Evaluating the Long-Term Health Impact of Household Chlorination of Drinking Water in Rural Haiti Público
Harshfield, Eric (2012)
Abstract
Background: In rural Haiti, 50% of households use unimproved drinking water sources and 25% of children under five have diarrhea. Since 2002 the Jolivert Safe Water for Families (JSWF) program has addressed these issues by training Haitian technicians to: 1) manufacture quality-controlled sodium hypochlorite solution (chlorine); 2) enroll participants through sale of safe storage containers; 3) sell chlorine to participants; 4) maintain household sales records; 5) conduct household visits to monitor chlorine use and provide ongoing education.
Objectives: There has been significant recent criticism in the literature of the lack of sustained health impact in household chlorination programs. This study examined the effect of JSWF program enrollment on diarrheal disease, compared with non-enrolled controls.
Methods: Study participants were randomly selected from a list containing 2,670 program households enrolled from September 2002 to May 2010. Two control households were selected for each participant by walking three houses to their right. At each household enumerators: 1) administered a 15-minute survey covering demographics, water collection/storage/treatment, and health outcomes; 2) measured remaining volume of chlorine since purchase; 3) tested free chlorine residual using Hach Color Wheel Chlorine Test Kit; 4) recorded GPS coordinates. Differences between participants and controls were examined using Pearson's chi-square tests and two-sample t-tests. Multivariate logistic regression models were developed, accounting for household clustering and adjusting for potential confounders.
Results: The 201 participant and 425 control households had similar demographics. Forty-six percent of participants (vs. 5% of controls) reported treating their drinking water with program-supplied chlorine 24 hours prior to the survey; however, 56% (vs. 10%) had free chlorine residuals between 0.2-2.0 mg/L due to occasional use of other chlorine products. Participants had significantly less diarrhea (14% vs. 21%, p<0.001) with 26% reduced odds (OR=0.74, 95% CI 0.52-1.05). Among children under five, participant also had significantly less diarrhea (31% vs. 52%, p=0.001) with 55% reduced odds (OR=0.45, 95% CI 0.23-0.86).
Discussion: Diarrheal disease reduction after nearly eight years of program activity was comparable with many randomized, controlled interventions conducted over periods of one year or less. The JSWF program has achieved long-term behavior change among program participants, resulting in improved health.
Table of Contents
Chapter 1: Introduction - 1
1.1 Introduction and rationale - 1
1.2 Problem statement - 3
1.3 Purpose statement - 4
1.4 Significance statement - 4
1.5 Definition of terms - 5
Chapter 2: Comprehensive Review of the Literature - 7
2.1 Introduction - 7
2.2 Haiti household characteristics - 8
2.3 Use of improved drinking water and sanitation facilities in
Haiti - 8
2.4 Waterborne and diarrheal diseases in Haiti - 10
2.5 Point-of-use water treatment in Haiti - 10
2.6 The Safe Water System - 12
2.7 Impact of household chlorination on diarrheal disease -
12
2.8 Jolivert Safe Water for Families program overview and history -
13
2.9 Summary of current problem and study relevance - 16
Chapter 3: Methodology - 18
3.1 Introduction - 18
3.2 Population and sample - 19
3.3 Research design - 22
3.4 Procedures - 22
3.5 Instruments - 23
3.6 Analysis of survey data - 24
3.7 Analysis of spatial data - 27
Chapter 4: Results - 29
4.1 Introduction - 29
4.2 Household survey - 29
4.2.1 Demographics - 31
4.2.2 Water collection and storage - 33
4.2.3 Gadyen Dlo use - 34
4.2.4 Other water treatment methods - 38
4.2.5 Health outcomes - 39
4.3 Multivariate logistic regression models - 42
4.4 Summary - 46
Chapter 5: Discussion and Conclusions - 47
5.1 Discussion - 47
5.2 Limitations and delimitations - 49
5.3 Summary and conclusions - 51
Chapter 6: Implications and Recommendations - 53
References - 55
Appendix A: Principal Component Analysis - 59
Appendix B: IRB Study Exemption Letter - 60
Appendix C: Household Survey - 62
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