costs approximately $U.S. 0.26 and treats 1000 L of water. The social marketing program for WaterGuard, which has been continuous since 2003, consisted of mass media advertisements (predominantly by means of radio), wall paintings, and presentations at local markets where WaterGuard was being sold. In 2008, PSI sold nearly 1.7 million bottles of WaterGuard in Kenya. Easy and widespread access to WaterGuard facilitated efforts to implement two school-based safe water and hygiene interventions in Nyanza Province. In 2003, a pilot project was implemented in a rural boarding school, providing clay pots modified with narrow mouths, ceramic lids, and taps for drinking water, plastic tanks with taps for hand washing, WaterGuard for drinking water, and soap for hand washing. An evaluation of this project in 2004 showed that diarrhea rates among the students had decreased by more than half. 6 In 2005, the schoolbased safe water and hygiene intervention was expanded to an additional 70 public primary schools in southern Nyanza Province. An evaluation of this program in 2006 suggested that the use of water treatment and hand-washing promotion in schools resulted in a decrease in absenteeism of 35% compared with neighboring schools, and increased utilization of WaterGuard in students’ households. 7 The outcomes of these two projects have resulted in further expansion of the school programs in Nyanza Province. 8 ® ®

In laboratory- and village-based evaluations researchers compared chlorine decay and disinfection rates in turbid surface water that had been treated and stored in locally available clay vessels and plastic jerry cans. Three vessel types were evaluated: 1) wide-mouthed 20-liter clay vessels; 2) narrow-mouthed 20-liter clay vessels with lids and spigots; and 3) narrow-mouthed 20-liter plastic jerry cans with lids. Water was treated with 1% sodium hypochlorite while free chlorine levels were measured. The researchers assessed the microbiological quality of treated and untreated water. Overall results indicate that jerry cans and clay vessels can achieve adequate chlorine levels to disinfect turbid contaminated source water in laboratory and household settings. Moreover village evaluation findings suggest that disinfected water that is stored in traditional clay vessels may be at risk for contamination which may result from contact with hands during water retrieval. The study also revealed that wide-mouthed storage vessels have been implicated in the transmission of cholera.