Bethany Steen, MPH, School of Public Health, University of Alberta Raymond E Cantwell, PhD, PEng, Samaritan s Purse Canada April 10, 2011

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1 Bethany Steen, MPH, School of Public Health, University of Alberta Raymond E Cantwell, PhD, PEng, Samaritan s Purse Canada April 10, 2011

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3 Community Assessment Community Promotion Community Education Household Monitoring Filter Installation Filter Construction Dyck, K., R.E. Cantwell, A. Vreeken, Samaritan s Purse Strategic Implementation of the BioSand Filter. Proceedings of the IWA/AWWA Disinfection 2009 Specialty Conference, Atlanta, Georgia, February pp.

4 An Indonesian non-profit NGO established in 2008 Partner of Samaritan s Purse Canada Work based in the District of Serdang Bedagai, North Sumatra

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7 Are the follow-up visits at the household beneficial in improving (i) household practices around water and (ii) stored water quality?

8 HWP & Follow-up Intervention group Have had a BSF for 4 months and randomized to receive follow-up HWP & No Follow-up Have had BSF for 4 months and randomized to not receive follow-up until study is completed No HWP Do not have a BSF and receive no water or hygiene education

9 BEFORE - Water Testing and Survey HWP & No Follow-up 9 households HWP & Follow-up 18households No HWP 9 households 4 month follow-up Household follow-up for intervention households 30 days AFTER - Water Testing and Survey HWP & No Follow-up 9 households HWP & Follow-up 18 households No HWP 9 households

10 Inclusion Criteria Have had a BSF for 4 months and are using it Javanese ethnicity Child under 5 years of age in the household Randomization Random number generation to assign households to the intervention or non-intervention households Selection of Control Village Need to be as similar to intervention village as possible except for the HWP

11 Created using questions from: previous survey tools used by Samaritan s Purse the Demographic and Health Household Survey (Statistics Indonesia, 2008) Written in English, translated into Bahasa Indonesia and back translated to ensure the intent of the questions was retained Pilot run for survey and staff

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14 Panaskan terlebih dahulu inkubator dan Quanti-Tray Sealer Keluarkan samples dan Colilert reagen dari kulkas Tambahkan Colilert ke dalam setiap sample (kecuali blanks berwarna) Tutup rapat tabung dan putar untuk melarutkan reagen Berilah label pada Quanti-Trays dengan nomor-nomor sample Tuangkan samples ke dalam Quanti- Trays, keluarkan gelembunggelembung udara dan segel Berilah label pada bagian atas Tray dengan tanggal dan waktu Inkubasikan Trays selama 24 jam +/- 30 menit

15 Keluarkan trays dari inkubator Periksalah Trays untuk warna kuning yang signifikan. Catat jumlah positif wells dibawah bagian TC. Periksalah Trays untuk pemendaran yang signifikan menggunakan Illuminator. Catat jumlah positif wells dibawah bagian E. coli Tentukan Most Probable Number (MPN) untuk TC dan E. coli lalu catat.

16 YAS was indispensible in implementing study Survey translation & contextualization Survey data collection and quality control Sample collection and microbial analysis Data entry & quality control

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24 Main source of water was a borehole or well in the yard Typical household water usage of 30L /day 61% of respondents 5 th grade or less; 89% of respondents had 9 th grade or less The bread-winner in the household most likely worked as a farmer or laborer Median household daily income $3 USD 64% of households had livestock in yard

25 Test Group Median (IQR) CFU / 100 ml HWP & Follow-up HWP & No Follow-up No HWP Note: 2420 was the analytical limit E. coli Coliform Bacteria 192 2,420 (25 2,420) (269-2,420) 123 (5 979) 11 (0 497) 413 (35-2,420) 265 (2 1,653)

26 Source Median % Removal (IQR) This study 97% (83% to 99.2%) Median Log Removal (IQR) 1.63 (0.78 to 2.11 ) Duke et al. 2006; Earwaker 2006; Stauber et al. 2006; Liang % to 98.5% 0.95 to 1.83

27 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% High Risk 101 1,000 CFU/100m Medium Risk CFU/100mL Low Risk 0 10 CFU/100mL No Risk

28 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% High Risk 101 1,000 CFU/100m Medium Risk CFU/100mL Low Risk 0 10 CFU/100mL No Risk

29 Two-bucket System Soap in the home Covering storage container Hand washing knowledge

30 Households that used one bucket for both source water collection and filtered water storage. Group Before After HWP & Follow-up 5/18 (27%) 2/18 (11%) HWP & No Follow-up 1/9 (11%) 1/9 (11%) Total 6/27 (22%) 3/27 (11%)

31 Group HWP & Follow-up HWP & No Follow-up Household # Indicator Bacteria Colony count (cfu/100 ml) Before 4- month Follow-up After 4- month Follow-up Did hh switch from a 1- to a 2-bucket system? Was there a decrease in stored water colony count? Yes E. coli 0 0 Coliform bacteria Yes Yes E. Coli 11 0 Yes Yes Coliform bacteria >2, Yes E. Coli Yes Coliform bacteria 1, Yes Yes E. Coli No No Coliform bacteria 866 >2,420 No E. Coli 1 1 No Coliform bacteria No No E. Coli 8 >2,420 No No Coliform bacteria >2,420 >2,420 No

32 Group Before After HWP & Follow-up 14/18 (78%) 16/18 (89%) HWP & No Follow-up 9/9 (100%) 9/9 (100%) No HWP 7/9 (78%) 9/9 (100 %)

33 Group Before After HWP & Follow-up 10/18 (56%) 12/18 (67%) HWP & No Follow-up 7/9 (78%) 5/9 (56%)

34 The median response was to list 2 (of 4) critical times to wash hands (all 3 groups). Only 3 of 36 hhs in the study mentioned hand washing after defecation due to social taboo. No discernable impact of HWP or follow-up on hand washing knowledge.

35 Seeing E. coli and coliform bacteria enumeration first hand reinforced: Value of filtration Importance of practices to avoid recontamination Participating in study increased Confidence in the value of their work Understanding of software/m&e in wider program Organizational capacity for assessment, monitoring and internal quality control

36 Filter usage and health messaging (e.g. hand washing, covering stored water) was not retained based only on initial program Household follow-up visits were associated with some increase in 2-bucket usage and soap in home Close participation in the evaluation resulted in capacity building of the local health promotion staff & program reforms

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