A small community in Malawi built a water system for their villages and introduced hygiene and sanitation education activities with support from The Rotary Foundation and Rotary clubs. Then Elaine Lo, a U. of North Carolina graduate student in public health was asked to assist and visit the beneficiary households to assess if the Rotary program was a success.

Read more . about the tippy-taps, two-cup system, and other simple things that became a success with the locals in the fight against diarrhea.

Report submitted by Elaine Lo, University of North Carolina graduate student

As I was sitting in a bus crammed with passengers, luggage, chickens and crying babies, I peeked outside the window to see one of the passengers' children squatting and defecating next to the bus. The bus started to move, as if to warn them that it was leaving, and the mother immediately pulled up the child's pants, picked him up and ran into the bus. The feces remained outside and the flies started to pile around. I couldn't help but wonder, where were these flies going to be that day?

These flies are one of the many reasons why some people still have diarrhea in developing countries like Malawi, where diarrhea is one of the leading causes of death for under-five children. The Malawi government and NGOs like Rotary have tried for many years to promote hand-washing at critical points and the use of latrines and safe drinking water, yet the problem persists.

In 2006, with the support of Rotary clubs and The Rotary Foundation, the Church of the Central African Presbyterian Synod (CCAP) of Livingstonia initiated a program to provide as its mission access to safe water to ten surrounding villages through the construction of a gravity-fed water system. The program was supported by Rotary clubs from Mzuzu (Malawi) and the Olympia (Washington State, USA) and Dallas (Texas, USA) areas, three Rotary Districts and 55 Rotary clubs, as well as Wasrag (Water and Sanitation Rotary Action Group) leadership and the Rotary Foundation. Jenny and Henry Kirk, who have been working in Livingstonia since 1998, were key leaders on the ground as the work developed.

As the 35 miles of water pipe construction continued to serve all ten villages, the local community members developed a tariff arrangement in order to create a sustainable system that would continually increase communities' access to water and maintain any broken pipes or taps. However, the Rotary members working in Malawi and local villagers realized that there was also a need for hygiene and sanitation education because of the communities' lack of knowledge about water management and the prevention of diarrhea. In the last of ten phases of the project, the Rotary clubs and The Rotary Foundation funded CCAP's hygiene and sanitation education grant to teach the program beneficiaries about the importance of practicing good hygiene and sanitation behaviours. Leaders on the project included Marilouise Peterson and Sylvia Gentili, two non-Rotarian educators who travelled to Malawi many times, designed the curriculum and mentored Malawians to deliver it. 

In order to understand the local communities' hygiene and sanitation issues and needs, the Water and Sanitation Department of David Gordon Memorial Hospital in Livingstonia and the U. of Livingstonia's Rotaract Club conducted household surveys. About 25 young Rotaract members surveyed 1,250 households over two Saturdays.

Their findings revealed that about 35% of households reported a member having diarrhea, a problem commonly caused by lack of hand-washing, improper use of latrines, and consumption of contaminated water. Since only 70% of the villages had latrines and 11% had hand-washing facilities, the grant's education activities focused on the proper use of latrines and hand-washing at critical points. The Rotary clubs team wanted someone to evaluate the program midway to see if the grant activities were being implemented as intended and if the initial results were successful.

This is where I came in!

As a graduate student in public health at the UNC-Chapel Hill Gillings School of Global Public Health, which has a growing partnership with Wasrag, I was afforded the opportunity to complete my internship in Malawi. Members of the Rotary team approached Wasrag for assistance with evaluating their program, and a Rotarian at UNC looked for an intern with the right skills and experience. Because of my previous experience as a Peace Corps volunteer at a rural health center in Malawi and my area of focus and education at UNC, the Rotarians felt that I could assist them with technical skills. This amazing experience also gave me the opportunity to further develop my experience in monitoring and evaluating an on-the-ground public health program in rural Africa.

In Livingstonia, four water and sanitation officers and a nurse were identified to facilitate the hygiene and sanitation activities. Their most important activity - training of local leaders and villagers - was already underway. As an external evaluator I observed several training sessions, created pre-test/post-tests to assess the participants' knowledge gain from the training, and conducted interviews and household follow-ups. The tests revealed that the participants had increased their knowledge about the prevention of diarrhea, modes of transmission of diarrhea, critical points of hand-washing, and safe water management. The evaluations and interviews revealed that the demonstrations and group discussions helped participants learn more effectively about important practices for diarrhea prevention.

To find out if participants had applied the knowledge within their households, I conducted follow-ups at their households with the facilitators. After retesting their knowledge from the training, we observed their households' sanitation and looked for specific indicators that they were practicing hand-washing and protecting stored drinking water from contamination - particularly the tippy-tap and two cup system.

The tippy-tap is a simple yet efficient hand-washing facility that uses locally available resources - two wooden poles, two plastic bottles, and wires. Rather than bringing a bucket of water to the latrine or entering the house to retrieve water, this stationary facility allows users to simply pour water into a bottle poked with holes so they can wash their hands underneath running water. This new technology was so popular amongst the participants that 71% of the households we visited had adopted it. And, 90% also reported washing their hands after using the latrine, some of whom admitted that they had not done so in the past.

Another new practice - the two cup system - is a simple method to prevent contamination of drinking water. The participants did not realize that the simple addition of a cup used for pouring water into another cup for drinking could help prevent people's saliva from contaminating their bucket of water. This was another success, as 75% of the households we surveyed had started practicing this system.

A new tool that interested many participants was composting latrines. This new type of eco-sanitation latrine was being introduced through a non-profit, Water for People, to promote the use of human manure as fertilizer. In an agricultural national like Malawi, many villagers were interested in the additional benefit of using a latrine. Some of the participants had already begun constructing composting latrines.

Even though the communities at Livingstonia were starting to show some changes within their households, behaviour change can take a long time. I have recommended a few simple additions to accelerate and sustain change. In addition to the training, vulnerable groups may need resources to enable them to adopt the new behaviours. For example, people living with HIV/AIDS and the elderly may need financial or physical assistance to build a composting latrine. Follow-ups can keep participants accountable for their behaviour and reinforce behaviour change. Community-wide competitions that reward those who displayed exemplary behaviours as role models would help reinforce behaviour change because of the positive feedback and health benefits the awardees receive. This would also encourage others to model their behaviours.

My internship was the start of a successful partnership between Wasrag and UNC-Chapel Hill. While I was able to apply the theories and skills I learned from the program, I was also able to share my knowledge and tools with my Malawian partners, both at Livingstonia and in other regions.

My hope is that, long after I am back in the US, they will still be able to use the tools to improve the quality of their public health work, thereby improving the quality of life for Malawians.

Before I left Livingstonia, the trainees and facilitators kept thanking me and Rotary profusely for the work that was being done in their communities. At every training session the participants expressed their gratitude through words, songs and dance. The facilitators were enthusiastic about being able to use the tools to help evaluate their work. One of the facilitators told me that my work gave him a better perspective of why the work he was doing was so important; of how Rotary and his job came in full circle to do one very important thing - and that was to "save people's lives."