effects of health promoter training in improving ceramic...
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Effects of Health Promoter Training in Improving Ceramic
Water Filter Use
Barbara Donachy, MPH
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).
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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.
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Resettlement community in San Juan de Limay
Background
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Delivery of ceramic filter receptacles to San Juan de Limay.
Background
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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.
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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.
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Background
A small follow-up and education project was conducted in 2003 in the communities of La Perlaand Achuapa.
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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.
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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).
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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).
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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).
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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
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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.
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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
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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.
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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.
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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.
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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.
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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
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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
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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.
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Methods: Training
How to use the Filtron How to wash your Filtron
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Methods: Training
When to wash the Filtron How to prevent diseases
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Methods: Training
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Conditions caused by parasites Diseases caused by contaminated water
Methods: Training
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Advantages of Filtron Types of intestinal parasites
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.
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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
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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.
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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.
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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.
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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).
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Results
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Baseline Sample1 Sample2 sample3 sample4 sample5
Movimondo
AVODEC
San Lucas
sol
Percent of Water Samples Testing Positive
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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.
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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.
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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.
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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.
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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?
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