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Effects of Health Promoter Training in Improving Ceramic Water Filter Use Barbara Donachy, MPH

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Page 1: Effects of Health Promoter Training in Improving Ceramic ...hwts.web.unc.edu/files/2014/09/1-2-Donachy-Effects-of-Health-Prom… · 01/09/2014  · Effects of Health Promoter Training

Effects of Health Promoter Training in Improving Ceramic

Water Filter Use

Barbara Donachy, MPH

Presenter
Presentation Notes
Here to present the results of an training intervention and follow-up study conducted in 2004 in four regions of Nicaragua in collaboration with four nicaraguan NGOs . The intention of the training was to create a corp of rural health promoters who could provide traing to Filter users, assess problems, and provide remediation. The filter is a colloidal silver impregnated ceramic water filter produced and distributed in Nicaragua
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Background

In Nicaragua, after Hurricane Mitch in October of 1998, the rural water supply was largely contaminated.

In January 1999, after a large influx of emergency donations, Potters for Peace started training workers and began construction of a water filter production workshop in Ciudad Sandino to produce these home-use filters (Filtrons).

Disinfection 2011

Presenter
Presentation Notes
5000 killed 18% of population effected Water systems serving 800,000 people were damaged 55,000 relocated to refugee camps Wells, rivers, ponds were contaminated with fecal material Potters for Peace Nicaragua coordinator Ron Rivera began work on construction of a water filter production workshop, and Also know as ceramic pots, ceramic purifiers. The commonality is that they are fabricated from a combination of clay, sand, and combustible material, made in a press, firec to 900 C and coated with colloidal silver, placed in a receptacle.
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Background

The filters were distributed by emergency organization such as the Red Cross and later by Nicaraguan and international health organizations.

5000 Filtrons were delivered in the first 6 months of 1999 to communities hit hardest by the hurricane.

Disinfection 2011

Presenter
Presentation Notes
Filters were distributed with an instructional sticker or handout but without training and without a plan for follow-up. PFP relied on these relief organizations to provide any health and hygiene education and use and maintenance. They were not however able to perform these functions. One key concept that seemed problematic was that the filtered water, though free of microbes had no residual disinfection capability.
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Resettlement community in San Juan de Limay

Background

Disinfection 2011

Presenter
Presentation Notes
San juan de Limay was one of the communities hardest hit by the hurricane and floods. The community was washed away and relocated several miles up from the river. Relief efforts here had progressed to a point where homes had metal roofs if not walls. Filtrons were distributed in this community by Fundacion Sol.
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Delivery of ceramic filter receptacles to San Juan de Limay.

Background

Disinfection 2011

Presenter
Presentation Notes
Although all of the filter elements were produced at the Filtron factory and then distributed in five-gallon plastic buckets, some receptacles were made by rural potters. Clay receptacles had the advantage of keeping water cool, resembling traditional water containers, and providing income for potters.
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Background

The first field study conducted by AlethiaEnvironmental in 2001 found

– Microbiological contamination• 75% of families cleaned receptacles with source water• Instructions did not distinguish between how to clean filter

elements and receptacles• Only 1 of 24 Filtrons removed total coliform• 6 removed H2S producing bacteria• 8 of 15 removed E.coli

– Filter elements were not being scrubbed vigorously• Flow rates ranged from .13 to 3.5 L/hr• Filter elements were cleaned with corn husks or “clean” rags.

Disinfection 2011

Presenter
Presentation Notes
Laboratory tests of filter elements carried out at the Nicaragua national lab beginning in 1999 showed a >99.9% removal of bacteria and 100% removal of protozoa. However, results from the first in depth field study was not what we had hoped for. Contamination was attributed largely to cleaning of receptacles. A major issue was that different methods of cleaning were needed for cleaning filter elements (no chlorine) and receptacles that necessitated the use of chlorine and/or soap. Cleaning a filter with a soft rag is like cleaning sandpaper with a paper napkin.
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Background

• Filter element breakage/disuse– 27% were no longer in use (9)– 6 were because of broken filter elements– Rates of “filter” cleaning ranged from once a day to

once a month– Disuse was associated with lack of follow-up.

• Lack of understanding of clean water– No correlation existed between perception of clean

source water and actual contamination.

Disinfection 2011

Presenter
Presentation Notes
Filtron instructions advised people to clean their filter twice a week. This was determined to be excessive and led to a high percentage of breakage. Surveys showed that people did not understand contamination that could not be seen. The Alethia study recommended education about water contamination routes and maintaining a sterile receptacle.
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Background

A small follow-up and education project was conducted in 2003 in the communities of La Perlaand Achuapa.

Disinfection 2011

Presenter
Presentation Notes
Hach pathoscreen pillows were used to test for the presence absence of hydrogen sulfide producing bacteria associated with fecal contamination. Water samples positive for contamination turn black within 24 hours. Above are samples of well water after 24 hours that were put on display in the community of Achuapa by a local health promoter. This created quite a stir and awareness of contaminated water coming from apparently clean wells.
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Background

Water samples from 8 homes at 8 hours. All samples turned black within 24 hours.

Health promoter from Achuapaadding pathoscreen packet to water samples to test for presence/absence H2S.

Disinfection 2011

Presenter
Presentation Notes
Vilma had worked as a health promoter in Achuapa and was recommended to us. She was trained in correct maintenance techniques and how to take and read water samples using the pathoscreen tests. She provided training to a small number of filtron users but mostly did water sampling. She left to work as a maid.
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Background: Studies

Associations found between education, cleaning, maintenance, follow-up and water quality and continued use.

– Plastic faucets and improper cleaning of receptacles were primary sources of contamination (AFA Guatemala 1996).

– All filtered water samples from communities (n=13) tested positive (Walsh 2000).

– Continued use ranged from 70 to 20%--lowest in communities with no follow-up and free chlorine pills (Nims 2000).

Disinfection 2011

Presenter
Presentation Notes
Numerous other studies and surveys both prior to and after the Alethia study produced similar findings. Walsh Nicaragua Nims Nicaragua
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Background: Studies

– 60% of families used source water for cleaning. Training and follow-up indispensible to success (Valerio 2001).

– One-third of Filtrons tested showed post filtration contamination. (Bullard 2002).

– Majority of households washed their Filtrons with pond or rainwater, did not use soap, few washed hands with soap before cleaning (Smith 2004).

Disinfection 2011

Presenter
Presentation Notes
Valerio Honduras Bullard Cambodia Smith Vietnam
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Background: Studies– Presence of bacteria in filtered water attributed in

large part to improper handling and cleaning (Brown 2007).

– CWP users cleaned receptacles with source water. Clear and repeated instructions needed (Dundon2009).

– CWPs improved water quality but product water still highly contaminated. Contamination of post-filtration container suspected (Swanton 2009).

Disinfection 2011

Presenter
Presentation Notes
Brown Cambodia Dundon Peru Swanton Ghana
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Methods: Study area

Regions included in study were those those served by four NGOs. From top: Fundacion Sol, AVODEC, Movimondo, and Fundacion San Lucas

Disinfection 2011

Presenter
Presentation Notes
Purpose of the training intervention was to establish a corp of highly trained rural health promoters who would in turn train filter users in their communities. Four NGOs that had been distributing filters since 1999, agreed to participate in the training and follow-up study.
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Methods: Partners and Beneficiaries

Movimondo: rural development, health, education, and human rights

– 567 participants– Department of Managua– 36 communities in municipality of San Francisco

Libre.• According to the study carried out by the “Water Resources

Investigations Center, (CIRA)”, nine of ten springs analyzed contain E. Coli and fecal Streptococos.

Disinfection 2011

Presenter
Presentation Notes
Movimonda, an Italian NGO with Nicaraguan staff took on the responsibility of being the lead agency. The communities they serve are on the north eastern border of Lake Managua. Participants were those who received training.
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Methods: Partners/Beneficiaries

Fundación San Lucas: latrine and well construction, potable water, reforestation of water sources, and hygiene and sanitation.

– 617 participants – Department of Caraso– La Conquista second highest rural population with

73% below poverty level

Disinfection 2011

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Methods: Partners/Beneficiaries

Fundación Sol: maternal and child health, education, and sustainable development.

– 297 participants– Department of Nueva Segovia.– El Batidero de Macuilizo, Ciudad Antigua, El Jicaro

• Families were chosen on the basis of proximity towater source and their lack of knowledge of waterquality.

Disinfection 2011

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Methods: Partners/Beneficiaries

AVODEC: self-help housing, technical assistance, agriculture credits, vegetable gardens, and breastfeeding.

– 354 participants in the Department of Jinotega• And 17 communities surrounding Lake Apanas,

where the contamination of water is severe.

Disinfection 2011

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Methods: Partners/Beneficiaries

Population Characteristics– Filters in use for one to 4 years– Drinking water obtained primarily from rivers, wells,

springs and watersheds– average education level 3rd to 5th grade– average family size five members– Majority headed by single mothers– Average income around $30 a month.

Disinfection 2011

Presenter
Presentation Notes
A total of 1538 households received training.
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Methods: Training

Development of training manual covering– Project description– History and design of filter– Diarrhea and its causes– Microbes, pathogens, and diseases– Definitions of potable, purified, water and treatment

processes– Problems encountered in the field and remediation– How to test water, filters, and receptacles– Sampling instructions, evaluation and monitoring

forms.

Disinfection 2011

Presenter
Presentation Notes
The training manual was based primarily on information in the 2001 Alethia study and intended to provide organizations distributing Filtrons with a deeper and broader understanding of the advantages and drawbacks. A reference book for problem solving, and a base for developing other training materials.
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Methods: Training

Four day training session for primary trainers in Nicaragua included

– 2-3 field staff from each NGO– Representative from AFA Guatemala– Representatives from Filtron– Representative from CDC– Representative from Potters for Peace

Disinfection 2011

Presenter
Presentation Notes
One NGO was the Red Cross but they dropped out
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Methods: Training

Training session included (3 days)– Visit to Filtron factory– Visit to filter users in Conquista– Presentation on bacterial sampling– Discussion of diarrheal disease and causes– Presentation on oral rehydration therapy– Demonstration of filter cleaning– Review of results of sampling– Meeting of NGOs to develop training and monitoring

plan and schedule

Disinfection 2011

Presenter
Presentation Notes
The training was based on the topics covered in the training manual.
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Methods: Training

NGOs developed health promoter materials– 14-page 24” x 30” hand-painted cloth poster

presentation designed by AVODEC field staff and produced by a Nicaraguan popular education promoter/artist were made for the use of the four organizations and as a tool for health promoters.

Disinfection 2011

Presenter
Presentation Notes
The four particating NGOs met to decide how to carry out the training and monitoring plan and develop training materials.
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Methods: Training

How to use the Filtron How to wash your Filtron

Disinfection 2011

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Methods: Training

When to wash the Filtron How to prevent diseases

Disinfection 2011

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Methods: Training

Disinfection 2011

Conditions caused by parasites Diseases caused by contaminated water

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Methods: Training

Disinfection 2011

Advantages of Filtron Types of intestinal parasites

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Methods: Training

• Training program for health promoters– Half day training – Objectives at the end of the training

• Understand different methods of water purification• Understand use and maintenance of the Filtrons• Understand appropriate techniques for washing Filtrons• Able to implement activities for the prevention of diarrhea.

Disinfection 2011

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Methods: Training

Number of Training Sessions and Participants

Organization Promoters Trained

CommunitiesReceiving Training

Training Events

for Health Promoters

Training Events

For Filter Users

Filter Users Receiving Training

AVODEC 40 12 2 22 354

Movimondo 27 20 5 16 567

Fund Sol 14 5 3 15 297

Fund San Lucas 15 10 3 30 617

TOTAL 96 47 13 83 1835

Disinfection 2011

Presenter
Presentation Notes
Conducted between September and November of 2004
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Methods: Monitoring

• 108 households were chosen for the follow-up study—27 from each NGO service region.

• Baseline samples were collected of community source water and filtered water and tested – In the field for H2S producing bacteria– At the Nicaraguan national laboratory for total coliforms.

• Bi-monthly samples were taken by trained NGO staff and field tested for H2S producing bacteria.

Disinfection 2011

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Results

At baseline, prior to the community trainings the proportions of Filtrons that tested positive were:

– 85% Movimondo– 37% AVODEC– 92% Fundación San Lucas – 37% Fundación Sol.

Disinfection 2011

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Results

The proportions of Filtrons producing positive results after the training were:

– 48% (Movimondo)– 4% (AVODEC)– 79% (Fundación San Lucas) and – 33% (Fundación Sol). – Promoters revisited homes that had positive results

to review cleaning and maintenance.

Disinfection 2011

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Results

In the final sample, the proportions of Filtronsproducing positive results were

– 0% (Movimondo)– 4% (AVODEC)– 18% (Fundación San Lucas)– 0% (Fundación Sol).

Disinfection 2011

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Results

0

10

20

30

40

50

60

70

80

90

100

Baseline Sample1 Sample2 sample3 sample4 sample5

Movimondo

AVODEC

San Lucas

sol

Percent of Water Samples Testing Positive

Disinfection 2011

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Results: Subsample

• A subsample of data from AVODEC was analyzed using SPSS statistical package.

• The change between the beginning and second sampling was highly statistically significant (p<0.001) and increased over time.

• or simply stated, the likelihood that we would observe this improvement between the baseline and second sample by chance alone is one in a thousand.

Disinfection 2011

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Results: Subsample

• Seventy-five percent of the filters exceeded the recommended maximum flow rate of 2/L hr.

• No statistically significant correlation was noted– between the flow rate and reported number of

times/month that the filter was cleaned nor – between flow rate and water contamination.

Disinfection 2011

Presenter
Presentation Notes
This could be the result of too small of a sample size to detect a difference or it could indicate that if done correctly, it doesn’t matter how frequently the filter is cleaned. This self reporting is probably not accurate.
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Results: Subsample

• Reliability of results– All source water samples from each of the samplings

were positive for H2S producing bacteria and concurred with lab tests.

– All blanks were negative.– All duplicate sample results were in agreement.

Disinfection 2011

Presenter
Presentation Notes
Water that tested positive for H2S also tested positive for coliformes and water that tested negative for h2S tested negative for coliforms
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Results: Subsample

• No breakage was reported or observed of the filter elements during the monitoring but 15% of the households reported Filtrons with broken faucets.

Disinfection 2011

Presenter
Presentation Notes
Less frequent washing appears to reduce breakage of filter elements.
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• In-depth training and follow-up improved water quality.

• Well-trained local health promoters provide the best opportunity for continuing follow-up.

• As late as 2009 the some of the same issues were observed as were identified in 2001.

• Do uniform protocols exist for training, testing, or follow-up.

• Do the benefits of the research reach the organizations and populations who are being studied?

Disinfection 2011