Gadyen Dlo "Water Guardian": A Qualitative Study of the Influence of Cholera on Household Water Treatment Practices in Haiti Open Access

Abstract

Background: Lack of improved water and sanitation were determined to be key factors in the rapid spread of the cholera epidemic in Haiti. Household water treatment is a point-of-use water quality intervention that is being increasingly used in developing countries to address the need for safe drinking water. Deep Springs International (DSI), a US-based NGO operating in Haiti, supervises the local production and distribution of a sodium-hypochlorite water treatment solution Gadyen Dlo and a safe storage container and provides community education on the use of household water treatment. The aim of this study was to explore how perceptions of cholera influenced the uptake of HWT in Haiti. Methods: Twelve focus group discussions (FGDs) with HWT program participants were conducted in communities served by DSI's Gadyen Dlo program; 6 in Gadyen Dlo's Jolivert program region, 3 from the North program region and 3 from the Leogane program region. Topics of discussion included perceptions of cholera and perceptions and behaviors relating to household water treatment methods and practices. Data were analyzed using thematic analysis in MAXQDA version 10 software. Results: Results from this study show that the Haitian community suffers from fear, uncertainty and confusion about the cholera epidemic. Many people attributed the arrival of cholera in Haiti to the government or foreign entities. Fear of cholera emerged as a major motivator for uptake of water treatment in the community. Most FGD participants understood the importance of and correct usage of Gadyen Dlo and a few other HWT products. Communities generally liked the taste and quality of the Gadyen Dlo product over other products. Discussion: This thesis presents important data about how perceptions of cholera may influence the work of international NGOs and others working in public health in Haiti. The study also presents a conceptual framework to understand the 'change factors' that influence a person's movement through the three important stages of the HWT behavior change continuum: awareness, action and maintenance . Findings from this thesis can be utilized by the Gadyen Dlo program and other NGOs providing HWT to the Haitian community to improve the planning and implementation of HWT interventions in Haiti.

Table of Contents

Table of Contents

Chapter 1: Introduction and Project Aims...1

1.1 Study Context...1

1.2 Deep Springs International (DSI) and Gadyen Dlo...1

1.2.1 Gadyen Dlo and SWS...2

1.2.2 History and Organization of Deep Springs International...3

1.3 Problem Statement and Research Questions...4

Chapter 2: Literature Review...6

2.1 Household Water Treatment...6

2.1.1 Behavior Change Theory Related to Household Water Treatment...7

2.1.2 Adherence to Household Water Treatment (HTW)...8

2.1.3 Point of Use Water Treatment in Emergency Settings...9

2.1.4 Sustained Uptake of Household Water Treatment...10

2.2 Cholera and Water Treatment in Haiti...15

2.2.1 History of Cholera in Haiti...15

2.2.2 Perceptions of Cholera in Haiti...16

2.2.3 Water and Sanitation in Haiti...17

2.2.4 Water Treatment in Haiti...17

2.2.5 Implications of Cholera on Uptake of SWS and Household Chlorination...18

2.2.6 A Case Study of Success of Household Chlorination in Haiti...19

Chapter 3: Methods...21

3.1 Qualitative Methods Overview...21

3.2 Study Site...22

3.2.1 Léogâne...22

3.2.2 Jolivert...24

3.2.3 North. 26

3.3 Instrument Development and Field Staff Training...28

3.4 Field Work...30

3.4.1 Participant Recruitment for Focus Group Discussions...30

3.4.2 Focus Group Discussions (FGDs):...32

3.5 Data Storage...33

3.6 Analysis...34

Chapter 4: Results...37

4.1 Cholera...37

4.1.1 Fear of cholera...37

4.1.2 Cholera is dehumanizing...44

4.1.3 Where does cholera come from?...46

4.1.4 Seasonality of cholera...59

4.1.5 Confusion, Disbelief, and Outrage...60

4.1.6 Se Toujou La (It is still there)...64

4.2 Water Treatment...65

4.2.1 Treatment Methods or Products...65

4.2.2 Water Treatment Behaviors...70

4.2.3 Behavior Change...72

Chapter 5: Discussion...83

5.1 Role of Location...83

5.2 Fear, Distrust and Uncertainty...84

5.3 Behavior Change...88

5.3.1 Conceptual Framework for Household Water Chlorination Behavior Change...90

5.3.2 Impact of Distrust and Uncertainty Fueled by Cholera on Self-Efficacy...100

5.4 Disaster Response...100

5.5 Recommendations...101

5.5.1 Recommendations for WASH NGOs working in Haiti...101

5.5.2 Recommendations Specific to Gadyen Dlo...102

5.6 Limitations...103

Chapter 6: Conclusion...106

References...108

Appendices...112

A.1 Appendix 1 Focus Group Discussion Guides -English...112

A.2 Appendix 2 Focus Group Discussion Guide-Haitian-Kreyol...126

A.3 Appendix 3 In-Depth Interviews...138

A.3.1 In-Depth Interview Methods...138

A.3.2 In-Depth Interview Discussion Guide-English...145

A.3.3 In-Depth Interview Guide-Haitian-Kreyol...156

List of Tables

Table 1 Summary of Focus Group Discussion Data Collection by Region...32

Table 2 Summary of how FGDs were analyzed by Gadyen Dlo Program Region...34

Table 3 Months Focus Groups Reported Cholera was Worst in their Community...60

List of Figures

Figure 1 Gadyen Dlo Sodium Hypochlorite Solution and Special Bucket...3

Figure 2 PATH's Safe Water Program Behavior Change Continuum (Wood et. al, 2012)...8

Figure 3 DSI Program Sites and Household Coverage in Communities Served...22

Figure 4: Conceptual Framework for Household Water Chlorination (HWC) Behavior Change in the Time of Cholera in Haiti...89

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, Public Health
Keyword	perceptions Household water treatment behaviors Cholera Haiti
Committee Chair / Thesis Advisor	Null, Clair, Emory University
Committee Members	Andes, Karen, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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