Evaluation of an Inexpensive Handwashing and Water Treatment Program in Rural Health Care Facilities in Three Districts in Tanzania, 2017

Round 1

Reviewer 1 Report

The authors have done a nice job responding to the original critiques, I believe that this manuscript is ready for publication. 

Author Response

Thank you for the review.

Reviewer 2 Report

Thank you for the opportunity to review this interesting manuscript, which deals with a very important public health issue (i.e. the increase in the basic service level for hygiene in rural areas).

The study design is appropriate and the methods are clearly described. The discussion and conclusion are supported by the findings.

Overall, the manuscript is very well written and presented, and I believe it will be well received by the academic community.

I have only a minor suggestion the authors could consider: I believe that too many acronyms are used in the text, and it is not useful to the reading. I believe that the whole text will be much more readable if the acronyms were limited to the essential ones.

I would like to congratulate the authors for their work, and I hope they will follow the suggestions, as I believe that the study will be of interest to the readers. 

Author Response

Thank you for the opportunity to review this interesting manuscript, which deals with a very important public health issue (i.e. the increase in the basic service level for hygiene in rural areas).

The study design is appropriate and the methods are clearly described. The discussion and conclusion are supported by the findings.

Overall, the manuscript is very well written and presented, and I believe it will be well received by the academic community.

I have only a minor suggestion the authors could consider: I believe that too many acronyms are used in the text, and it is not useful to the reading. I believe that the whole text will be much more readable if the acronyms were limited to the essential ones.

I would like to congratulate the authors for their work, and I hope they will follow the suggestions, as I believe that the study will be of interest to the readers.

• As requested, we reduced the number of acronyms in the text.

Reviewer 3 Report

I think this is an interesting paper that will be of interest to readers.  There are a few areas that are unclear and require either clarification or more details.  Some of these areas are quite important and make it difficult for me to know if the conclusions are fully supported by the results (especially the lack of information on survey respondents).

1. I would like the authors to include a map showing the locations of these 3 study sites.  As someone who knows Tanzania fairly well, I had to google the location of Simiyu Region.
2. The total number of HCFs in these 3 districts is unclear.  100 were included in this study.  In September surprise visits were made to all HCFs.  Does this 100 number include all HCFs in these districts?  When visits were made to all in September, do the authors mean all that were later included in the study?  If 100 is just a sample of the total facilities, how were they selected?
3. The authors should do a better job clarifying how they are distinguishing improved water sources: 75 have an improved water source, 43 have supply on premises, and 32 have improved on premises.  Are they using JMP definitions for the improved not on premises or some other metric?  Regardless, they need to specify.
4. Likewise what do they mean by pipe?  In Tanzania it's common to have groundwater piped to a facility or kiosk.  Does pipe include any type of water?  Or are they indicating some type of treated publicly supplied water?
5. Could they please clarify placenta pits?  I think this paper will be of interest to the broader WASH community who might not have a medical background.  They should also consider whether some of the other indicators on Table 3 need definition - or even are necessary to the results presented here.
6. The results section could benefit from sub-headings.  It provides an overview of the HCFs and then suddenly jumps to changes from baseline to the 2018 follow-up.  It would be helpful to include the baseline and endline dates again in the results section and on tables.
7. Who are the survey respondents mentioned on page 7?  They are never identified nor do we know how many there were.  What were they asked?  How were they selected?  On page 3 (line 110) it mentions some additional questions were asked but much more information is needed in order to use these responses to support conclusions or interventions. 

Author Response

Reviewer 3

Comments and Suggestions for Authors

I think this is an interesting paper that will be of interest to readers.　 There are a few areas that are unclear and require either clarification or more details.　 Some of these areas are quite important and make it difficult for me to know if the conclusions are fully supported by the results (especially the lack of information on survey respondents).

 

I would like the authors to include a map showing the locations of these 3 study sites.　 As someone who knows Tanzania fairly well, I had to google the location of Simiyu Region.

• We have added a map with project districts highlighted

 

The total number of HCFs in these 3 districts is unclear.　 100 were included in this study.　 In September surprise visits were made to all HCFs.　 Does this 100 number include all HCFs in these districts?　 When visits were made to all in September, do the authors mean all that were later included in the study?　 If 100 is just a sample of the total facilities, how were they selected?

• Added to line 91: "Monduli, Hai and Itilima Districts had 33, 35, and 32 HCFs in each, and all HCFs were assessed.," also added n to tables 1, 2, and 3.

 

The authors should do a better job clarifying how they are distinguishing improved water sources: 75 have an improved water source, 43 have supply on premises, and 32 have improved on premises.　 Are they using JMP definitions for the improved not on premises or some other metric?　 Regardless, they need to specify.

• Added to line 92 We used the JMP definition of improved water sources, "Improved water sources are those which by nature of their design and construction have the potential to deliver safe water; these include piped water, boreholes or tubewells, protected dug wells, protected springs, rainwater, and packaged or delivered water;".

Likewise what do they mean by pipe?　 In Tanzania it's common to have groundwater piped to a facility or kiosk.　 Does pipe include any type of water?　 Or are they indicating some type of treated publicly supplied water?

• See response to comment #3

 

Could they please clarify placenta pits?　 I think this paper will be of interest to the broader WASH community who might not have a medical background.　 They should also consider whether some of the other indicators on Table 3 need definition - or even are necessary to the results presented here.

• Added to line 91 "…incinerators and placenta pits (ventilated and cement-lined pits for disposal of potentially pathological waste)."

The results section could benefit from sub-headings.　 It provides an overview of the HCFs and then suddenly jumps to changes from baseline to the 2018 follow-up.　 It would be helpful to include the baseline and endline dates again in the results section and on tables.

• We did not add subheadings to results because journal formatting instructions indicated no subheadings should be used; however, we added dates of baseline and follow-up to help to distinguish the sub-sections. We would b happy to include subheadings if it would be acceptable to the editors.

 

Who are the survey respondents mentioned on page 7?　 They are never identified nor do we know how many there were.　 What were they asked?　 How were they selected?　 On page 3 (line 110) it mentions some additional questions were asked but much more information is needed in order to use these responses to support conclusions or interventions.　

• Clarified these questions on line 90: "The tool comprised observations by surveyors and interviews with the HCF in-charge or another staff person with knowledge of the WASH situation in the HCF."

 

 

 

Round 2

Reviewer 3 Report

I appreciate the changes made by the authors.  They have addressed all but one of my concerns.  In my first review, I asked for more details on the survey respondents.  The authors did add a little information ("The tool comprised observations by surveyors and interviews with the HCF in-charge or another staff person with knowledge of the WASH situation in the HCF".)

To me, that isn't quite clear enough.  I would appreciate knowing who exactly these HCF in-charge or staff people were.  A simple sentence with more detail would be enough  (The HCF in-charge are lead doctors and staff members included nurses and doctors - or whatever the case was).

Then at line 160 they talk about survey respondents but earlier they have talked about interviews which is still unclear.  Simply changing that to refer back to observations and interviews with HCF workers would be helpful.

These are minor quibbles but each time I've read the paper I've had to go back and forth between those sections trying to figure out if they are referring to the same thing.

Author Response

Comments and Suggestions for Authors

I appreciate the changes made by the authors.  They have addressed all but one of my concerns.  In my first review, I asked for more details on the survey respondents.  The authors did add a little information ("The tool comprised observations by surveyors and interviews with the HCF in-charge or another staff person with knowledge of the WASH situation in the HCF".)

To me, that isn't quite clear enough.  I would appreciate knowing who exactly these HCF in-charge or staff people were.  A simple sentence with more detail would be enough  (The HCF in-charge are lead doctors and staff members included nurses and doctors - or whatever the case was).

Then at line 160 they talk about survey respondents but earlier they have talked about interviews which is still unclear.  Simply changing that to refer back to observations and interviews with HCF workers would be helpful.

These are minor quibbles but each time I've read the paper I've had to go back and forth between those sections trying to figure out if they are referring to the same thing.

 

• Thank you for the comments. We agree it is important to clarify what types of health workers were interviewed in the clinic, and to be consistent with the language around interviews. Changes made to this end are listed below:
  • Added this to line 88, noting that the assessment tool was designed “to obtain information on WASH characteristics at these rural HCFs from the staff person most knowledgeable about the facility’s WASH infrastructure (hereafter referred to as “knowledgeable staff person”). In most HCFs, the knowledgeable staff person was the HCF in-charge (usually a doctor), while in the other HCFs the knowledgeable staff person was either a clinical officer, nurse or midwife.”
  • Line 171 changed “survey respondents” to “knowledgeable staff”
  • Line 172 changed “respondents” to “knowledgeable staff.”
  • Line 240 changed “survey respondents” to “knowledgeable staff persons.”

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

In this interesting report the authors present an examination of WASH access after an intervention (improved coverage to handwashing stations, chlorine, etc.) in three rural Tanzanian districts. This is a very nice report and I enjoyed reading it. My specific comments are below:

• The second sentence in the abstract ("We assessed WASH coverage...") is very long and difficult for the reader to follow. It is nice that you present your interventions early in the abstract, but please break this sentence up so it is more clear what interventions you are bringing to the community and what you are evaluating. 
• Your introduction is very well researched and helpful to the reader, but it would be helpful here to define what is meant by "adequate" sanitation and/or hygiene. This can likely be solved with the addition of one sentence. 
• In line 51 (the sentence starts on line 50, "Unsafe WASH in HCFs...") you have a colon, I believe this should either be a semi-colon or a period and a new sentence. Please watch these long sentences as they are difficult for the reader to follow. I understand your connection between the two points here, but the longer the sentence the trickier for readers to keep the points together. 
• In the materials and methods section it would be helpful to give a bit more information about the two districts near the PATH office (Monduli and Hai District). Are these also rural districts? What kind of populations do these HCFs serve? 
• Similar to the point above, it may be useful to provide more information overall on what you mean by "rural" HCFs. How far are these facilities from larger, urban centers. Again, what kind of populations do they serve? If you do not feel that this is relevant to the primary manuscript, I could see it fitting into a supplemental section. 
• The results and discussion section sections are very nicely presented here. I particularly appreciate your discussion of the limitations of this study. This section is very clear, and I would have commented on this if it were missing. 

Author Response

Reviewer 1: Comments and Suggestions for Authors

In this interesting report the authors present an examination of WASH access after an intervention (improved coverage to handwashing stations, chlorine, etc.) in three rural Tanzanian districts. This is a very nice report and I enjoyed reading it. My specific comments are below:

• The second sentence in the abstract ("We assessed WASH coverage...") is very long and difficult for the reader to follow. It is nice that you present your interventions early in the abstract, but please break this sentence up so it is more clear what interventions you are bringing to the community and what you are evaluating. 

• Changed to : “We assessed WASH coverage in HCFs in three rural Tanzanian districts to identify gaps and provided handwashing and drinking water stations, soap and chlorine to fill those gaps. We then evaluated program impact on access to WASH services and drinking water quality.”

• Your introduction is very well researched and helpful to the reader, but it would be helpful here to define what is meant by "adequate" sanitation and/or hygiene. This can likely be solved with the addition of one sentence. 

• Added: “The Joint Monitoring Program (JMP) of the World Health Organization (WHO) and UNICEF define basic WASH service levels as water source on premises; sex-segregated functioning toilets for staff and patients (including one with menstrual hygiene facilities and one accessible for people with limited mobility); functioning handwashing facilities with soap and water in proximity; waste segregation, treatment and disposal; and available protocols and trained personnel for basic environmental cleaning”

• In line 51 (the sentence starts on line 50, "Unsafe WASH in HCFs...") you have a colon, I believe this should either be a semi-colon or a period and a new sentence. Please watch these long sentences as they are difficult for the reader to follow. I understand your connection between the two points here, but the longer the sentence the trickier for readers to keep the points together. 

• Separated into two sentences

• In the materials and methods section it would be helpful to give a bit more information about the two districts near the PATH office (Monduli and Hai District). Are these also rural districts? What kind of populations do these HCFs serve? 

• Changed to: “Itilima District in Simiyu Region was selected because HCFs there are farther from major trading centers and transport routes than the other districts and were known to have poor WASH infrastructure. All three districts are rural, with populations that are engaged in small-scale agriculture, cattle herding, and informal economic activities.” The most isolated clinics in each district were approximately 7-9 hours from the nearest tertiary referral hospitals on unimproved and improved roads.

• Similar to the point above, it may be useful to provide more information overall on what you mean by "rural" HCFs. How far are these facilities from larger, urban centers. Again, what kind of populations do they serve? If you do not feel that this is relevant to the primary manuscript, I could see it fitting into a supplemental section. 

• See changes noted in the above response.

• The results and discussion section sections are very nicely presented here. I particularly appreciate your discussion of the limitations of this study. This section is very clear, and I would have commented on this if it were missing. 

• Thank you.

 

Reviewer 2 Report

 

This study examines hand washing access in rural health care facilities in Tanzania. Data is presented before and after a series of improvements in the number of hand washing facilities, availability of soap, water and chlorination. The authors present how these measures have improved hand washing access.

 

I find the text easy to read and the level of language is very strong. The paper is also very clearly organized and agrees with the scope of Water. I cannot say that the study is original, or completely developed. While the introduction provides good supportive arguments for the importance of hand washing and the lack of hand washing access in Tanzania, these are not controversial claims. Similarly with the intervention conducted in this study, the conclusion is that taking limited steps to improve hand washing access resulted in a limited improvement in hand washing access.

 

I did not find that the improved hand washing stations were adequately described. Did they completely replace other hand washing systems? Were the systems maintained during the test? Where did waster come from to be used in these systems. When was chlorine added and was it ever monitored by the supervisors?

 

The real heart of this study seems to focus on how the provided hand washing stations deteriorated (ie., no water, no soap, more bacteria), but I do not see how the survey data is linked to these complications. For example, was the storage capacity of a water system linked to a higher percentage of time with water available? What factors correlated to the variable performance in E.coli concentrations between different locations (one got better, one got worse). This is the type of analysis that would allow us to identify useful lessons and suggestions from this study. As the study is currently presented, I find it difficult to learn what should be done differently in the future to achieve a better outcome. I do not recommend to accept this paper in this form, but I would encourage the authors to review their data and see if there is more constructive analysis from their data that and be presented.

 

 

Additional comments,

 

I am curious to know how much the improvements cost and how this cost compared to other projects.

 

I would also suggest to please reformat table 4 so it is easier to read. The other tables are presented more clearly. I suggest left justify for the first column and deliberate spacing (less than a full line) between entries. There is also no visual grouping between the different sites. This could be done with spacing, breaks in the underline or background shading.

Author Response

Reviewer 2: Comments and Suggestions for Authors

 

This study examines hand washing access in rural health care facilities in Tanzania. Data is presented before and after a series of improvements in the number of hand washing facilities, availability of soap, water and chlorination. The authors present how these measures have improved hand washing access.

 

I find the text easy to read and the level of language is very strong. The paper is also very clearly organized and agrees with the scope of Water. I cannot say that the study is original, or completely developed. While the introduction provides good supportive arguments for the importance of hand washing and the lack of hand washing access in Tanzania, these are not controversial claims. Similarly with the intervention conducted in this study, the conclusion is that taking limited steps to improve hand washing access resulted in a limited improvement in hand washing access.

 

I did not find that the improved hand washing stations were adequately described. Did they completely replace other hand washing systems? Were the systems maintained during the test? Where did waster come from to be used in these systems. When was chlorine added and was it ever monitored by the supervisors?

 

• We clarified the above points by providing a photograph of a handwashing station in Figure 1 and indicating that these water stations “supplement[ed] existing facilities to ensure full coverage in patient care areas.” We indicated in lines 83-84 that we collected information on handwashing and drinking water stations.
• We added more information on the handwashing stations at baseline (lines 128-133): “Existing handwashing infrastructure varied between HCFs, including some sinks with taps connected to a water supply, open buckets for handwashing and drinking water, drinking cups situated next to storage tanks, and buckets with taps for handwashing. In all HCFs, water for handwashing and drinking came from the HCF water supply, either piped directly to the tap or collected from the source and carried to the water station.” Table 4 shows the percent coverage of handwashing and drinking water stations at baseline for HCFs, by district.

• We added information about maintenance and chlorination (lines 98-100): “Healthcare workers were trained about proper maintenance of the handwashing and drinking water stations, and the importance of daily chlorination of drinking water and replenishment of soap. No system of monitoring was set up.”

 

 

The real heart of this study seems to focus on how the provided hand washing stations deteriorated (ie., no water, no soap, more bacteria), but I do not see how the survey data is linked to these complications. For example, was the storage capacity of a water system linked to a higher percentage of time with water available? What factors correlated to the variable performance in E.coli concentrations between different locations (one got better, one got worse). This is the type of analysis that would allow us to identify useful lessons and suggestions from this study. As the study is currently presented, I find it difficult to learn what should be done differently in the future to achieve a better outcome. I do not recommend to accept this paper in this form, but I would encourage the authors to review their data and see if there is more constructive analysis from their data that and be presented.

We addressed this comment in the results section (lines 159-168): “On multivariable analysis, the odds of having full drinking water stations were greater in HCFs with water storage capacity greater than 1000 liters than HCFs with less water storage capacity (OR 11.6, p 0.02, 95% CI: 1.4—95.3); the odds of having full handwashing stations were similar between HCFs with different water storage capacity (OR 0.79 p .6 95% CI: 0.3—1.9). The odds of stored drinking water yielding either free chlorine residual or E. coli did not differ by HCF water source, presence or absence of persons responsible for filling and treating water, different average patient loads, or differences in total HCF staff.”  

 

Additional comments,

 

I am curious to know how much the improvements cost and how this cost compared to other projects.

• See supplementary table. As you can see from the table, the average cost per healthcare facility was just over $1100. This amount included a number of costs that are more typical of pilot projects that you would expect to decrease over time. These costs compare favorably to a similar project in western Kenya that averaged over $400 per healthcare facility but had the advantage of a more robust local economy.

 

I would also suggest to please reformat table 4 so it is easier to read. The other tables are presented more clearly. I suggest left justify for the first column and deliberate spacing (less than a full line) between entries. There is also no visual grouping between the different sites. This could be done with spacing, breaks in the underline or background shading.

• We added vertical lines to help visually separate these columns.

Round 2

Reviewer 2 Report

I am sorry to give such a negative evaluation of your study, but I believe the scientific contribution of this study is limited. I do not see a great value here to help inform future interventions. Unfortunately not every project, no matter how productive, is appropriate for publication as a scientific article. I wish you the best of luck with future projects.