Evaluating the Long-Term Consistency of Purchase and Use in a Household Chlorination Program in Rural Haiti Pubblico

Abstract

Background: Fifty percent of rural Haitians lack access to an improved water source, exposing them to diarrheal disease, which is a leading cause of death in children. The Jolivert Safe Water for Families (JSWF) program has provided safe water to rural Haitians since 2002 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; and, 5) conduct unannounced household visits to monitor chlorine use and provide ongoing education.

Objective: There is significant criticism in the current research regarding the long-term sustainability of water chlorination programs. The published research makes conclusions based on data from programs in existence for 5 years or less; this study examined the long-term take-up of JSWF program based on 8 years of sales records and household visits.

Methods: Hand-written program records that included chlorine purchases and results of unannounced chlorine residual tests were transcribed into an Excel document. Study participants for the health evaluation were randomly selected from the program records.

Results: The JSWF program enrolled 4,609 households in 186 communities and sold 47,862 bottles of chlorine between September 2002 and May 2010 - enough to treat about 11.5 million gallons of water. Various inacuracies were discovered in the program records, therefore analysis was restricted to the program area with the most accurate records (n=1,304). A total of 64.0% (n=835) of participants had at least one recorded chlorine purchase and 57.3% (n=747) had multiple recorded purchases. More than 20% of participants made enough purchases to treat all of their drinking water in a given year. Overall, 77.3% (n=2,733) of the unannounced chlorine residual tests conducted were positive, indicating the presence of chlorine in the water.

Discussion: After 8 years of program operation, the number of participants and communities continues to expand, though the quality of the data prevented a definite conclusion to be made regarding the long-term consistency of chlorine purchase and use in the JSWF. However, the data analysis on the participants that live near Jolivert showed consistent purchases and positive chlorine residual tests.

Table of Contents

List of Figures................................................................................................................. 9

List of Tables................................................................................................................. 10

Chapter 1: Introduction.................................................................................................... 11

1.1 Background........................................................................................................... 11

1.2 Significance.......................................................................................................... 13

1.3 Introduction to the Jolivert Safe Water for Families Program......................................... 14

1.3.1 JSWF Operations.............................................................................................. 16

Chapter 2: Literature Review............................................................................................ 21

2.1 Point-of-Use Treatment Methods............................................................................... 21

2.2 Limitations of Water Chlorination Program Studies....................................................... 25

2.3 Consistency of Use................................................................................................. 25

2.4 Measuring Use....................................................................................................... 27

2.5 Documented Use.................................................................................................... 28

Chapter 3: Methodology.................................................................................................. 34

3.1 Population and sample............................................................................................ 34

3.2 Sales Database Data Collection................................................................................ 35

3.2.1 Resellers........................................................................................................ 39

3.2.2 Database Analysis............................................................................................ 40

3.3 Household Survey.................................................................................................. 40

3.3.1 Selection of chlorine user households:................................................................ 40

3.3.2 Selection of control households......................................................................... 41

3.4 Plans for data analysis........................................................................................... 42

Chapter 4: Results......................................................................................................... 44

4.1 Program Records Summary.................................................................................... 44

4.1.1 Chlorine Sales................................................................................................. 44

4.1.2 Household Visits.............................................................................................. 45

4.1.3 Chlorine Residual Tests..................................................................................... 46

4.1.4 Distance......................................................................................................... 48

4.1.5 Program Growth............................................................................................... 51

4.2 Data Validity......................................................................................................... 53

4.2.1 Previous JSWF Research.................................................................................... 53

4.2.2 Monthly Financial Records and Paper Records........................................................ 54

4.2.3 Resellers........................................................................................................ 56

4.3 Survey................................................................................................................ 58

4.3.3 Distance........................................................................................................ 62

4.4 Valid Data Set...................................................................................................... 63

4.5 Consistency of Use................................................................................................ 64

4.5.1 Sales Records................................................................................................. 64

4.5.2 Household Visits.............................................................................................. 64

4.5.3 Consistency of Use........................................................................................... 65

4.6 Survey Results...................................................................................................... 67

4.6.1 Survey demographics....................................................................................... 67

4.6.2 Treatment methods.......................................................................................... 68

4.6.3 Gadyen Dlo Use............................................................................................... 70

4.6.4 Program participant training............................................................................... 73

4.6.5 Survey Results by Geography............................................................................. 75

4.6.6 Health Impact Results from Survey..................................................................... 77

4.7 Limitations........................................................................................................... 78

Chapter 5: Discussion.................................................................................................... 81

5.1 Quality of Program Records..................................................................................... 81

5.2 Data Quality.......................................................................................................... 82

5.2.1 Analysis Restriction.......................................................................................... 83

5.3 Consistent Use...................................................................................................... 84

5.3.1 Chlorine Purchases........................................................................................... 84

5.3.2 Household Visits.............................................................................................. 86

5.4 Program Size and Accessibility................................................................................. 87

5.5 Value of Household Visits........................................................................................ 90

5.6 Culture of Chlorination in Haiti................................................................................. 91

5.7 Health Impact and Behavior Change......................................................................... 92

Chapter 6: Recommendations.......................................................................................... 93

6.1 Resellers and Program Staff................................................................................... 93

6.2 Regional Headquarters........................................................................................... 95

6.3 Conclusion........................................................................................................... 96

References................................................................................................................... 98

Appendix A: Household Survey........................................................................................ 101

Appendix B: IRB Study Exemption Letter........................................................................... 105

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Hygiene
Parola chiave	Household water treatment Consistency of use Safe water system Monitoring and evaluation Haiti Water chlorination
Committee Chair / Thesis Advisor	Null, Clair, Emory University
Committee Members	Lantagne, Daniele, CDC
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.) CDC

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