mwendera chikondi dissertation.doc2 131109

UNIVERSITY OF MALAWI

COLLEGE OF MEDICINE

Impact of water and sanitation component of the Lungwena

Health and Agriculture Multidisciplinary Research Project

By

Chikondi Andrew Mwendera Bachelor of Science in Environmental Health

A Dissertation Submitted in Partial Fulfillment of the Requirements of the

Master of Public Health Degree

June 2009

Impact of water and sanitation component of the Lungwena Health and Agriculture Multidisciplinary Research Project

i

CERTIFICATE OF APPROVAL

The Thesis of Chikondi Andrew Mwendera is approved by the Thesis Examination

Committee

________________________

(Chairman, Post Graduate Committee)

_________________________

(Supervisor)

______________________ (Internal Examiner)

_______________________ (Head of Department)


ii

DECLARATION

I, Chikondi Andrew Mwendera hereby declare that this thesis is my original work and

has not been presented for any other awards at the University of Malawi or any other

University.

Name of Candidate: Chikondi Andrew Mwendera

Signature: _________________________

Date: June 2009


iii

ACKNOWLEDGEMENTS

Sincere appreciation and many thanks are extended to many people who helped me to

bring this work to completion. The research could not have been successful without the

contribution of various people, who gave their constructive criticisms and support:

I give glory to God Almighty for keeping me safe throughout the entire program

and for the provision of abundant blessings

My Supervisor, Prof. Kenneth Maleta, who diligently guided me to focus on my

area of interest and provided expertise in the research process.

Dr. Steve Taulo for encouraging me to work towards successful completion of

this research and his critical review of the report

Mr. Henry Limula for his enthusiastic support during sample collection and water

sample analysis

Mr. Innocent and Mr. Shaibu for their efforts during data collection

All the research participants who provided invaluable information for this

research to be a success. May God bless them.


iv

ABSTRACT

In Lungwena, Mangochi, only 1.7% of the population has access to improved sanitation

while 73.3% has access to safe water. Contamination of stored water is a common

practice in the area. As part of a Health, Agriculture and Environment multidisciplinary

research project, sanitation platforms and Information, Education and Communication

(IEC) interventions were conducted in Lungwena on a pilot basis. This study describes an

assessment of the impact of the water and sanitation interventions conducted in the area.

The study describes sanitation coverage, bacteriological quality of stored water, and

diarrhoeal morbidity in intervention and control villages.

A total of 313 households (157 and 156 households in control and intervention villages

respectively) were studied. Interviewer administered questionnaires were used and

samples of stored drinking water were assessed for bacteriological quality. Morbidity was

assessed by prevalence of 2-week recalled under five year old diarrhoeal morbidity.

Prevalence (95% confidence interval) of improved sanitation was 78.3% (68.4%-86.2%)

in intervention and 21.7% (13.8%-31.6%) in control villages. The proportional difference

(95% C.I. of difference) in sanitation coverage was 56.6% (30.8%-70.1%), which was

statistically significant (p=0.000, Chi square test). The proportion (95% C.I) of

households with presence of E. coli in stored water was 37.9% (29.1%-47.4% C.I) in

intervention villages and 62.1% (52.6%-70.9% C.I) in the control villages with the

proportional difference (95% C.I. of difference) of 24.2% (4%-28.5% C.I.), which was

statistically significant (p=0.007 Chi square test). The difference in bacteriological

quality of stored drinking water may be attributed to the improved sanitation coverage

and the source of drinking water. Incidence (95% C.I.) of diarrhoeal morbidity was

33.3% (18.6%-51.0%) in intervention villages and 66.7% (49.0%-81.4%) in control

villages with an incidence difference (95% C.I. of difference) of 33.4% (1%-41.9% C.I.),

which was not statistically significant, (p= 0.7305, chi square test).

The study recommends that: (a) Sanplats should be extended to other villages and village

headmen should ensure that households use such facilities, (b) boreholes should be

maintained for access to safe water and (d) appropriate IEC materials should be

developed and promoted to ensure availability of water hygiene practices at three levels

of water handling points (at source, during transportation, and storage in the home).


v

TABLE OF CONTENTS

Page(s)

CERTIFICATE OF APPROVAL .................................................................................... i DECLARATION............................................................................................................... ii ACKNOWLEDGEMENTS ............................................................................................ iii

ABSTRACT ...................................................................................................................... iv LIST OF TABLES .......................................................................................................... vii LIST OF FIGURES ....................................................................................................... viii

ACRONYMS AND ABBREVIATIONS ........................................................................ ix CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW .......................1

1.1 Introduction .......................................................................................................... 1 1.1.1 Water supply coverage ...................................................................................1

1.1.2 Sanitation coverage .......................................................................................2 1.1.3 Water and sanitation interventions ...................................................................3

1.1.4 The Lungwena NUFU project ........................................................................5 1.1.5 Contribution of the researcher.......................................................................5

1.2 Literature review .................................................................................................. 6

Indicator Microorganisms ...........................................................................................7

CHAPTER TWO: RESEARCH OBJECTIVES AND METHODOLOGY...............10 2.1 Objectives of the study....................................................................................... 10

2.1.1 Broad............................................................................................................ 10

2.1.2 Specific ......................................................................................................... 10 2.2 Research methodology ....................................................................................... 10

2.2.1 Study place ................................................................................................... 10 2.2.2 Study population and sampling .................................................................... 11 2.2.3 Data collection ............................................................................................. 12

2.2.4 Ethical considerations and consent ............................................................. 14 2.2.5 Dissemination of the results ......................................................................... 14

2.2.6 Challenges in the study ................................................................................ 14

CHAPTER THREE: RESEARCH FINDINGS ............................................................ 16 3.1 Socio-demographic characteristics of the sampled population .............................. 16

3.2 Sanitation coverage ............................................................................................ 17

3.3 Sources of drinking water ................................................................................. 19 3.3.1 Bacterialogical quality of the water in the sampled villages ....................... 22 3.3.2 Source of contamination .............................................................................. 26

3.4 Water and sanitation health problems of the villages ........................................... 28

CHAPTER FOUR: DISCUSSION ................................................................................. 32 4.1 Sanitation coverage ............................................................................................ 32 4.2 Water quality ...................................................................................................... 37 4.3 Diarrhoea morbidity ........................................................................................... 39

CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS ..........................41 5.1 Conclusion ......................................................................................................... 41 5.2 Recommendations .............................................................................................. 42

REFERENCES ................................................................................................................. 43


vi

APPENDICES .................................................................................................................. 48 Appendix 1: Introduction and consent ........................................................................... 48 Appendix 2: Introduction and consent (Yao version) .................................................... 49 Appendix 3: Household questionnaire ........................................................................... 50

Appendix 4: Household questionnaire (Yao Version) ................................................... 57 Appendix 5: Map of Lungwena ..................................................................................... 64


vii

LIST OF TABLES

Table 1: Age of the respondents .....................................................................................16

Table 2: marital status of the respondents corresponding to sex ................................17

Table 3: latrine coverage in the intervention and control villages ..............................18

Table 4: Source of drinking water ..................................................................................19

Table 5: drinking water storage containers...................................................................21

Table 6: Coliform test ......................................................................................................22

Table 7: E. coli Test results .............................................................................................23

Table 8: E. Coli Test results in relation to source of drinking water ..........................24

Table 9: E. coli Test results in relation to the type of water storage container ..........25

Table 10: E. coli results in relation to the type of toilet ................................................25

Table 11: Diarrhoea morbidity in relation to the type of toilet ..................................30

Table 12: Diarrhoea morbidity in relation to E. coli tests............................................30

Table 13: diarrhoeal morbidity in relation to source of drinking water ....................31

Table 14: Diarrhoeal morbidity in relation to drinking water storage containers ....31


viii

LIST OF FIGURES

Figure 1: Faecal-oral infection transmission route. ........................................................4

Figure 2: Improved latrine coverage ..............................................................................18

Figure 3: Drinking water treatment practice ...............................................................20

Figure 4: Presence of in stored drinking water .............................................................24

Figure 5: main source of drinking water contamination at household level ..............26

Figure 6: Sources of water contamination at source ....................................................27

Figure 7: major water and sanitation health problems in the villages .......................28

Figure 8: Diarrhoea morbidity in the villages ...............................................................29


ix

ACRONYMS AND ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

C I Confidence Interval

COMREC College of Medicine Research and Ethical Committee

DALYs Disability Adjusted Life Years

DHO District Health Office

HMIS Health Management Information System

HSA Health Surveillance Assistant

IEC Information Education Communication

MDGs Millennium Development Goals

MNSP Malawi National Sanitation Policy

NSO National Statistical Office

NUFU Norwegian Centre for International Cooperation in Higher Education

OECD Organisation for Economic Cooperation and Development

SanPlat sanitation Platform

UNICEF United Nations International Children Education Fund

UN United Nations

WHO World Health Organisation


1

CHAPTER ONE

INTRODUCTION AND LITERATURE REVIEW

1.1 Introduction

Lack of safe and adequate water supply, basic sanitation and hygiene practices are

associated with high morbidity and mortality due to the increased ease with which enteric

and water borne diseases are spread [1]. Consumption of contaminated water remains one

of the most significant causes of ill health worldwide [2] [42]. In 2004, World Health

Organization (WHO) and the United Nations International Children Education Fund

(UNICEF) estimate that 80% of all illness in developing countries is linked to water and

sanitation and 15 million children under the age of five years die every year due to

diarrhoeal diseases. It is further estimated that about a billion people in developing

countries do not have access to safe water supply and proper sanitation facilities [3].

The Millennium Development Goals (MDGs) constitute eight international development

goals that 189 member states of the United Nations and at least 23 international

organizations have agreed to achieve by the year 2015. One of the goals is to ensure

environmental sustainability (MDG 7). Some of the indicators for monitoring this MDG

are the proportion of households with improved sanitation and access to safe drinking

water. This MDG targets to halve, by 2015, the proportion of the people without

sustainable access to safe drinking water and basic sanitation [4]. In order to meet the

MDG targets of access to improved water supply and improved sanitation, an additional

260,000 people per day should gain access to improved water source and an additional

370,000 people per day should gain access to improved sanitation respectively [5]. This

is also the emphasis of the Malawi National Sanitation Policy (MNSP), which has

highlighted the vital role that water and sanitation impacts on all the MDGs [6].

1.1.1 Water supply coverage

In 2002, the WHO estimated that globally 1.1 billion people lacked access to improved

water, which represented 17% of the global population whereas in the Sub-Saharan

Africa, 42% of the population is still without improved water [5]. In 2004,

WHO/UNICEF reported that 68% of the rural population has access to improved water


2

supply in Malawi [3]. In Mangochi, 73.3% of the households have access to improved

water sources with 67.8% of the households having access to boreholes [7]. From the

Lungwena household census, it was established that 91.9 % of the households were

collecting drinking water from protected water sources. Predominant sources of drinking

water were boreholes (91.2%), rivers/streams (4.5%), unprotected wells/springs (3.6%),

and protected wells/springs (0.7%) [8]. Despite collection of drinking water from

protected water sources, it has been established that water contamination practices are

common and management of water during storage is very poor in all the villages [9].

1.1.2 Sanitation coverage

The Malawi National Sanitation Policy (MNSP) defines basic (excreta) sanitation and

improved (excreta) sanitation as follows:

Basic (excreta) sanitation shall be limited to access to a latrine that:

Should allow for the safe disposal of faeces into a pit or other receptacle where it

may be safely stored, composted or removed and disposed of safely elsewhere.

Should offer privacy for the user.

Should be safe for the user to use, for example not in a dangerous state, liable to

imminent collapse or dangerously unhygienic.

The latrine pit or receptacle should be functional i.e. not full or over flowing.

The latrine should be at least 30 meters from a ground water source or surface

water course.

While improved (excreta) sanitation shall be as above (for basic sanitation) with the

addition that there should be an impermeable floor and a tight fitting lid to the latrine, or

in the case of ecological sanitation (ecosan) where no lid is needed, the ecosan latrine

should be properly looked after with the regular addition of soil, ash and other organic

material [6].

In 2002, 2.4 billion people lacked access to improved sanitation, representing 42% of the

global population. In Sub-Saharan Africa, sanitation coverage is a mere 36% and that

only 31% of the rural population in developing countries have access to improved


3

sanitation compared to 73% of the urban dwellers [5]. In Malawi only 6% of the

population has access to improved sanitation [10]. Sixty-nine percent has access to

sanitation with traditional pit latrines [7]; while 3.1% have latrines with sanitation

platforms [10]. However, the MNSP reports the estimated improved sanitation coverage

to be between 25% and 33%, dropping to less that 7% in some rural communities

although it reaches as high as 95% where sanitation projects have been active in

promoting hygiene and sanitation in an integrated manner [6]. In Mangochi 88% have

access to some form of sanitation with pit latrines [7]. Results from the baseline survey

done in 2004 in Lungwena, Mangochi revealed that only 1.7% of the households have

access to improved sanitation [8].

1.1.3 Water and sanitation interventions

Human excreta and the lack of adequate personal and domestic hygiene have been

implicated in the transmission of many infectious diseases including cholera, typhoid,

hepatitis, polio, cryptosporidiosis, ascariasis, and schistosomiasis [11]. Human excreta-

transmitted diseases predominantly affect children and the poor in developing countries

and result in deaths due to diarrhoea [12].


4

Figure 1 below shows how faecal-oral infections can be transmitted to people and

barriers that can be put in place to break the transmission cycle:

Primary barrier

Secondary barrier

Secondary barrier

Secondary barrier

Figure 1: Faecal-oral infection transmission route. Adapted from Curtis [13]

Safe excreta disposal and handling, act as the primary barrier for preventing excreted

pathogens from entering the environment. Once pathogens have been introduced into the

environment they can be transmitted via either the mouth (e.g. through drinking

contaminated water or eating contaminated vegetables/food), which calls for secondary

barriers that may include; a safe water source, proper handling of water at point of

source, transportation, and point of use, supplemented with adequate health education to

reduce such transmission [11]. The interventions in Lungwena aimed at the provision of

sanitation platforms with covers, which provide the primary barrier, health education

with emphasis on collection of drinking water from a safe source i.e. boreholes, usage of

the two cup system, and household and environmental sanitation as prevention measures

to faecal-oral infections [14].


5

1.1.4 The Lungwena NUFU project

The Lungwena NUFU project is an agriculture, health and environmental project with the

main objective of reducing the problem of poverty, food insecurity, malnutrition, and ill-

health through multi-sectoral and multi-disciplinary approaches. The Department of

Environmental Health at the Polytechnic, in which the researcher was part of the team,

was involved in this project with its interventions in Lungwena, Mangochi as the study

area that is aimed at improving the public health.

In order to contribute to the MDG 7, the project introduced sanitation platforms, and IEC

interventions, which emphasized on proper handling and storage of drinking water, in

three villages. The IEC component was provided in collaboration with Chancellor

Colleges component of theatre for production, whose main interventions were

conducting drama with messages based on the results of the baseline survey.

Sanitation platforms (Sanplats) are concrete slabs with a hole in the middle that has a

cover and are installed on a hole to provide safe disposal of human excreta. It was,

therefore, proposed that 500 households be provided with these sanplats. These sanplats

were donated free to the communities, however, for them to gain ownership, each

household was required to collect sand and small stones while the project provided

cement and reinforcement steel bars. Training was conducted to prepare village

committees on how to cast sanplats and by September 2005, three out of eight villages

were ready for casting and it is in these villages where the evaluation was conducted.

This study intended to highlight changes in sanitation coverage, keeping quality of

drinking water and relate them to diarrhoeal morbidity with the aim of learning from

experience so that when scaling up the project, either new strategies could be adopted or

the existing ones could be improved or maintained.

1.1.5 Contribution of the researcher

The researcher was part of team from the Polytechnic that developed the interventions

implemented in the area. The researcher developed and conducted the evaluation. The


6

researcher also conducted laboratory tests, organized, analyzed the data and compiled this

report.

1.2 Literature review

The impact of poor sanitation and water supply is well documented. Murray and Lopez

[15] calculated that in 1990, 5.3 % of all deaths and 6.8% of all Disability Adjusted Life

Years (DALYs) lost are associated with diarrhoeal and selected parasitic infections,

stemming from inadequate access to water and sanitation. Annually, there are around 2.4

million deaths related to water and sanitation mainly resulting from diarrhoeal diseases

and occurring mostly among children under five years old [16]. Improving the quantity

and the quality of water available, providing adequate sanitation facilities and adopting

better hygienic practices interrupt the transmission of most faecal-oral diseases [17].

An adequate and safe water supply, satisfactory sanitation, and continuing public health

and hygiene education coupled with sufficient investment in the sector have been shown

to dramatically lower the incidence of water-borne diseases, particularly in infants and

children. Reviews by Esrey [18], show a 16% to 25% decrease in diarrhoeal morbidity

resulting from improved water supply. Esreys reviews also examined the evidence of the

impact of sanitation on health outcomes. Of the 30 studies that looked at sanitation, 21

documented some reduction in diarrhoeal diseases, with a median reduction of 22% [18].

The type of improved excreta disposal method was important, with the greatest

reductions reported for flush toilets, although pit latrines were also associated with

morbidity reductions. Feachem and Koblinsky [19] noted reductions in diarrhoeal

diseases of 32-43% through hand washing with soap in different settings. Boot and

Caincross [20] showed that hand washing, education and soap availability resulted in

reductions of 30-48% in disease prevalence. Therefore, strategies to encourage hand

washing can reduce the incidence of diarrhoea by one third [21]. Hands must be washed

after defecation, after any direct or indirect contact with stools, before preparing food,

before eating, before feeding children [11].


7

From the Malawi MDGs 2008 report [43], there is an indication that the country is

making good progress towards achieving improved access to sanitation since it has

changed from 72 percent in 1990 to 88 percent in 2006. However, the target has been

projected that access to improved sanitation is likely to increase to about 98 percent by

2015. Provision of the sanplats in Lungwena complements the efforts made by the

Government of Malawi towards the projected figures. Sanplats serve as improved

sanitation for the purposes of creating a barrier for faecal-oral infections since where

basic sanitation is lacking, there is more likelihood of indicator bacteria from faeces

being introduced into stored water [22].

In rural areas where water from a treatment plant is not available, boreholes serve as

source of safe water. These boreholes are situated some distance away from households

and require people to travel and fetch this water. In this situation there is a great chance

of contamination of water during transportation and at the point of use in the household

due to dipping of hands/fingers as the containers are usually uncovered [23] [24]. Having

a safe source of water gives households some sense of security and tend to boil or treat it

less not knowing that water could be contaminated at different points from source to

consumption at home [25]. Therefore, proper health education messages should be

disseminated with emphasis that contamination of water may occur at any point and

proper handling and storage is important in maintaining safe water [26].

The types of storage vessels play a major role in keeping water safe during storage. Wide

mouthed containers offer great chance for contamination from hands, dusts, and unclean

utensils [27]. Sometimes microbiological quality of water may improve when it has been

stored for a long period since microorganisms die-off as they compete for survival [28].

Indicator Microorganisms

Consumption of safe water is vital in the maintenance of good health. Water has to be

stored in clean vessels at all times and should not be liable to contamination. Detection of

contamination is based on the presence of indicator bacteria. Indicator bacteria are used

to measure the effectiveness of a treatment plant in removing, or inactivating, bacteria.

The different types of bacteria used as indicators are coliform bacteria, Escherichia coli


8

(E. coli), Intestinal Enterococces and Clostridium perfringens. When these are present in

drinking water it signals fecal contamination [29].

Coliform bacteria are genera of bacteria which belong to the family Enterobacteriacae.

They are a wide range of aerobic and facultative anaerobic, Gram-negative, non-spore

forming bacilli capable of growing in the presence of relatively high concentrations of

bile salts, with the fermentation of lactose, and production of acid or aldehyde within 24h

at 35-37C [29]. This genera includes the Escherichia, Citrobacter, Enterobacter and

Klebsiella [30]. The total coliform group includes both faecal and environmental species,

and also includes species that can survive and grow in water. Total coliforms are found in

both sewers and natural waters, and are not an index of faecal contamination or of health

risk, but they do give basic information about the quality of the water source [31]. If

detected in treated drinking water, insufficient treatment or contamination within the

distribution system is likely to have occurred. Some of the coliforms are able to grow at

higher temperatures. These are defined as thermotolerant coliforms. These groups of

bacteria are defined as coliforms, which are able to ferment lactose at 44-45C [29].The

most important genus in this group of bacteria is Escherichia and only E.coli is

considered to be of faecal origin [32].

Escherichia coli (E. coli) are commonly found in the faeces of warm-blooded animals,

and concentrations up to 109 per gram can be found in fresh faeces. In general the

bacteria grow at 44-45C on complex media, ferments lactose and mannitol with the

production of acid, and produce indole from tryptophan. Some strains may also grow at

37C and not at 44-45C, and some do not produce gas [29]. If E. coli is detected in

drinking water there is a high probability that recent faecal contamination has occurred.

Recent faecal contamination also increases the probability that other pathogens

transmitted by the faecal-oral route are also present in the water [29].

The WHO guidelines stipulate that all water intended for drinking should not contain

E.coli or thermotolerant coliforms in any 100 ml sample of treated or untreated water. In

addition, total coliforms should not be detected in any 100ml sample. The requirements

are stricter for treated water entering the distribution system. Water in the distribution


9

system should also conform to the above guidelines and that total coliforms must not be

present in 95% of samples taken throughout any 12-month period [33]. It is against this

background that this study stressed on isolation of total coliform and E. coli.


10

CHAPTER TWO

RESEARCH OBJECTIVES AND METHODOLOGY

2.1 Objectives of the study

2.1.1 Broad

The main objective of the study was to assess the impact of the water and sanitation

interventions conducted in the study area.

2.1.2 Specific

(a) To determine the sanitation coverage in the intervention and control villages in

Lungwena

(b) To examine the bacteriological quality of stored drinking water at household level

in the intervention and control villages in Lungwena.

(c) To compare diarrhoeal morbidity, within the period of data collection, among

under five children in the intervention and control villages in Lungwena.

2.2 Research methodology

This was a descriptive study comparing 156 and 157 households in intervention and

control villages respectively. It involved the three villages in which the interventions

were implemented and three non-intervention (control) villages which were randomly

selected but with similar characteristics with the intervention villages in terms of size and

location. The study was conducted in the dry season in the months of September and

October 2007.

2.2.1 Study place

The study was conducted in Lungwena, Mangochi district. Lungwena is situated on the

eastern side of Lake Malawi. It is bounded by the lake on the western side and a range of

mountains on the eastern side. Because of the relief distribution in the area, the east is an

upland area while the west is lowland. The health centres catchment area makes a

northward stretch side by side of the road. Lungwena is 20km long and about 5 km wide.

It is about 40km away from Mangochi town and 70km from Makanjira. The catchment

area of Lungwena health center covers villages in two Traditional Authorities (TAs);


11

namely Makanjira and Chowe. There are 26 villages and the first village on the south is

Matenganya and the furthest on the northern end is Mdoka (refer to the map in appendix

5).

The area has about 20,000 people living in 4,200 households. Approximately 49% of the

population are below the age of 15 years. Among the under 15 years old, there are more

males than females whilst among the adult age range 15 39 years old the reverse is true.

Most of the people belong to the Yao tribe and their main occupation is subsistence

farming and fishing. Along the lakeshore, fishing is the major source of livelihood.

Inland, a variety of crops are grown which include maize, cassava, rice, sweet potato,

beans and vegetables. Maize is the staple food. Islam is the predominant religion in the

area. The family organization is matrilineal. Traditionally the women who remain near

their mothers home even when married inherit land. However, men are considered as

heads of households .

2.2.2 Study population and sampling

The study population came from villages in which the interventions were implemented

and control villages where no sanitation interventions were implemented. The baseline

survey was conducted in all the villages of the area, therefore, controls were used to

reflect the baseline situation of the intervention villages with the assumption that the

situation remained constant.

The villages in this area are located either in the upland or the wetland. Two of the

intervention villages namely; Kwilasya and Ntumbula are from the upland while Nlani

Chapola is from the wetland. The control villages were selected to match with these

characteristics in terms of location and size and these were Mbanda and Taliya from the

upland, and Mbale from the wetland. In terms of household numbers, the sizes of the

villages are as follows; Kwilasya (225), Ntumbula (158), Nlani Chapola (88), Mbanda

(138), Taliya (289), and Mbale (54). The sample size was calculated with the following assumptions, a diarrhoea prevalence

of 41 cases per 100 based on 2004 under five diarrhoeal prevalence Lungwena health

center facility data [34], and intervention effect of reducing the prevalence by 15%.

Based on these assumptions the sample size required was 310 households through


12

calculation of independent samples by comparing two binomial proportions with 5%

level of significance and a power of 80% [35]. Hence a total of 155 households in

intervention and 155 households in control villages were required. Selection of individual

households was based on proportion to population using the following formula:

(a/b)*155; where a= total number of households in the village, b= total number of

households either in the intervention or control villages), for example to determine the

number of households from Nlani Chapola village with 88 households in total would be

(88/471)*155, which came up to 29 households. This resulted in the following numbers

of households sampled per village:

Intervention villages

Nlani Chapola 29 households

Ntumbula 52 households

Kwilasya 74 households

Control villages

Mbale 17 households

Taliya 93 households

Mbanda 45 households

The NUFU census provided identity (ID) numbers to households of the villages in the

Lungwena area. These ID numbers were used to randomly select households in each

village for evaluation. For example, in Kwilasya with 228 households, the ID numbers

were allocated pin numbers from 1 to 228. Therefore, using random number [36], 74

households were randomly selected and the households corresponding to the pin numbers

were visited.

2.2.3 Data collection

2.2.3.1 Questionnaire

The same questionnaire used during the baseline survey was adopted for evaluation with

some questions added to address specific areas to be explored.

An interviewer administered questionnaire was used to collect data from the household

member responsible for day to day household activities/chores. This included data on


13

sources of household water supply, storage of water in the households, use and treatment

of water in the home, among others. On sanitation, data was collected on availability of

pit latrines at the household level, hand washing practice after using the toilet, availability

of bath shelters and how wastewater and solid wastes are disposed of. In addition, data

was also obtained on water and sanitation IEC messages.

The same questionnaire was used to capture under five children in the households.

Therefore, only those households with under five children are included in the analysis of

diarrhoea morbidity. A follow up question was made to identify children that had

suffered from diarrhoea two weeks prior to the interview. This method identified incident

cases during the period of data collection.

2.2.3.2 Bacteriological tests

Samples from stored household drinking water were collected by asking the household

owner to transfer the water into the 100ml collection bottles. These samples were

transported using cooler boxes that contained icepacks to keep the environment at low

temperatures and hence limit the multiplication of microorganisms. Examination of

samples was conducted within six hours after collection. Positive and negative controls

were run, for every batch of samples, as standards for reference. Viable E. coli was used

for positive controls, while distilled water was used for the negative controls. It should be

noted that the tests carried were qualitative as they did not quantify the microorganisms

but rather determine presence/absence of coliforms and E. coli a bacterial indicator for

faecal contamination.

2.2.3.2.1 Coliform test

This test was carried out in two phases; the presumptive test and the confirmatory test for

E. coli. 10ml of water sample was put in a test tube to which 10ml of Mackonkeys broth

was added. These preparations were incubated aerobically at 37 degrees Celsius. After 24

to 28 hours of incubation they were inspected to note any colour changes by the acid

produced and the production of gas in the Durham tubes in the test tubes. This presumed

the presence of total coliform [37].


14

2.2.3.2.1 E.coli test

Samples that were positive were then subjected to a confirmatory test. From the sample

showing gas or acid, 1 ml was transferred into sterile 10 ml tubes of tryptone water

media. This was then incubated at 44 degree Celsius in a water bath for 18 to 24 hours

after which a drop or two of Kovacs reagent was added. A red ring at the interface is

indole positive signifying the presence of E. coli [37].

2.2.4 Ethical considerations and consent

The study was reviewed and approved by the College of Medicine Research and Ethical

Committee (COMREC). Consent was also sought from relevant authorities and those that

were interviewed had to sign on the consent forms (Appendix 1) i.e. the Village Headmen

and household heads to participate in the research and collection of water samples.

2.2.5 Dissemination of the results

The results will be disseminated to the community and may be written up for publication

in peer-reviewed journals.

2.2.6 Challenges in the study

Time and funding were the prominent constraints. However, adjustments were done to

accommodate the major activities of the study. The study was limited at identifying the

presence of coliforms and E. coli only; otherwise if funds were available bacteria counts

could have been conducted. Funding also affected the period of data collection, which

was not enough to detect any significant change in the morbidity of diarrhea that could be

attributed to the interventions. Another effect on diarhoeal morbidity could be that the

study was conducted in the dry season when diarrhea prevalence is usually low.

Bacteriological tests were only conducted on drinking water stored in the household since

it was assumed that water from borehole source was safe as earlier researched by Taulo

[39] in the same area. It might also appear that most samples from control villages tested

E. coli positive because most households from these villages collected their drinking

water from unprotected sources as their boreholes were not functional at the time of the

study (refer to plate 3). Another limitation of the study could come from the fact that

comparison of the intervention villages was conducted against control villages and not

from the baseline situation of the intervention villages due to limited data from the


15

baseline. Therefore, controls were used to reflect the baseline situation of the intervention

villages with the assumption that the situation remained constant.


16

CHAPTER THREE

RESEARCH FINDINGS

3.1 Socio-demographic characteristics of the sampled population

There were 157 households sampled in control and 156 households sampled in

intervention villages. More households by one were interviewed in control villages by

unknowingly. Otherwise the villages were comparable in terms of age, marital status, and

sex distributions as shown in tables 1 and 2 below.

Table 1 below shows that the majority of respondents in both intervention and control

villages came from the age group of 26-35 years old, with 47 (30%) and 54 (34%) of the

respondents coming from intervention and control villages, respectively.

Table 1: Age of the respondents

Age groups Intervention villages Control villages Total

15-25 43(28%) 34(22%) 77(25%)

26-35 47(30%) 54(34%) 101(32%)

36-45 19(12%) 22(14%) 41(13%)

46-55 9(6%) 18(12%) 27(8%)

56-65 14(9%) 10(6%) 24(8%) >65 24(15%) 19(12%) 43(14%)

Total 156(100%) 157(100%) 313(100%)

Table 2 below, shows that from the intervention villages there were 27 (17.4%) married

male respondents and 103 (66%) married female respondents, while from the control

villages 27 (17%) were married males and 103 (65.8%) were married females.


17

Table 2: marital status of the respondents corresponding to sex

Characteristics Intervention villages Control villages

SEX Male Married 27(17.4%) 27(17%)

Single 1(0.6%) 1(0.6%)

Widowed 0(0.0%) 1(0.6%)

Female Married 103(66%) 103(65.8%)

Single 1(0.6%) 0(0%)

separated 16(10.4%) 11(7%)

Widowed 8(5%) 14(9%)

TOTAL 156(100%) 157(100%)

3.2 Sanitation coverage

During the baseline survey (census) that was conducted in 2004 in Lungwena, Mangochi

it was revealed that only 1.7% of the households had access to improved sanitation.

Therefore, one of the interventions was provision of sanitation platforms in order to

increase improved sanitation coverage in some selected villages. Table 3 below shows

the present sanitation coverage in the intervention and control villages. This shows a

significant coverage of improved sanitation, and this is the effect of the sanplat

intervention introduced in the area. The most common type of toilet in these villages with

traditional pit latrines being the major type of latrine in the control villages, while

improved latrines are a major type in the intervention villages.


18

Table 3: latrine coverage in the intervention and control villages

The type of toilet

Whether intervention villages or control villages

Total


Control villages

pit latrine

60(38.5%) 127(80.9%) 187(59.7%)

Improved latrine with sanplat/dome

72(46.2%) 20(12.7%) 92(29.4%)

none

24(15.4%) 10(6.4%) 34(10.9%)

Total 156(100.0%) 157(100.0%) 313(100.0%)

Chi-square (2) 59.159 indicating P= 0.000

Figure 2 below shows only the improved sanitation coverage between the intervention

and control villages. The proportional difference in sanitation coverage was 56.6%

(30.8%-70.1% C.I.), which was statistically significant (p=0.000, Chi square test of

52.5536). Prevalence of improved sanitation was 78% (68.4%-86.2% C.I.) in intervention

and 22% (13.8%-31.6% C.I) in control villages.

Figure 2: Improved latrine coverage

Intervention villages, 72,

(78%)

Control villages, 20,

(22%)


19

3.3 Sources of drinking water

Table 4 below shows different types of drinking water sources accessed by households in

both intervention and control villages. Boreholes are the most common source overall

(p


20

If water is treated before drinking

noyes

Fre

qu

en

cy

160

140

120

100

80

60

40

20

0

Type of villages

intervention village

Control villages

Figure 3: Drinking water treatment practice

On whether households treat their drinking water or not, out of the total households

studied in the intervention village (156), 10 (6%) said they treat their water before

drinking while the rest 146 (93.6%) do not treat their water. In the control villages (157

households), 25 (16%) indicated to have treated their water while 132 (84%) households

did not. The common methods of treatment were usage of chemicals followed by boiling.

Households were also asked whether they use two cup system when drawing water from

their storage container, 116 (50.2%) of the households in the intervention villages

indicated using this system while 115 (49.8%) households in the control villages

indicated the same. However, upon request for the water samples none of the households

used the system in drawing the water samples.

Table 5 below shows the various containers used for storing drinking water at household

level with clay pots being commonly used in both types of village. P=0.07, shows that

there is no significant difference in the types of storage containers used in the various

villages sampled.


21

Table 5: drinking water storage containers

The type of water storage container


Total


Control villages

Tin bucket

28(17.9%) 21(13.4%) 49(15.7%)

Plastic bucket

35(22.4%) 53(33.8%) 88(28.1%)

Jerry can

4(2.6%) 1(.6%) 5(1.6%)

Clay pot

87(55.8%) 82(52.2%) 169(54.0%)

Drum

2(1.3%) 0(0%) 2(.6%)

Total

156(100.0%) 157(100.0%) 313(100.0%)



22

3.3.1 Bacterialogical quality of the water in the sampled villages

3.3.1.1 Coliform tests

Table 6 below shows the results of coliform tests done in all the water samples from the

313 households. It therefore, shows that 124 (79.5%) households from the intervention

villages were found to be positive. While 138 (88%) households from the control villages

were found to be positive.

Table 6: Coliform test

Test results


Total


Control villages

Positive

124(79.5%) 138(87.9%) 262(83.7%)

Negative

32(20.5%) 19(12.1%) 51(16.3%)

Total

156(100.0%) 157(100.0%) 313(100.0%)



23

3.3.1.2 E.coli test

Table 7 below shows E. coli test results. Thirty six percent (44 households) of samples

from intervention villages were positive, while 72 (52%) samples in the control villages

were positive.

Table 7: E. coli Test results

E. coli Test results


Total


Control villages

Positive

44(35.5%) 72(52.2%) 116(44.3%)

Negative

80(64.5%) 66(47.8%) 146(55.7%)

Total

124(100.0%) 138(100.0%) 262(100.0%)



24

While figure 4 analyses E. coli positive prevalence in the stored drinking water of the

households in the intervention and control villages. The proportion of households with

presence of E. coli bacteria in stored water was 37.9% (29.1%-47.4% C.I) in intervention

villages and 62.1% (52.6%-70.9% C.I) in the control villages, with the proportional

difference of 24.2% (4%-28.5% C.I.), which was statistically significant (p=0.007 Chi

square test of 7.3459).

Table 8 below summarizes E. coli test results in comparison with the source of water. It

shows that 48 (63%) out of 76 samples from unprotected well/spring were positive, while

49 (33%) out of 148 samples from boreholes were positive of the E. coli test.

Table 8: E. Coli Test results in relation to source of drinking water

E. Coli Test results

Source of drinking water

Total River/stream

Unprotected well/spring

Protected well/spring Boreholes

Positive

4(66.7%) 48(63.2%) 15(46.9%) 49(33.1%) 116(44.3%)

Negative

2(33.3%) 28(36.8%) 17(53.1%) 99(66.9%) 146(55.7%)

Total

6(100.0%) 76(100.0%) 32(100.0%) 148(100.0%) 262(100.0%)

Chi-square (2) 19.771 indicating P=0.000

Figure 4: Presence of E. coli in stored drinking

water


(38%)


(62%)


25

Table 9 below shows E. coli test results from different storage containers with 36 (51%)

out of 71 samples from plastic buckets being positive. While 57 (39%) out of 145

samples from clay pots were positive on the E. coli test.

Table 9: E. coli Test results in relation to the type of water storage container


The results from table 10 below include only the households that indicated having any

type latrine. The analysis therefore, examines all households with improved sanitation

from both intervention and control villages, in relation to E. coli test. It shows that of all

the E. coli positive samples from 104 households, 79% of the samples were from

households with pit latrines, while 21% were from households with improved sanitation.

This is a significant difference (P=0.001).

Table 10: E. coli results in relation to the type of toilet

E. coli Test Total positive negative

The type of toilet

pit latrine 82 (78.8%) 105 (60.0%) 187 (67.0%)

Improved latrine with sanplat/dome

22 (21.2%) 70 (40.0%) 92 (33.0%)

Total 104(100.0%) 175 (100.0%) 279(100.0%)


E. coli Test results

The type of water storage container Total Tin bucket Plastic bucket Jerry can Clay pot Drum

Positive

21(50.0%) 36(50.7%) 2(100.0%) 57(39.3%) 0(.0%) 116(44.3%)

Negative

21(50.0%) 35(49.3%) 0(.0%) 88(60.7%) 2(100.0%) 146(55.7%)

Total

42(100.0%) 71(100.0%) 2(100.0%) 145(100.0%) 2(100.0%) 262(100.0%)


26

3.3.2 Source of contamination

Main source of contamination at household

other

unhygienic household

unclean storage cont

unhygienic handling

Respondents

100

80

60

40

20

0


Control villages

l

Figure 5: main source of drinking water contamination at household level

Results from figure 5 above show the perceptions of the interviewees on the source of

contamination at household level. Therefore, it was established that unhygienic

household conditions were mentioned as the most common source of contamination with

78 (50%) out of 156 and 64 (40%) out of 157 households in both the intervention and

control villages respectively indicated so, followed by unhygienic handling of water.


27

Main source of water contamination at source

others

children

dust

storm w ater

use of unclean conta

animals

Household

s

100

80

60

40

20

0


Control villages

Figure 6: Sources of water contamination at source

Figure 6 above shows the perceptions of the interviewees on the source of contamination

at point of drinking water source. From the figure it can be shown that usage of unclean

containers is perceived as the main source of contamination at point of source followed

by dust.


28

3.4 Water and sanitation health problems of the villages

Figure 7 below shows the water and sanitation health problems as mentioned by

respondents: Diarrhoeal diseases were mentioned as the most common problem in both

the intervention and control villages (104- 33% and 96- 31% households, respectively)

and cholera was the common disease in both types of villages during the rainy season.

Respondents defined diarrhoea as the passage of loose stool for more than three times a

day.

Major water and sanitation health problems

other

bilharzia

scabies

diarrhoeal diseases

cholera

malaria

Fre

quency

120

100

80

60

40

20

0

Type of villages


Control villages

Figure 7: major water and sanitation health problems in the villages


29

Figure 8 below shows diarrhoeal cases that were recorded in the period of data collection.

These cases came from the under five children that were found in the households and

therefore, it is shown that there were 12 cases in the intervention villages and 24 cases

were recorded from the control villages.

Therefore, Diarrhoeal morbidity was 33.3% (18.6%-51.0% C.I) in intervention villages

and 66.7% (49.0%-81.4% C.I) in control villages with an incidence difference of 33.4%

(1%-41.9% C.I.), which was not statistically significant (p= 0.7305, chi square test of

0.1187).

Figure 8: Diarrhoea morbidity in the villages


(33%)


(67%)


30

Table 11: Diarrhoea morbidity in relation to the type of toilet

The type of toilet

Total pit latrine

Improved latrine with

sanplat/dome

Who suffered from diarrhoea

1 27(75.0%) 9(25.0%) 36(100.0%)

none 103(62.0%) 63(38.0%) 166(100.0%)

Total

130(64.4%) 72(35.6%) 202(100.0%)

Chi-square (2) 2.168 indicating P=0.141

The analysis above considers 202 households with one or more under five children.

Among those who had suffered from diarrhoea, 75% were children from households with

pit latrines, while only 25% were from households with improved sanitation. Although

this difference is not significant (P=0.141).

Table 12: Diarrhoea morbidity in relation to E. coli tests

E. Coli Test Total positive negative


1 12(33.3%)

24(66.7%)

36(100.0%)

none

55(33.1%)

111(66.9%)

166(100.0%)

Total

67(33.2%)

135(66.8%)

202(100.0%)

Chi-square (2).001 indicating P=0.981

The analysis in table 12 above considers 202 households with one or more under five

children. Therefore, among the diarrhoea cases 33% were from households that had

positive E. coli test results in stored drinking water, while 67% of the cases were from

households with negative E. coli test results in stored drinking water. This was not

significant (P=0.981).


31

Table 13: diarrhoeal morbidity in relation to source of drinking water

Source of drinking water

Total River/stream

Unprotected well/spring

Protected well/spring Boreholes


1 0(.0%) 10(27.8%) 4(11.1%) 22(61.1%) 36(100.0%)

none 4(2.4%) 41(24.3%) 11(6.5%) 113(66.9%) 169(100.0%)

Total

4(2.0%) 51(24.9%) 15(7.3%) 135(65.9%) 205(100.0%)

Chi-square 2.008 indicating P=0.571

Table 13 above shows the relationship of diarrhoea morbidity and the source of drinking

water. There was no significant difference (P=0.571) with the sources of drinking water

in relation to morbidity of diarrhoea. However, 22(61%) of diarrhoea cases were from

households with boreholes as their source of drinking water, while 10(28%) of the cases

sourced their drinking water from unprotected sources.

Table 14: Diarrhoeal morbidity in relation to drinking water storage containers

The type of water storage container Total Tin bucket Plastic bucket Jerry can Clay pot Drum


1 4(11.1%) 7(19.4%) 2(5.6%) 23(63.9%) 0(.0%) 36(100.0%)

none 14(8.3%) 21(12.4%) 0(.0%) 133(78.7%) 1(.6%) 169(100.0%)

Total

18(8.8%) 28(13.7%) 2(1.0%) 156(76.1%) 1(.5%) 205(100.0%)

Chi-square 11.798 indicating P=0.019

Table 14 above shows that from cases of diarrhea, 23(64%) were from households that

stored their drinking water in clay pots while 7(19%) were from households that stored

their drinking water in plastic buckets. This is shown to be significant with P=0.019.


32

CHAPTER FOUR

DISCUSSION

4.1 Sanitation coverage

The baseline survey, in Lungwena area was done on 421 households, had shown a high

use of traditional pit latrines (85 percent) as a means of excreta disposal in the area. A pit

latrine consists of a hole in the ground, with a wooden and mud platform (plate 1 below)

and a mud or straw superstructure for privacy. Only, 1.7 percent of households in the

baseline had sanitation platform (Sanplat) as a form of improved sanitation. Therefore,

nearly 98 percent of households in Lungwena were without access to improved

sanitation.

Plate 1: A traditional pit latrine from one of the control villages


33

Such types of latrines pose a great danger to users and more especially to children, they

are liable to collapse at any time and become even more difficult to use at night. Dust

from such latrines is a source of contamination to water and food at household level.

Improved latrines in the form of sanitation platforms are made of concrete, which

withstands many external forces and are very user friendly even to children.

From the evaluation, it shows coverage in improved latrines of 78.3% (68.4%-86.2%

C.I.) in intervention and 21.7% (13.8%-31.6% C.I) in control villages. The proportional

difference in sanitation coverage was 40.9% (30.1%-51.1% C.I), which was statistically

different (p=0.000, Chi square test of 52.5536). This difference can be attributed to the

provision of sanplats in the intervention villages.

The plate 2: An improved latrine in one of the intervention villages

The type of latrine shown in plate 2 above has many advantages when compared to the

traditional pit latrines. The concrete slabs shown above are long lasting. They can also be


34

removed and installed on another pit when they fill up. This prevents the cutting of trees

that are used in the traditional latrines. A sanplat has a small opening that does not pose

any danger to children since they are designed in such a way that even an infants head

cannot fit. It also has raised foot prints that make it easy to use in the dark and hence one

cannot contaminate the latrine if they stand on these raised foot prints. Sanplats have

smooth surfaces that are easy to clean and do not produce any dust, which can be a source

of contamination. These sanplats are made to have a hole-cover, which is supposed to be

used after every use. This prevents houseflies from accessing the pit latrine. As a result,

the flies are controlled and cannot transmit infections [14].

However, to achieve the objective of disease prevention, it is advisable that all the

households in a particular village should have the sanplats. Some households in the

intervention villages did not have the sanplats while others did not install them as they

indicated that their traditional pit latrines had not yet filled up and therefore, there was no

point in constructing another latrine. Such types of practices do not serve the purpose of

these sanplats. The whole objective of these improved latrines is to reduce the spread of

faecal-oral infection by forming a barrier so that pathogens from faecal matter do not

have access and end up being ingested i.e. through water or food. If a neighbour still uses

a traditional pit latrine, flies or dust can still spread germs to those houses with improved

latrines. Some households did not obtain these sanplats because they did not participate in

the mobilization of local resources. As a result, they were denied access to these sanplats.

One chief in the intervention villages had two sanplats where the other was being used as

a bathing slab. This abuse of power denied other households access to these slabs and

furthermore defeating the purpose of having a high coverage of improved latrines.

Some households in the control villages had improved latrines in the form of sanitation

platforms. They indicated to have bought them from some builders who sell them.

However, some had accessed them from neighboring intervention villages.

During dissemination of health education in the intervention villages, one of the

messages emphasized was on the source of drinking water. Since there are no stand pipes

as a source of safe drinking water in the study area, boreholes serve as the only source of

improved safe drinking water supply. However, the intervention took advantage of the


35

existing boreholes in the villages and only encouraged households to collect drinking

water from these sources.

From the results it can be noted that from the intervention villages 80% were using

boreholes as a source of drinking water while in the control villages only 41% were using

the boreholes. With P= 0.000, indicating a significant difference in the usage of

boreholes as a source of drinking water in the intervention villages, it can likely be

concluded that the health education messages worked in making the households use

boreholes as their source of drinking water. However, in two of the control villages,

boreholes from each village had broken down which made households to collect their

drinking water from nearby unprotected sources as seen from the plate 3 below. As

observed, water from the surface runs back into the well that further contaminates the

water source and with animals grazing around, and using the same well as a source of

drinking water, there is likely to be high faecal contamination.

Plate 3: unprotected well at Mbanda village (a control village)

When drinking water is fetched far away from a rural home it needs treatment despite

being from a safe source, because water fetched away from home is contaminated during

transportation [25]. From the evaluation it was established that 6% of households in the


36

intervention villages mentioned that they treat their water before drinking and 16% of

households from the control villages mentioned to doing so as well. However, on being

asked whether the drinking water from which we collected samples from had been

treated, all the households indicated that they did not treat it. They clarified that water

treatment is usually done during cholera outbreak threats and that they wait for chemicals

such as water guard to be provided by the Health Surveillance Assistance (HSA).

Households felt boiling was expensive because it requires firewood, which is rarely

found, while some households were contented with their water being safe if it comes

from a borehole. This is a misconception as water is usually contaminated during

transportation and in storage [25].

The usage of the two-cup system was another area that was investigated. This is a system

whereby one cup is solely used for drawing drinking water from the storage container and

the water is poured in another cup that is used for drinking. From the results it was noted

that 50.2% and 49.8% of households indicated the usage of the two-cup system in the

intervention and control villages respectively. However, when asked for water samples

after the interview, none of the households used the system signaling that they just

indicated using it because they had been asked about it. This type of behaviour is difficult

for household members to maintain and use, especially children.

There was no significant difference on the type of drinking water storage in both the

intervention and control villages. This may indicate that the types of storage containers

do not vary greatly between the two types of villages with 56% and 52% households

mentioning that they use clay pots (seen in plate 4 below) as their drinking water storage

containers in both intervention and control villages respectively. This reflects what was

found during the baseline survey, whereby 71% of the households were storing their

water in clay pots the reason being that water becomes cold and has a pleasant taste.


37

Plate 4: clay pot, the common type of drinking water storage container

4.2 Water quality

In the preliminary water samples were tested for coliform bacteria, which are among the

indicator bacteria in water. The samples that tested positive underwent a further test to

detect the presence of E. coli. The results showed a significant difference (p = 0.044) in

the presence of coliform in stored drinking water between the intervention and control

villages and this possibly indicates that the presence of boreholes in the intervention

villages played a significant role in minimizing incidences of bacterial contamination as

reported by the WHO [5]. Although boreholes offer safe water [5], results of coliform

tests show contamination of water from borehole source. Contamination may have

occurred during transportation, storage or handling as noted by Moyo [23].

The test for E. coli indicates faecal contamination and hence signals a high probability of

presence of other pathogenic microorganisms [29]. The presence of E.coli in stored water

was 37.9% (29.1%-47.4% C.I) in intervention villages and 62.1% (52.6%-70.9% C.I) in

the control villages, which was statistically different (p=0.007 Chi square test of 7.3459).


38

The possible explanation could be that most of water samples from control villages were

from unprotected water sources, which could be contaminated with faecal matter.

However, some water samples from intervention villages were tested positive for E. coli;

these were from unprotected sources while for those from boreholes, contamination may

have occurred during transportation and in storage and handling. Upon examining, it was

found out that 63% of water samples from unprotected sources were E. coli positive

while 33% of the boreholes samples were E. coli positive. This was found to be

significant (P= 0.000) showing that the differences were not due to chance, hence water

from unprotected sources was highly contaminated. These findings are in agreement with

those of Moyo [23], who detected greater contamination in the water drawn from

unprotected wells than those from protected ones. Some samples from unprotected

sources, (37%) and unprotected wells (33%) did not test positive for E. coli. It is likely

that these samples were collected from water that had been stored for some time that

caused a natural die-off of the pathogens and hence its bacteriological quality may have

improved as microorganisms fight for food and survival [28]. Water from boreholes is

considered to be safe at point of source. In the present study, 33% of the borehole water

samples were found to be positive and the result agrees with those of Taulo [39], who

found that 23% of borehole water samples had E. coli. This explains that contamination

may have happened during collection, transportation, or storage.

The type of storage containers also poses a risk of contamination, although in this

evaluation risk of contamination with type of storage container did not show any

significant difference P= 0.121. However, usage of narrow mouthed containers prevents

contamination since no contact is made with water as pouring is the only way to draw

water rather that dipping of a cup into the water hence introducing microbes, as observed

by Roberts [27]. This proves to be effective if water is well handled from a safe source.

From the results in table 10, it can be shown that a significant number of water samples

from households without improved sanitation were contaminated. This significant

relationship indicates that contamination of water in these households may be attributed

to having unimproved sanitation, this reflects what Suthar [40] explored about

deterioration of drinking water quality in rural habitations of northern Rajasthan, India,

which was attributed to poor sanitation. However, as earlier explained some of the water


39

samples were from households that collected their drinking water from unprotected

sources, therefore, it cannot be conclusive to indicate that poor sanitation was the only

factor to poor water quality, because water may have already been contaminated at the

source.

Perceptions of households in both types of villages on sources of contamination at source

and households is a strong basis for encouragement during IEC. This knowledge can be

used to enforce households to practice safekeeping of water, and all it needs is

reinforcement of health education.

4.3 Diarrhoea morbidity

Diarrhoeal diseases were the major water and sanitation health problem in both types of

villages with cholera being common during the rainy season. Diarrhoea will significantly

affect under five children and cause serious complications such as malnutrition. Data was

collected on the incidence of diarrhoea from those households that had under five

children. The results show diarrhoeal morbidity was 33.3% (18.6%-51.0% C.I) in

intervention villages and 66.7% (49.0%-81.4% C.I) in control villages with an incidence

difference of 11.5% (1%-29.9% C.I.), which was not statistically significant (p= 0.7305,

chi square test of 0.1187), that is why it can be noted that the confidence intervals of the

interventional and control villages are overlapping. There are many factors that contribute

diarrhoea infection such as health education, and nutrition, therefore, improvement of

sanitation alone cannot guarantee change in diarrhoea morbidity. However, Victoria [38]

investigated in a case-control study and they found out that improvement in the quality of

water and sanitation was related to the reduction of diarrhoeal diseases in children under

the age of five.

Although table 11 shows that 27 (75%) of the cases with diarrhoea came from households

with pit latrines, it was not a significant difference (P=0.141). However, there are several

factors that influence development of diarrhoea at household and individual level [41].

Analysis of diarrhoea in relation to E. coli tests were not significant (P=0.981). One of

the factors to be considered for the insignificance could be that the cases were identified

from the two week period previous from the collection of the samples. It was likely that

the drinking water may have been different at that time with a different bacteriological


40

quality altogether. Another reason is that occurrence of diarrhoea has many contributing

factors. The source of drinking water is crucial in the control of diarrhoeal diseases.

However in table 13 it is shown that there was no significant difference among the

difference source of drinking water in relation to diarrhoeal morbidity. Although 61% of

the cases were from households that collect their drinking water from boreholes. Water

collected from safe sources may be contaminated at different levels up to the point of use

[25]. Diarrhoea infection is determined by many factor hence it is not conclusive to

indicate that a particular source of water caused diarrhoea but rather contributed to

diarrhoea infection [41].

Clay pots are a common drinking water storage container in the area, therefore it is likely

that cases of diarrhoea were from these households. However, clay pots have been

implicated to harbours the multiplication of microorganisms as most of the times water is

just topped up without cleaning the container. Therefore, microorganisms are not washed

away.


41

CHAPTER FIVE

CONCLUSION AND RECOMMENDATIONS

5.1 Conclusion

Goal 7 of the MDGs relates to environmental sustainability that focuses on the correct

use of natural resources. One of the indicators for this goal is the proportion of the

population with access to improved sanitation. The 2008 Malawi Government MDGs

document indicates that there has been good progress towards achieving improved access

to good sanitation. However, the Government has a number of challenges, one being

inadequate services coverage. Therefore, the interventions were aimed at complementing

the Government in the provision of improved sanitation. From this evaluation, it can be

concluded that coverage of improved latrines has increased in the intervention villages

and hence contributing to MDGs. Implementation of sanplats saves wood which is used

in local pit latrines and since these sanplats can be used again once the pit is filled up, it

means that trees are not cut down for constructing pit latrines. The sanplats contribute

directly and indirectly in addressing the MDGs. Installing and using them correctly will

reduce diarrhoea incidences and therefore reduce child mortality. In this way, they are

preventing many faecal-oral and soil mediated infections. As a result, peoples health is

improved contributing to greater work output and the nations development.

The project has had several impacts in the area. Improved sanitation coverage increased

and this spread to the control villages, where sanplats were discovered to be available and

these were present due to the fact that people in the control villages realized the

importance of improved sanitation and hence they took an initiative to access them.

The presence of E. coli in water indicates faecal contamination and signals the presence

of other pathogenic microbes in water. Water from unprotected sources has high

probability of faecal contamination, while boreholes are considered to provide safe water.

The presence of E. coli indicates contamination at point of source to the point of use.

Therefore, poor household hygiene and practices are the major sources of contamination.

If people are educated in proper housekeeping and safe keeping of water, contamination


42

will be addressed. Emphasis should be made to maintain a high standard of hygiene from

collection of water, storage, and usage. It is a good sign that households perceive

different sources of contamination. Therefore, health education should be directed at

strengthening knowledge that the community already has.

People should appreciate the importance of prevention as this averts complications when

one gets sick. However, people appreciate curative approach because they can see the

impact once they get well but cannot see the impact of prevention when they are in good

health since they cannot relate their well being to prevention. By the end of the day,

prevention is better than cure.

5.2 Recommendations

In view of the above findings, the following recommendations are put forward:

Based on availability of funds, these sanplats should be extended to other villages

and village headmen should ensure that households have access to them.

Boreholes should be maintained so that access to safe water is restored in those

villages where boreholes had broken down.

Appropriate IEC materials should be developed and promoted for water hygiene

at three levels (at source, during transportation, and storage in the home) and

disseminated in the villages through drama.


43

REFERENCES

1. Chabalala P, Mamo H. Prevalence of water-bourne diseases within the health facilities

in Nakuru District, Kenya. Kenya: University of Nairobi; 2001.

2. Ford T. Microbiological safety of drinking water: United States and global

perspectives. 1999.

3. WHO/UNICEF. Meeting the MDG drinking-water and sanitation: A mid-term

assessment of progress [Internet]. Geneva, Switzerland: World Health Organisation;

2004. Available from: www.who/water_sanitation_health/monitoring/jmp2004/en/

4. UN. The Millennium Development Report Goals. New York: United Nations; 2005.

5. WHO. Water, Sanitation and Hygiene Links to Health. Geneva, Switzerland: World

Health Organisation; 2004.

6. Ministry of Water and Development. The Malawi National Sanitation Policy: Leading

to better life for Malawians. 2006.

7. NSO. Integrated Household Survey 2004 2005. Zomba, Malawi: National Statistical

Office; 2005.

8. Lungwena Cencus. Lungwena NUFU 2004 census report 2005. College of Medicine

University of Malawi.

9. Taulo S, et al. Microbiological quality of water, associated management practices and

risks at source, transport and storage points in a rural community of Lungwena,

Malawi. African Journal of Microbiological Research. 2008.


44

10. Chilowa W. Malawi social Indicators Survey a survey of the state of health,

nutrition, water, sanitation and education of the children in Malawi. Zomba, Malawi:

Center for Research; 1996.

11. WHO. WHO recommended strategies for prevention and control of communicable

diseases. Geneva, Switzerland: World Health Organisation; 2001.

12. WHO. WHO report on infectious diseases- Removing obstacles to healthy

development. Geneva, Switzerland: World Health Organisation; 1999.

13. Curtis V, Cairncross S, Yonli. Domestic hygiene and diarrhoea- pinpointing the

problem. Tropical Medicine & International Health. 2000 ;522-32.

14. Wood C, de Glanville H, Vaughan J. Community Health. 2nd ed. Nairobi, Kenya:

African Medical and Research Foundation (AMREF); 1997.

15. Murray C, Lopez A. The Global Burden of Disease: A Comprehensive Assessment of

Mortality and Disability from Diseases

mwendera chikondi dissertation.doc2 131109

Documents