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

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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].

I ndicator 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

Intervention
villages
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<0.05). However, 125 (80%) of households in the intervention villages access their
drinking water at boreholes while only 65 (41%) of those in control villages utilize
boreholes. In the control villages 56 (35%) have access to unprotected well/spring for
drinking water.
Table 4: Source of drinking water
Source of drinking water

or control villages
Total

Intervention
villages
Control
villages
River/stream

6(3.8%) 0(.0%) 6(1.9%)

Unprotected well/spring

25(16.0%) 56(35.7%) 81(25.9%)

Protected well/spring

0(.0%) 36(22.9%) 36(11.5%)

Boreholes

125(80.1%) 65(41.4%) 190(60.7%)

Total

156(100.0%) 157(100.0%) 313(100.0%)
Chi-square (
2

20
If water is treated before drinking
no yes
F
r
e
q
u
e
n
c
y
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
or control villages
Total

Intervention
villages
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%)
Chi-square (
2

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

or control villages
Total

Intervention
villages
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%)
Chi-square (
2

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
Whether intervention
villages or control villages
Total

Intervention
villages
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%)
Chi-square (
2

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
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
Figure 4: Presence of E. coli in stored drinking
water
Intervention
villages, 44,
(38%)
Control
villages, 72,
(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
Chi-square (
2
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%)
Chi-square (
2

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
R
e
s
p
o
n
d
e
n
t
s
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 water
use of unclean conta
animals
H
o
u
s
e
h
o
l
d
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
F
r
e
q
u
e
n
c
y
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
Intervention
villages, 12,
(33%)
Control
villages, 24,
(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

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
Who suffered
from diarrhoea

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

Total
River/stream
Unprotected
well/spring
Protected
well/spring Boreholes
Who
suffered
from
diarrhoea

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
Who
suffered
from
diarrhoea

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
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Malawi. African Journal of Microbiological Research. 2008.

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10. Chilowa W. Malawi social Indicators Survey a survey of the state of health,
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Center for Research; 1996.

11. WHO. WHO recommended strategies for prevention and control of communicable
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12. WHO. WHO report on infectious diseases- Removing obstacles to healthy
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14. Wood C, de Glanville H, Vaughan J. Community Health. 2nd ed. Nairobi, Kenya:
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15. Murray C, Lopez A. The Global Burden of Disease: A Comprehensive Assessment of
Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and
Projected to 2020. 1996.

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;68(4):455-463.

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Infectious Diseases. 2005 ;5(1):42-52.

18. Esrey S, et al. Effects of improved water supply and
sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection,
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schistosomiasis, and trachoma. Bulletin of World Health Organization. 1991
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19. Feachem R, Koblinsky M. Interventions for the control of diarrhoeal diseases
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20. Boot M, Cairncross S. Action speak: The study of hygiene behaviour in water and
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21. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing
diarrhoea. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.:
CD004265. DOI: 10.1002/14651858.CD004265.pub2

22. Ologe J. Household water in rural Kwara. 1989.

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24. Chindavaenzi M, et al. An evaluation of water urns to maintain domestic water
quality. 24th WEDC Conference, Islamabad, Pakistan: Loughborough; 1998.

25. Lindskog R, Lindskog P. Bacteriological contamination of water in rural areas: an
intervention study from Malawi. J Trop Med Hyg. 1988 Feb;91(1):1-7.

26. Wright J, Gundry S, Conroy R. Household drinking water in developing countries: a
systematic review of microbiological contamination between source and
point-of-use. Tropical Medicine & International Health: TM & IH. 2004 ;9(1):106-
117.
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27. Roberts L, et al. Keeping clean water clean in a Malawi refuge camp: A randomized
intervention trial. Bulletin of World Health Organization. 2001 ;79(4):280-287.

28. Momba M, Notshe T. The microbiology quality of ground water derived drinking
watre after long storage in household containers in a rural community of South
Africa. Journal of Water Supply Research and Technology. 2003 ;5267-77.

29. WHO. Guidelines for drinking-water quality. Geneva, Switzerland: World Health
Organisation; 2004. ISBN 9241546387.

30. Gleeson C, Gray N. The Coliform Index and Waterborne Disease: Problems of
microbial drinking water assessment. E & FN SPON. 1997 ;38-59.

31.WHO-OECD. Assessing Microbial Safety of Drinking Water, Improving approaches
and Methods. London; 2003: ISBN 1 84339 036 1 (IWA Publishing).

32. Payment P, Waite M, Dafour A. Assessing Microbial Safety of Drinking Water.
London: 2003.

33. World Health Organisation. Guidelines for drinking-water Quality. Geneva,
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34. DHO. Health Management and Systems Information Management. Mangochi; 2004.

35. Rosner B. Fundamentals of Biostatistics. New York: Duxbury press; 1994. ISBN
9780534418205.

36. Campbell M, Machin D. Medical Statistics: A Commonsense Approach. Third
edition. England: John Wiley and Sons; 1999. ISBN 0471987212.

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37. Collins C, Lyne P. Microbiological Methods: Laboratory Techniques Series . Fourth
Edition. England: Butterworth & Co; 1976.

38. Victoria C, et al. Water Supply, Sanitation and Housing in Relation to the Risk of
Infant Mortality from Diarrhoea. International Journal of Epidemiology. 1988
;17(3):651-654.

39. Taulo S. Microbiological risk assessment of households' food and water in a rural
community: a case study in Lungwena, Malawi. Norwegian University of Life
Science; 2008.

40. Suthar S, Chhimpa V, Singh S. Bacterial contamination in drinking water: a case
study in rural areas of northern Rajasthan, India. Journal of Environmental
Monitoring and Assessment; 2008.
41. WHO. Water quality interventions to prevent diarrhoea: cost & cost-effectiveness.
Geneva Switzerland: World Health Organisation; 2008.
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2005 June; 39(2): 4445.

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Lilongwe, Malawi: Ministry of Economic Planning and Development; 2008.
Available from: www.undp.org.mw

48
APPENDICES
Appendix 1: Introduction and consent

Informed consent

Hello. My name is and I am working with NUFU project.
We are conducting a survey to evaluate some of the interventions implemented by NUFU
in this area. We would very much appreciate your participation in this survey. I would
like to ask you about issues related to water and sanitation of this household, we would
also like to collect a drinking water sample from your storage container for examination.
This information will help us plan better in the extension of our project. Participation in
this survey is voluntary and you can choose not to answer any question or all of the
questions. However, we hope that you will participate in this survey since your views are
important. The interview will take less than 30 minutes. If you have any questions, please
feel free to ask.

Name of the participant ____________________________________________________

Signature of participant_____________________________________________________

Date____________________________________________________________________

49

Appendix 2: Introduction and consent (Yao version)

Informed consent

Elo, lina langu nukamula masengo ni NUFU
Project. Tikutenda ya kusakasaka ya kukwaya yikutendedwa ni NUFU mumala agano.
Tikuwa wakupunda kutogolera nope pakudyingala nawo itendo yakusakasakayi. Ngusosa
nalalile wawodyo yakukuya nimesi nikasamalidwe kamesi gakumnyumba, tikusosasoni
kudyigara mesi gawo gasasunga mululo kuti akalije.Chimanyiso chelechi
chichitikamuchisye pakukusya ndondomeko dyetu. Pakudyigala mbli yakusakasaka
tikusakagamba mboleche. Akwete ukwetu wakukwangu uso kapena angadyanga
pamausogo. Tikwete chikhulupi kuti pakudyingala nawo mbali dyakusakasakayi
pamalamusike ngenu ngali yakusoseka.

Mauso yethuwa tikachidyingala mwangapunda ndema yakukwana 30 minutes.
Kangakwete mauso chonde awe wangopoka kuusya.

Lina la mutu wakudyingala nawo mbali ............

Usayinila wakudyingala nawo mbali .

Date .

50
Appendix 3: Household questionnaire

Section A: Personal information

1. Date of interview:

2. Name of Interviewer:

3. Village location:

4. NUFU T/A number:

5. Sex of interviewee:

6. Age of interviewee:
15-25 1
26-35 2
36-45 3
36-55 4
56-65 5
>65 6

7. Marital status:

Dryland 1
Wetland 2
Chowe 1
Makanjira 2
Male 1
Female 2
Married 1
Single 2
Widowed 3
Separated 4
Divorced 5
51
Section B: Water supply questions

8. Common source of water

Frequent source of
drinking water

9. What type of container is used to transport water to your household?

10. Is the transporting container covered during transportation?

11. What type of container is used for storage of drinking water in your household?
(Observe)

Frequent source of
domestic water

Source of water Code
River/stream 1
Lake 2
Unprotected wells/springs 3
Protected wells/springs 4
Boreholes 5
Piped water supply 6
Others (specify) 7
Container Code
Tin bucket 1
Plastic bucket 2
Jerry can 3
Clay pot 4
Drum 5
Other (specify) 6
Yes 1
No 2
Container Code
Tin bucket 1
Plastic bucket 2
Jerry can 3
Clay pot 4
Drum 5
Other (specify) 6
52

12. What is the other use of the water storage container?

Use
Code
Bathing 1
Cleaning utensils 2
Washing clothes 3
None 4
Fetching water 5
Other (specify) 6

13. Do you use the 2 cup system in your household for drinking water? (If no, go to 15)

14. If yes, why do you use this system?

Reason Code
To avoid dust 1
To avoid contamination 2
Do not know 3
Other (Specify) 4
Not Applicable 5

15. Do you treat your water before drinking? (If no, go to 18)

16. If yes, why do you treat it?

Reason Code
To kill germs 1
For good taste 2
Do not know 3
Other (Specify) 4
Not Applicable 5

Yes 1
No 2
Yes 1
No 2
53
17. If yes, how do you treat it?
Method Code
Boiling 1
Filtering 2
Disinfecting using chemicals 3
Other (specify) 4
Not applicable 5

18. What do you think is the main source of contamination at the water source?
Source Code
Animals 1
Use of unclean drawing containers 2
Storm water 3
Dust 4
Children 5
Other (specify) 6

19. What do you think could be the main source of drinking water contamination in
your household?
Source Code
Unhygienic handling practices 1
Unclean storage containers 2
Unhygienic household conditions 3
Other (specify) 4

Section C: Sanitation

20. Does the household have a toilet that is used? (Observe). (If no, go to 23)

21. If yes, what type of toilet?
Type Code
Pit latrine 1
Improved pit latrine with sanplat/dome 2
VIP 3
Flush toilet 4
Other (specify) 5
Not applicable 6

Yes 1
No 2
54
22. Who uses the toilet?
User Code
Husband and wife only 1
Children only 2
All household members 3
Other (specify) 4
Not applicable 5

23. Do you wash your hands after using the toilet? (Observe the presence of hand
washing facility) (If no go to 25)

24. If yes, what do you use to wash your hands with?

25. Do you have a bath shelter? (Observe) (If no, ask on domestic water only)

26. If yes, how is the wastewater disposed of? (Observe)
Method Code Bath water Domestic water
Runs freely 1
Watering vegetables 2
Discharged to soak ways 3
Other (specify 4
Not applicable 5

27. How do you of your garbage? (Observe)
Method Code
Indiscriminate disposal 1
Bush 2
Refuse pit 3
Burning 4
Manure 5
Other (specify) 6

Yes 1
No 2
Material used
Code
Soap 1
Ash 2
With nothing 3
Other (specify) 4
Not applicable 5
Yes 1
No 2
55

28. What are the major water and sanitation-related problems in your area?
Problem Code
Malaria 1
Cholera 2
Diarrhoeal diseases 4
Scabies 5
Bilharzias 6
Other (specify) 7

29. How many underfive children do you have in this household?

30. How many suffered from diarrhoea among the underfives in the past two weeks?

Section D: Information, education, and communication

31. Have you ever received health education messages/lessons related to water and
sanitation? (If no, do not ask the remaining questions)

32. If yes, from what source?
Source Code
H.S.A 1
VHC 2
CDA 3
Printed media 4
Electronic media 5
NGOs 6
Religious leaders 7
Other (specify) 8
Not applicable 9

33. If yes, what type of message?

Yes 1
No 2
56

34. If yes, how often?
Period Code
Daily 1
Weekly 2
Fortnightly 3
Monthly 4
More than a month (specify) 5
Not applicable 6

57
Appendix 4: Household questionnaire (Yao Version)

Section A: Personal information

1. Date of interview:

2. Name of Interviewer:

3. Village location:

4. NUFU T/A number:

5. Sex of interviewee:

6. Age of interviewee:
15-25 1
26-35 2
36-45 3
36-55 4
56-65 5
>65 6

7. Marital status:

Dryland 1
Wetland 2
Chowe 1
Makanjira 2
Male 1
Female 2
Married 1
Single 2
Widowed 3
Separated 4
Divorced 5
58

Section B: Water supply questions

8. Common source of water

Frequent source of
drinking water

9. Mesi akusatechera mwapi pakwala kunyumba?

10. Chakusatechela mesicho chikusawaga cheunichile ndawi syosope?

11. Anaga akusasunjila mwapi mesi gakumwa?

Frequent source of
domestic water

Source of water Code
River/stream 1
Lake 2
Unprotected wells/springs 3
Protected wells/springs 4
Boreholes 5
Piped water supply 6
Others (specify) 7
Container Code
Tin bucket 1
Plastic bucket 2
Jerry can 3
Clay pot 4
Drum 5
Other (specify) 6
Yes 1
No 2
Container Code
Tin bucket 1
Plastic bucket 2
Jerry can 3
Clay pot 4
Drum 5
Other (specify) 6
59

12. Masengo gane gapi chele chakusasunjila mesicho chikusakamuchisidwa?

Use
Code
Bathing 1
Cleaning utensils 2
Washing clothes 3
None 4
Fetching water 5
Other (specify) 6

13. Ana akusakamuchisya ikapo iwiri pakumwa mesi mnyumba mwawo awo (observe)

14. Naga elo, ligongo chichi akusakamuchisya ikapo iwiri?

Reason Code
To avoid dust 1
To avoid contamination 2
Do not know 3
Other (Specify) 4
Not Applicable 5

15. Akusalinganyaga mesi ali mkanamwe?

16. Naga elo, ligongo chichi akusalinganyaga mesi

Reason Code
To kill germs 1
For good taste 2
Do not know 3
Other (Specify) 4
Not Applicable 5

Yes 1
No 2
Yes 1
No 2
60

17. Nga elo, akusalinganyaga china uli?

Method Code
Boiling 1
Filtering 2
Disinfecting using chemicals 3
Other (specify) 4
Not applicable 5

18. Akuganisya kuti chichikusantendesya ni chichi kuti mesi gawe gachabe
Pakutechelapo ?

Source Code
Animals 1
Use of unclean drawing containers 2
Storm water 3
Dust 4
Children 5
Other (specify) 6

19. Akuganisya kuti chichikusantendesya kuti mesi gakumwa gawe gachabe
mnyumba ni chichi?
Source Code
Unhygienic handling practices 1
Unclean storage containers 2
Unhygienic household conditions 3
Other (specify) 4

Section C: Sanitation
20. Panyumba pano pana chimbusi chakuchika,ulisya masengo (Observe). (If no, go 23)

21. Nga elo, chamtunduchi?

Type Code
Pit latrine 1
Improved pit latrine with sanplat/dome 2
VIP 3
Flush toilet 4
Other (specify) 5
Not applicable 6
Yes 1
No 2
61

22. Wakusaka,ulichisya masengo chimbusicho wani?

User Code
Husband and wife only 1
Children only 2
All household members 3
Other (specify) 4
Not applicable 5

23. Akusanawa mmyala naujepo kuchimbusi? (Observe the presence of hand
washing facility) (If no go to 25)

24. Nga elo, akusanawaga nichichi?

25. Akwete chowela? (Observe) (If no, ask on domestic water only)

26. Nga elo, mesi gamajojego gakusajala kwapi? (Observe)
Method Code Bath water Domestic water
Runs freely 1
Watering vegetables 2
Discharged to soak ways 3
Other (specify 4
Not applicable 5

27. Ana iswani akusajasa kwapi? (Observe)

Method Code
Indiscriminate disposal 1
Bush 2
Refuse pit 3
Burning 4
Yes 1
No 2
Material used
Code
Soap 1
Ash 2
With nothing 3
Other (specify) 4
Not applicable 5
Yes 1
No 2
62
Manure 5
Other (specify) 6

28. Ana mavuto gekulungwa gakayana ni ulwele wakwisa ligongo iya mesi ni chasa
mdera ajino nigapi?

Problem Code
Malaria 1
Cholera 2
Diarrhoeal diseases 4
Scabies 5
Bilharzias 6
Other (specify) 7

29. Akwete wanache wangapunda yaka nsano panyumba pano

30. Pana jwaugwire mmatumbo pawanache welewa mawiki gawiri gapitega?

Section D: Information, education, and communication

31. Pakwete paoochela ulanngisi wakwayana ni mesi soni chasa? (If no, do not ask the
remaining questions)

32. Naga elo, wele ulangisiwu ukusaikaga ni wani?

Source Code
H.S.A 1
VHC 2
CDA 3
Printed media 4
Electronic media 5
NGOs 6
Religious leaders 7
Other (specify) 8
Not applicable 9

33. Nga elo, ulangisi wachi?

Yes 1
No 2
63

34. Nga elo, akusaupochelaga lalingwa kutyochela kwa wele wanduwa?

Period Code
Daily 1
Weekly 2
Fortnightly 3
Monthly 4
More than a month (specify) 5
Not applicable 6

64

Appendix 5: Map of Lungwena

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