Medical Missionaries conducted this study in 2009 while designing its clean water project to be conducted in Thomassique Haiti, where it built and continues to support a medical clinic to serve the health needs of Haitian villagers, the first medical facility in this Central Plateau region of Haiti where more than 125,000 people live.

Read more about the results of this project and Medical Missionaries’ use of Klorfasil for its water purifcation project in Haiti.

Read the original study below:

Medical Missionaries Water Purification Project Study Design

By Rita Baumgartner – January 2009

Project Title: Point-of-use Interventions for Safer Drinking Water in Thomassique, Haiti.

Purpose of the Study:  Increasing sustainable access to clean drinking water is an essential step in promoting health in developing countries.  The World Bank’s Millennium Development Goals call for a 50% reduction in the proportion of people without sustainable access to safe drinking water by 2015 (MDG7, Target 10). Drinking water can be contaminated with disease-causing bacteria, parasites, and viruses at the source, within the delivery system, or during transport to homes for use. Each year, over 1.8 million people around the world die from diarrheal diseases and this burden of disease falls very highly on children under five years of age: over 90% of deaths from diarrhea are among children under five years old (Nath et al., 2006). The World Health Organization (WHO) estimates that up to 94% of diarrheal illness is preventable with interventions to increase availability of clean water and through improved sanitation and hygiene.

In 2006, a Cochrane review of randomized trials suggested that point-of-use (POU) water quality interventions are essential in reducing death and illness from diarrhea. Point-of-use water quality interventions are interventions that affect the quality of water from where it is accessed in the community as opposed to treatment at the source or changes to the infrastructure. Examples of POU interventions include large slow-sand filters at community water pumps, household filters, boiling water in the home, chlorine and other chemical disinfectants used in the home, and UV or sunlight treatment. POU interventions are also sometimes referred to as “household water treatment and safe storage interventions” or “HWTS.” POU interventions are ideal for improving water quality in developing countries because they are highly cost-effective, can be rapidly deployed and taken up by vulnerable populations, and are considered some of the most effective of water, sanitation and health interventions (WHO and UNICEF, 2006).

Thomassique, Haiti, is a poor, rural community of approximately 60,000 people, located in the east of Haiti’s Central Plateau. Thomassique’s major source of water is a spring located approximately 15 miles away in the town of Cerca-la-Source. The water delivery infrastructure was constructed in the 1980s and has had little repair since this time. Approximately 20% of Thomassique residents have water piped to their households. All other residents get water from public fountains (tiyo). Recent microbiological tests of the water from these fountains revealed high levels of bacterial contamination. This study is a pilot study to increase understanding of Thomassique residents’ current drinking water and sanitation practices and to learn what POU intervention is most effective in Thomassique. This study will increase knowledge in 5 areas:

1. Residents’ current drinking-water and sanitations practices
2. Residents’ opinions regarding the quality and accessibility of water in their community
3. Rates of diarrheal diseases among children under 5 years old and adults over 50 years old
4. Residents’ willingness to invest in public and private POU interventions
5. Relative effectiveness of two different POU interventions among residents of Thomassique

With this increased knowledge, a large-scale clean water project will be designed in order to extend positive outcomes to a greater portion of the Thomassique community. The pilot study is essential in the success of the final clean water project to have positive health impacts because the pilot study will demonstrate which technology is most relevant and acceptable to residents in Thomassique and what community education is needed to promote effective use. This study might further assist in designing clean water projects in other communities on the Central Plateau with similar disease burdens and cultural preferences as Thomassique.

Study Population:  The participant population will be three groups of 20 households (60 households total) living in the northeastern zone of Thomassique. The three groups will be randomly assigned from within the 60 households. The person in the household to which the survey and educational information will be directed is the head woman of the household. This population was chosen for the study for three reasons. First, the northeast zone of Thomassique is remote from downtown Thomassique and will therefore most likely not benefit from any improvements in water supply infrastructure or water quality provided by the town in the near future. Second, the Medical Missionaries Fellows, who will be carrying out the pilot study, live at Saint Joseph Clinic, which is located in northeastern Thomassique. Therefore, if any participants have questions, comments, or problems, the Fellows will be easily accessible to them. Finally, the head woman of each household was selected as the target for the survey and education because, since the women doing most of the childcare, food preparation, and cleaning, they will be most familiar with the precise water situation. Furthermore, because the women are the primary care providers, the mothers in the household will be able to pass on the information they learn regarding proper water treatment and sanitation to their children.

Recruiting Participants:  Participants will be recruited through personal contact by the Medical Missionaries Fellows, who are acquaintances of many people living in the northeastern zone of Thomassique due to their work at Saint Joseph Clinic, their other community outreach efforts, and the fact that they are easily identifiable as the only foreigners in Thomassique. The Fellows will go to the homes of people living in the area and ask them if they would be willing to be included in the study. (See Appendix A for the interview protocol.  Note:  All materials will be translated into Creole.)  This method of recruitment is preferable because many of the residents of this zone are not literate and thus any written advertisements or flyers would not reach much of the target population. The Fellows will go to people’s homes in the late afternoon, between 3:30 pm and 6 pm. At this time, the afternoon meal will have already been prepared and any family members who were working in the fields or doing other tasks will have returned. This is the time we will most likely be able to find the head woman of the household at home and relatively unoccupied.

Study Activities:  After a resident has agreed to participate in the research, she will be led through an oral informed consent process and asked to sign an informed consent form and a photo consent form.  (See Appendices B and D.)  The next step of the pilot study is a pre-intervention oral questionnaire designed to gain information regarding residents’ current drinking-water and sanitations practices, residents’ opinions regarding the quality and accessibility of water in their community, rates of diarrheal diseases among children under 5 years old and adults over 50 years old in each household and residents’ willingness to invest in public and private POU interventions. (See Appendix E.)  This questionnaire is partially based on “Core questions on drinking water and sanitation for household surveys” (WHO and UNICEF, 2006). The questionnaire will be the same for all three study groups.

For each child under 5 years of age who is reported to have had diarrhea in the past two weeks, the researcher will asses the severity of each child’s dehydration based on the clinical classification of severity of dehydration taken from “Lecture Notes on Tropical Medicine,” edited by G. Gill and N. Beeching (2007). This system classifies individuals into three groups: mild, moderate, and severe dehydration. Please see Appendix I for a description of the classification system. Such classification is important to ensure that any children with severe dehydration receive medical attention. Children determined to have moderate dehydration will be given oral rehydration solution and their parents informed as to warning signs that the child is becoming dangerously dehydrated. Children with severe dehydration will be given oral rehydration solution and referred immediately to the clinic. Classification into these three groups will also lead to more consistent comparisons between severity of diarrhea pre- and post- intervention.

The next step of the study is a short education session, which will occur approximately 2 weeks after the initial administration of the questionnaire. (See Appendix F.)  The Fellows will give a presentation on basic causes of diarrheal disease, safe stool disposal, hand washing, approaches to improve household drinking-water quality and how a household can benefit from improved drinking-water quality and sanitation. The presentation will be oral and will contain some pictures to aid in comprehension. (See Appendix G.)  This presentation will last approximately 15 minutes. All three groups in the study will see the same initial 15-minute presentation. After the general presentation, each study group will receive a different additional 5-minute presentation focused on the intervention specific for that group. The three focus presentations will address:

1. General review of all other information covered in original session (control)
2. Use of chlorine to treat drinking-water
3. Use of solar disinfection to treat drinking water.  (Participants in group 1 will not receive any additional study materials.)

Participants in group 2 will be provisioned with a “Klorfasil” system (a bucket with a tap and enough chlorine to treat 5 gallons of water each day for 18 months). This system is currently being introduced in Hinche, a city approximately 20 miles away. These participants will be asked to attend a distribution session run by the Klorfasil representative from Hinche. She is Haitian and will give a detailed presentation about correct use of the system. Participants in group 3 will be given two 16.9 ounce bottles made of clear PET plastic for each member of the family. These two specific interventions were selected based on their potential to cause immediate, low-cost impact on the quality of drinking water available in the outlying areas of Thomassique. They would both be very feasible to extend to a large number of people very quickly.

The population targeted in this study is large, spread over a wide geographical range, and very poor. Therefore, many of them are unlikely to experience major changes in infrastructure or access in the near future. These two interventions would allow many people very immediate access to clean drinking water at very low cost. The Klorfasil treatment system has recently been introduced in some parts of Hinche and has been reported as being successful. The chlorination program in Hinche would be relatively easy to extend to Thomassique. For solar treatment, the only necessary material is clear plastic bottles, which are widely available in Thomassique. Other options may be better longer term but before we invest in a large amount of money in household filters, community filters, bigger infrastructure projects, etc, we want to ensure we know how people feel about these, so we will ask people about their willingness to invest in such interventions.

The next step of the study is a short post-intervention oral questionnaire. (See Appendix H.)  This questionnaire will be administered 3 separate times in each household: 2 weeks following the education session, 1 month after the education session, and 2 months after the education session. The post-intervention questionnaire contains only 7 questions and should not take more than 10 minutes of participants’ time to complete. The questionnaire will be administered three times in each household in order to demonstrate whether the interventions are effective in changing people’s behavior over time and not just immediately following the education session. We are interested in developing a safe drinking-water culture that lasts well beyond the duration of the study and thus we want to know how adherence to the intervention changes over time.

Benefits to the Participants:  Participants will receive education and, in groups 2 and 3, materials that will enable them to improve the quality of drinking water and sanitation in their households. By improving drinking water and sanitation, the participating households will most likely decrease their burden of diarrheal disease and increase health among all members of the household.

Indirect Benefits:  We will gain better understanding of current sanitation practices, information on residents’ resources, knowledge, and options to influence home hygiene. The knowledge gained from this study will be used to inform further safe drinking-water projects in Thomassique. For example, if one intervention shows more improved health outcomes than the others, future projects will extend this intervention to more residents of Thomassique. Also, the information gained regarding residents’ willingness to invest in public and private POU interventions will ensure that no future projects are undertaken without community dedication to maintenance and sustainability. Finally, following this study, a presentation will be given to members of the Thomassique Water Committee, who are responsible for upkeep and development of the current water delivery system. They are interested in including education among their future activities and this study will help them design their education program to be most effective in Thomassique.

Principal Investigators:
Rita Baumgartner (Medical Missionaries Fellow): rita.baumgartner@gmail.com

Meryl Colton:  meryl.colton@duke.edu

Appendices

A.  Script for initial personal contact
B.  Informed oral consent form
C.  Business Card
D.  Photo consent form
E.  Pre-intervention oral questionnaire
F.  Notes for education session
G.  Focus presentation content
H.  Post-intervention questionnaire
I.  Classification of dehydration severity

Appendix A: Script for initial personal contact

Good afternoon! How are you this afternoon? How is your family? May we please speak to the head woman in the household?

Our names are Rita and Nick and we work in Clinic Saint Joseph, in the Pierre-Louis zone. We are very interested in how people in this neighborhood obtain their water and what sanitation and hygiene practices people use.  We are doing a research project to learn more about water in this zone and how people think it could be improved.

For our project, we would like to ask you some questions regarding how many people live here, if people in your home have had diarrhea, where you get your water from, and where you go to the toilet. After we ask these questions, we would like to return to your home to do an education session about how clean water and better sanitation can improve your life. After the education, we would like to return to your home three times to ask you a few additional questions. Each time we visit your home and ask you questions, we will give you three bars of soap to thank you for the time you gave to help us.

Do you think you would like to help us with this project?

Yes—Thank you very much! We are very interested in learning more about your situation here. Can we ask you some questions now?

No—Thank you very much for your time. We hope that everyone in your home is healthy and have a good day!

Appendix B: Oral informed consent form, with fingerprint

Script: Before we begin asking you questions, we want to make sure that you understand what our project is about. We will read you this form that explains what we are going to do in our project to make sure that you want to participate.

Our project has 5 important objectives. The first is to gain a better understanding of how people in Thomassique treat their water and what sanitation practices you use. We also want to understand how you would like to improve your situation concerning water. We want to know how often the very young and very old people in your household have diarrhea. We want to know if people in Thomassique would want to give their time and money to have things that would change the quality of their water. Finally, we want to know what ways of treating water work best for the people of Thomassique.

Our project has some benefits too. All people who decide to participate will receive education and materials that will help them improve their drinking-water, sanitation, and hygiene practices. This will help make everyone in your household healthier. Each time we come to visit your house, you will also receive 3 bars of soap. The information we learn from the project will be used to help more people in Thomassique have water that is safe for drinking.

There are also a few risks in our project. We will ask some personal question about your health. We will make many efforts to keep this information private. The other risk is that if you do not closely follow the directions for treating the water, it may not be completely safe. We will take great caution to make sure you understand all the directions.

If you want to quit the study at any time, you are always able to do so. Also, if we ask any questions that you do not want to answer, you do not have to answer them.

Do you have any other questions for us? If you have other questions in the future, you can always reach us at Saint Joseph Clinic, located in Pierre-Louis.

If you still want to participate, we would like you to put your fingerprint on this sheet to show that, at this time, you would like to participate in the study.

Fingerprint of participant:                                                          Signature of Investigator:

Appendix C: Business Card

Appendix D: Photo consent form

Script: If you agree, we would also like to take some photos of your home and where you keep your water. You can participate in the study even if you do not want us to take pictures. The pictures will be used for presentations at the clinic and future education sessions, here and abroad.

We will keep your identity private when we are using the pictures. Please let us know what parts of your home you feel comfortable with us taking pictures; we will not take pictures anywhere you don’t want us to. Also, we can bring copies of the photos for you to have, if you would like them.

I agree to have my picture taken in my home showing how we treat water in our home. I agree that my picture can be used in presentations of this project and for future education sessions.

Fingerprint of participant:                                                          Signature of Investigator:Participant Household Number:

Appendix E: Pre-Intervention Oral Questionnaire

Opening questions:

1. How many people live in this house?
2. How many children under 5 years old?
   1. How many times has each child under 5 had diarrhea, more than 3 times in a day, during the past 2 weeks?
3. How many adults over 50 years old?
   1. How many times has each adult over 50 had diarrhea, more than 3 times in a day, during the past 2 weeks?

Questions 4-8 taken from “Core questions on drinking-water and sanitation for household surveys,” (WHO and UNICEF, 2006)

4. What is the main source of drinking-water for members of your household?
5. How long does it take to go there, get water, and come back?
6. Who usually goes to this source to fetch the water for your household?
7. Do you treat your water in any way to make is safer to drink?
8. What do you usually do to make it safer to drink?
9. How can you tell if the water you are drinking is clean?
10. Can unclean water cause people in your household to become sick?
    1. How?
11. What would you like to do to improve the quality of drinking-water in your household?
12. Would you be willing to pay for this improvement?
    1. If yes, how much?
13. Would you use a filter to clean the water in your home?
    1. Would you be willing to buy such a filter?
    2. Would you be willing to pay for maintenance?
14. Would you buy a chemical which you could add to the water you drink to make it clean?
    1. How much would you be willing to pay for this chemical?
15. Would you be happy if a filter to clean the water was built at the public water pump?
16. Would you be willing to help your neighbors pay for maintenance of the water filter at the public water pump?
    1. If yes, how much?

Questions 17-20 taken from “Core questions on drinking-water and sanitation for household surveys,” (WHO and UNICEF, 2006)

17. What kind of toilet facility do members of your household use?
18. Do you share this facility with other households?
19. How many households use this toilet facility?
20. The last time (name of youngest child) passed stool, what was done to dispose of the stools?

Appendix F: Notes for education session

Goal of session: increase health in families in order that families can be happy, productive and safe. We want to accomplish this goal by teaching and talking about ways we can get sick from water and how we can protect ourselves and our families.

Common illness in Thomassique—diarrhea. Diarrhea is bad because it causes us to lose nutrients and fluids from their bodies. In very young children, this can be very dangerous.

What causes diarrhea? (ask for ideas). Microbes cause diarrhea. Do you know what a microbe is?

• A microbe is a living thing that is very very small, too small to be seen without a microscope.
• Microbes can cause humans to become sick and they can cause diarrhea.
• Many bad microbes are found in feces.
• Feces are enemy number 1!

How can feces get to people to make them sick? (handout F diagram, next page)

• Feces can get onto hands when people are cleaning after going to the bathroom and then microbes can be spread onto food, eaten, and people can get diarrhea.
• Feces on the ground can get into water sources, then the water can be drunk by a child who will get diarrhea
• Flies can spread microbes from poop onto food

How can we protect people from contact with feces and help them stay healthy? 3 ways:

1. 1. Safe stool disposal
      1. Safe stool disposal for ALL stool, including children and animal stool
      2. All feces must be buried to protect other people from contact
      3. Why should we bury feces?
         • The yard will look clean and nice for visitors
         • No bad smells
         • People will not walk in stools
         • he neighbors will respect our clean yard
         • KEEPS FAMILY HEALTHY!

1. 2. Washing hands
      1. Washing with only water  does not get rid of sticky particles that contain microbes
      2. Must use ash or soap to wash hands after going to the bathroom or cleaning up after a child.
      3. Hand washing demonstration
         • Wet hands
         • Apply soap
         • Scrub for 20 seconds
         • Don’t forget between fingers, back of hands, and under fingernails
         • Rinse
         • Use a towel to dry hands that is not used for other purposes
         • Distribute hand washing pictures

1. 3. Treat drinking water
      1. Very important to treat water for drinking to prevent people from drinking microbes and becoming sick
      2. Clean water=better health
      3. Cannot tell if water is clean by looking at it—demonstration with two bottles, one with treated water, one without. Ask people to guess which has clean water.
      4. Ways to keep water clean:
         • Do not put hands in container where drinking water is kept
         • Keep animals away
         • Use bottles with narrow-necks
         • Cover water after it is collected
         • No defecating near water
         • Pay attention to your water, look for contamination as described above 

Focus education sessions:

Solar water disinfection (with instruction sheet)

• Find a clean bottle
• Put water in a small, clear plastic container. Close lid.
• Bottles like this, with one side painted black, are best
• Put water bottle on a metal sheet or on roof.
• Leave the bottles out for 6 hours in the sun
• After 6 hours on a sunny day, the water is clean!
• On cloudy days, you must leave the bottle outside for two days.

Chlorination

• Chlorine is a chemical that can be added to water to kill microbes
• Have you ever heard of the Klorfasil system? They use it in Hinche.
• We would like you to attend a session with Madame Joslin from Hinche. She will be at Saint Joseph Clinic (insert date). She will give you the chlorination system and tell you how to safely use it. Also, when you come for this session, we will give you three more bars of soap. Please bring this paper (hand over paper indicating inclusion in study) when you come!
• (Show example system) This is what you will use to dispense the chlorine. The most important thing to remember is to add only one dose to your water. But you must add the whole dose. (Demonstrate how it works).
• Please make sure your children do not have access to the chlorine dispenser.
• Madame Joslin will give you much more information. If you still have questions after you speak to her, please come talk with us.
• (Specific instructions will be added after a source of chlorine is determined)
• Be careful! Adding too much chlorine to water can make you sick!

Conclusions: Thank you very much for paying attention! Do you have any questions? (ask a few review questions)

Please come see Nick and me at any time at St. Joseph Clinic if you have questions.

We will come back in two weeks to ask a few more questions.   Have a good day!

Appendix G:  Focus Presentation Content

Microbe Transmission:

Hand Washing Illustrations:

Solar Water Treatment Instructions:

Appendix H: Post-Intervention Oral Questionnaire

1. How many people live in this house?
2. How many children under 5 years old?
   1. How many times has each child under 5 had diarrhea, more than 3 times in a day, during the past 2 weeks?
3. How many adults over 50 years old?
   1. How many times has each adult over 50 had diarrhea, more than 3 times in a day, during the past 2 weeks?
4. Do you treat your water in any way to make is safer to drink?
5. What do you usually do to make it safer to drink?
6. Do you have any problems with the way you are treating your water?
   1. If yes, what are they?
7. What would you like to do to improve the quality of drinking-water in your household?
8. What kind of toilet facility do members of your household use?
9. The last time (name of youngest child) passed stool, what was done to dispose of the stools?

Appendix I: Classification of Dehydration Severity from Lecture Notes on Tropical Diseases, eds. Gill, G.V. and N.J. Beeching. Blackwell Science, Malden, MA: 2007.