Impact on Diarrhoeal Illness of a Community Educational Intervention to Improve Drinking Water Quality in Rural Communities in Puerto Rico

This two-part study, published in BioMed Central Public Health, was done to assess the impact of an educational intervention designed to improve water quality and estimate the contribution of water to the incidence of diarrhoeal disease in economically poor rural communities in Puerto Rico.

As described in the Methods section: "An educational intervention was delivered to communities relying on community water supplies. This intervention consisted of student operators and administrators supervising and assisting community members who voluntarily 'operate' these systems. These voluntary operators had no previous training and were principally concerned with seeing that some water was delivered. The quality of that water was not something they either understood or addressed. The impact of this intervention was measured through water sampling for standard bacteriological indicators and a frank pathogen. In addition, face-to-face epidemiological studies designed to determine the base-line occurrence of diarrhoeal disease in the communities were conducted. Some 15 months after the intervention a further epidemiological study was conducted in both the intervention communities and in control communities that had not received any intervention."

The communities in this intervention study were part of a community-based organisation (CBO) called Cooperativa de Acueductos de Patillas (CAP), in which water supplies are either state-managed or community-managed and include 9 small potable water systems serving approximately 6,000 persons. "The intervention consisted of meetings with the system management committee (the CAP board) after which two trainee operators and two trainee administrators were identified in each system and enrolled in CECIA [Center for Environmental Education, Conservation and Research of Inter American University of Puerto Rico] professional certification programs. The CECIA programs were designed to provide education and training to persons who were or wanted to be responsible as operators or administrators of small potable water systems. The courses gave a basic understanding of the physics, chemistry and engineering underlying maintenance and safe operation of potable water systems....An essential part of the course was work experience within the trainees' home systems assisting the regular volunteers [in] maintaining the system and administering it. For the operations course this included work towards making disinfection more reliable, cleaning and repairing tanks and water lines, supervising or providing operational assistance, measuring residual chlorine concentrations and suggesting changes in feed rate to system operators. Trainees were supervised on-site by project personnel... in their interactions with the existing volunteers so that their new learning would be shared with existing personnel."

Changes measured in the study included:

• There was a significant decrease in the occurrence of Salmonella before and after the intervention.
  
• In studies of the incidence of diarrhoea and/or vomiting, in the communities where the intervention was used, there was, generally, a marked reduction in relative risk of illness compared to non-intervention communities.
  

The discussion offers a comparison of this intervention with those focussing on individual household or point-of-use treatment devices. It suggests that because this kind of intervention required the identification and training of relatively few individuals within the community, continuing education costs are projected to be much smaller. Also, this training model may achieve better sustainability in areas concerning completeness of community coverage and long-term continued use of water treatment strategies. In the intervention programme, system administrators were asked to nominate members of their community for the programme, and 17 operator and 14 administrator students were enrolled. Of the 17 students in the operator training programme, 14 graduated, and all of these took the operator certification examination - the first time operators from community systems did this in Puerto Rico. Of these, 7 passed the examination at the highest level - these included the first woman operator certified in Puerto Rico.

The study concluded that: "Educational interventions directed both at identified individuals and the community in general in small communities with poor water quality is a way of giving communities the skills and knowledge to manage their own drinking water quality. This may also have important and sustainable health benefits, though further research preferably using a randomised control trial design is needed."