I Need Help Getting Started Course Project Part 1
This week, you will be expected to identify a topic and create a framework for your Course Project. By now, you have consumed a vast amount of information and it may be difficult to delineate a specific topic area. In order to pick a topic, consider developing a research question. You have selected a geographic location to study. You have also considered the health statistics, demographics, and policies that may impact the area. Now, you are expected to delineate a topic area.
For example, you might ask, what types of services are provided for diabetic patients in Oklahoma? What are the policies related to diabetes (PLWD) care in Oklahoma? What are some of the social determinants of health that may impact the risk of diabetes or diabetes management? What are preventive methods? What have leaders in Oklahoma done to assure prevention and management of diabetes?
You might also ask, how will the implementation of the Affordable Care Act impact pregnant women in my state. Narrowing down your topic area to a specific policy and target population will enable you to focus your research and in writing your assignment. It is critical that you understand the purpose and intent of the policy as well as study your target population and the policies of the state or community you chose. It will also be important for you to understand what advocacy and community organizations are doing in your state in support or against the implementation of the policy.
Read the following case study from your textbook:
Case 7: Challenges with Implementing a Community-Based Potable Water System Project in a Rural Honduran Community
Then, accomplish the following tasks to complete this assignment:
Choose a health topic or issue that significantly or adversely impacts the target population in the geographic region or location you have chosen. Describe why the health topic or issue is important to consider.
Research health policies, programs, resources, and all other related materials, such as news articles, press releases, etc., that may provide relevant information on the topic.
Summarize your findings and create an outline for your Course Project in the following format:
On the first page, provide background information on your selected target population and region.
Then, provide demographic information as well as major health issues in your chosen area.
On the following pages, highlight the topic areas of your paper in an outline format.
On a separate page, cite all sources using the APA format. CASE 7
Challenges with Implementing a Community-Based Potable Water System Project in a Rural Honduran Community
ELIZABETH L. ANDRADE AND KATHRYN L. ZOERHOFF
A MORNING WITHOUT MUCH WATER
Miguel’s eyes flickered like candles in his dark one-room house in San Gabriel, Honduras. He heard the roosters crowing from his neighbors’ yards and the radio streaming from houses in the distant hills, as he customarily did every morning at dawn. As he lay there in his hammock, he heard the noises of the countryside swelling to a humming chorus, and daylight lit the cracks in the tile roof. The hens were coming down from their roost, the men were starting to till cornfields in the distance, and the wooden wheel from the water well creaked and whistled as his wife starting pulling up water for the day. As he swung his feet over the side of the hammock and placed them on the packed, smooth dirt floor, a twinge in his stomach reminded him he had felt ill for days due to an intestinal infection—from the well water, he suspected. Nevertheless, today was an important day. He knew he couldn’t miss the community meeting where the community development association (asociación de desarrollo comunitario [ADC]) would be discussing construction progress of the community’s potable water system. Virginia and Cassandra, U.S. volunteers from Travelers University (TU) in Springfield, were visiting to provide updates about the project. His family had hoped to tie into the water system because during the dry season, there was always a shortage of water, and during the rainy season, he often missed work and his children missed school because of diarrheal disease and parasitism. It also took a significant amount of time to pull water up from the well, and when they boiled water for the baby, a large amount of firewood was required, depleting the brush and trees in the surrounding areas.
In San Gabriel, 60% of households use their home’s well water, 20% use their neighbor’s well, 15% have piped water in their home, and 5% use their neighbor’s piped water. The primary collectors of water in 90% of homes are women. The wells are highly contaminated with fecal coliform.
Lowering his head, Miguel stepped outside of his house, a precarious adobe frame with no windows, a leaky roof, and a pit latrine around back. As he emerged, he felt the dry, hot air warm his face and his feet kicked through the dust in the yard. His daughter was on the patio in their makeshift kitchen forming tortillas in her wet hands and slapping them onto the firewood griddle.
Homes in San Gabriel, in many cases, are precarious and relatively unstable. About 60% of homes have dirt floors and most have no sealed windows. Many of the homes (40%) have walls made of brick, 35% of adobe, 14% of cement, 6% of mud and 5% of baharenque (mud and wood). Roofing of homes is made of ceramic tiles (80%) and metal laminate (20%). Most households (75%) have electricity.
“Luisa!” Miguel called to his wife. “Can you bring me some water?”
“I’m not getting much water from the well, Miguel,” she answered from the side of the house where the well wheel was located. “What I’ve pulled up is just enough for cooking and to boil for the baby to drink. You’ll have to see if one of the neighbors with a deeper well has any water. The dry season has been long this year.”
“What about brushing my teeth? I’m so thirsty …” he grumbled.
He was interrupted by the TU volunteers, Virginia and Cassandra, who were staying with his family. When they emerged from behind the house, they were carrying clothes they had pulled from the clothesline.
“We couldn’t wash any clothes, Miguel,” said Virginia, “so we’ll have to wear the clothes we worked in yesterday. Here are your clothes from yesterday. I just hung them on the clothesline to air out.”
“Have you checked the rain catchment container on the roof?” asked Miguel.
“Nothing,” Cassandra sighed heavily. “You know we haven’t had rain for days.”
San Gabriel is located in one of the driest and hottest regions of Honduras, and on average, receives approximately 1,500–1,700 mm/year of precipitation. During the dry season, the land is parched and water is scarce, except when drawn from extremely deep wells or piped water systems.
“Don’t worry. We’ll see what we can find out at today’s meeting,” he said.
“Yes, at today’s meeting, we plan on giving updates on the project’s progress, and we’re going to tell everyone it shouldn’t be much longer to finish the construction of the water system,” offered Cassandra.
“We’ve been saying the same thing for so long to the community, and the economy is getting worse every day,” he responded. “I’m tired of being sick, and we can’t afford any more doctor’s bills or pills for parasitism. I can’t even afford enough rice and milk. I’ve brought my son, Marco, to the doctor three times in the past 2 months. He’s only 1 year old, and he’s been so dehydrated and had a few close calls. A lot of other kids get severe diarrhea too. I think it’s the most dangerous for children. You said it’s because of contaminated water and poor hygiene. We’ve made progress with hygiene, but we still need water, so I’m getting impatient to move forward on this water project.”
With nearly one in five child deaths due to diarrhea, it is the second most common cause of death for children under 5 years of age worldwide,1 second only to pneumonia. The death toll is greater than that caused by AIDS, malaria, and measles combined.2 Most people who die from diarrhea actually die from dehydration and severe fluid loss. Children are at greater risk of life-threatening dehydration because water constitutes a greater proportion of a child’s body weight, and excessive water loss can take a heavy toll on a child. Children are also at greater risk for exposure to higher levels of contaminants in water because they drink more water per day than adults due to higher metabolic rates.2
“Here,” responded Cassandra. “Here are some pills I picked up at the pharmacy yesterday. Instead of waiting until we feel sick, we have to work towards preventing illness. The whole community needs to move in the direction of prevention. I know it’s a different way of thinking for everyone, and many people don’t know about the causes of illness. There are still problems of poor hygiene and inadequate sanitation, but you’re right, we’re making progress,” she assured him. “Disease transmission is very complicated. We’ll have to improve hygiene, sanitation, and water quality to reduce disease as much as possible.”
According to the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF),2 diarrheal disease is usually a symptom of gastrointestinal infection caused by a variety of bacterial, viral (primarily rotavirus) and parasitic organisms that are transmitted through the fecal-oral pathway, which is a complex set of interdependent pathways through which microorganisms spread in contaminated food and drinking water or from person to person as a result of poor hygiene.2 More than 80% of the cases of diarrhea worldwide are produced by fecal-oral contamination.3–6 These pathways are represented in the F-diagram,7 which classifies contamination as mediated through food, fingers, fomites and flies.8,9 The purpose of diarrhea prevention strategies, such as improvement of water supply and quality, provision of sanitary facilities, and hygiene education programs, is to block these transmission routes. Disease transmission pathways are important to take into consideration when making decisions related to educational interventions or the type of structural interventions that might be selected (for example, communal versus household water access, and household point-of-use water treatment versus piped water system chlorination).
Cassandra continued, “The volunteers from Potable Water for All have constructed a lot of the water system, and they say it shouldn’t take too long to raise the rest of the needed funds and finish construction. That way, everyone will be hooked up instead of only some houses.”
“Maybe this new funding opportunity we heard about from Engineers, Ltd. to the municipality will give us what we need to make it happen soon,” Miguel said hopefully. “Are you ready to go to the meeting?”
“I’m ready, but we’re waiting for Ramón,” Cassandra said, and then added, “Here he comes.”
Ramón, a community health promoter, let out a sharp whistle to get their attention as he approached up the steep, rocky road. Miguel grabbed his notebook, kicked off his sandals, and slipped on the shoes he had polished the night before. He knew the roads were dusty this time of year, but he always wanted to look his best at ADC meetings, since he was the president.
“Buenos días,” Ramón called out, as he passed the house’s entrance. Miguel, Virginia, and Cassandra hurried to catch up to him on the road, and they set out quickly on their way.
A HISTORY OF CONTROVERSY OVER THE WATER PROJECT
“So what have you heard about the new funding from Engineers, Ltd.?” Ramón asked the others.
“I don’t know much yet, just that a representative from the municipality will be at the meeting and they say that this funding might help us to finish the construction of the water system immediately. But, they are proposing that the funding go through the municipality,” replied Miguel. “It sounds promising, but you know that anything coming from the chief commissioner will be controversial. I have my doubts about him because there have been concerns about accountability with some of his projects. To make it more complicated, half of the residents of San Gabriel belong to his political party and half to another, which will make it even more difficult to convince the second half to accept any project he proposes,” he added.
“Yeah, I hear there’s been a lack of transparency with water projects in this region,” offered Virginia. “So, you’re saying half of the community favors the chief commissioner and half doesn’t trust him?” she asked.
“That’s right,” said Miguel. “We’ve tried to do a water project so many times with the chief commissioner and we’ve come close. If we let go of our differences with him, maybe this time it will work out. I still have my doubts, though.”
“As long as the funds cover the health promoter hygiene promotion program and a gray water disposal mechanism, I’ll support it,” said Ramón. “Otherwise it won’t go over well with my counterparts in the Ministry of Health. Water is really important, but so is hygiene improvement. Without education from the health promoters, things won’t change and it won’t matter if there’s water or not,” he said.
Hygiene promotion projects have shown a reduction in diarrhea disease of 33%, and hand-washing interventions specifically have reduced diarrhea by 43%.10
Ramón continued, “They are predicting an outbreak of dengue fever this rainy season, and excess gray water from the water system would only make the problem worse.”
Gray water comes from washing, cooking, bathing, and other similar activities. If left as standing water in a yard for a long period of time, it will become malodorous and contain bacteria similar to sewage. Gray water can be used for agriculture or disposed of through subsurface irrigation.11
Gray water is a significant problem in San Gabriel, an endemic region for dengue fever. Combined with standing water from rainfall, agriculture, and watering of animals, gray water provides increased opportunity for mosquito breeding. As of 2009, almost 40% of households employed ineffective methods for eliminating standing water from their yards; a third of the community does not take any measure to prevent standing water; 6% let it flow freely from the yard; 3% of homes dig a passage for the water to flow away above ground, and small numbers of homes sweep the water puddles.
“Whatever happens, don’t forget what we’ve talked about,” Virginia reminded them. “The water system should be community owned and operated, and it should be equitable to all households. This way, you can make your own decisions about the system, ensuring that the system is well maintained and that the water is adequately chlorinated. If the system fees also pay the health promoters’ salaries, San Gabriel can maintain a community-run health program that can respond to the specific needs of the community. By empowering community members to be the decision makers, it minimizes reliance on outside resources, which may be scarce, inconsistent, and not always in touch with our community’s perspective.”12–26
“All I know is that people in San Gabriel are getting restless,” said Miguel. “They come to me and that’s all I hear about. Our attempts to get a water system have been unsuccessful for over 10 years, and we’ve tried to collaborate with the chief commissioner, with in-country nonprofit organizations and with engineering firms. We just don’t know how to navigate these relationships and people take advantage of us. It is good that Potable Water for All is helping us to learn more about this for future community projects. The community’s losing faith in ADC, and we have to keep them organized and motivated,” he added.
“I agree,” responded Virginia. “Community capacity building and empowerment will be the key to moving the community forward. You can see the success that we’ve had with the health promoter program; we have people in the community who are trained, respected leaders, and they are an important asset. They unify the people to work for the community’s well-being, and since they are from the community, people listen to them. We can be sure they have the community’s best interest at heart,” she added.27–35
A review of 121 rural water supply projects indicated that beneficiary participation was the most critical factor in the effectiveness of water projects, significantly determining both the overall quality of implementation and the quality of operation and maintenance.36
Cassandra chimed in, “They are losing faith because they can’t see the physical evidence of water in their taps. We know the project is moving forward with fund-raising in Springfield, but it’s hard to see on this end. Sure, we built the storage tank and chlorination system and the hygiene promotion project has been going now for 2 years, but that doesn’t put water in their taps. It is hard to encourage people about the project, and we’ve been disappointed with so many previous attempts. Without community support, we won’t have manual labor to dig ditches for the pipeline, we won’t have contributions to buy land that the pipes pass through, and we won’t be able to borrow equipment for digging or leveling the land. Community approval will be the deciding factor in anything. For any decisions that will be made as a result of this meeting, the community’s impatience and doubts will certainly be influential factors.”
In 2006, the community of San Gabriel reached out to Virginia and Travelers University School of Public Health about how to improve the health of the village. After an initial assessment, the public health team and community leaders concluded that improving the water supply and improving key hygiene behaviors would provide the greatest benefit to the community.
Next, the public health team approached the recently formed Potable Water For All (PWFA) chapter in Springfield, which agreed to take on the project and design a water distribution system. Since then, PWFA had been working with the residents of San Gabriel to develop a potable water system to serve 5,000 residents. The system design included a central water tank, pump, chlorination system, and a main water line extending throughout the community to which individual households could connect, and gray water pits for safe water disposal at each household. In addition, PWFA hired and trained five health promoters from the community who deliver household- and school-based hygiene promotion.
Phase I of the water system construction had already been completed. However, construction was stalled due to the withdrawal of a key funder. Phase I included the installation of a pump in a 100-meter-deep tube well, pipeline up to an elevated storage tank, the construction of the storage tank and chlorination system, and part of the distribution network to the main school and a limited number of households. Phase II was to include the expansion of the distribution network to include every home in the community that still lacked piped water.
As they continued on, Virginia thought once again about her worries for the project. It would be a challenge to keep all of the partners successfully engaged in the project because they all had different interests, but each partner had an important role. She wasn’t sure how she fit in, and didn’t want to involve herself inappropriately. She also worried that consensus regarding project decision making would be a challenge. Had they done a good job of clearly communicating partnership dynamics and negotiations with community members? Virginia reflected on how challenging it can be to make information accessible to community members, especially when there are language and/or cultural barriers or when the educational/literacy levels of community members limit them from fully understanding the details and implications of all aspects of the project. Virginia felt that it would be very difficult to connect community members and other partners all at the same level for planning, negotiating, and decision making.
Of the household heads in San Gabriel, 30% do not have any education, and another 30% have not completed primary school. Almost two thirds (65%) of the heads of household cannot both read and write.
THE PARTNERS AND THEIR PRIORITIES
The partnership seemed promising. The project had been community- and evidence-based and included partners from multiple disciplines. The project also responded to local development priorities. A relationship between partners had been cultivated since 2006, and all partners had been key in the identification of community development priority issues; assessment of needs and assets; conceptualization of project plans and timelines; and the implementation of engineering (potable water), public health (hygiene promotion), and community training project components.
Project partners included:
• ADC was the driving force behind the project, from the initial stages of conceptualization to the implementation stage. The members were elected and represented the community in their ownership of the resultant water and hygiene project. ADC’s priorities were for the water system to be community owned and managed, equitable, and delivered to households.
• Volunteers from Travelers University (TU). These volunteers initiated the relationship with the community in 2006 by conducting a needs/assets assessment and assembled the partnership. TU volunteers were another guiding force in developing the project, conducting formative assessments, and serving as community liaisons. TU provided training and oversight of the hygiene program. Volunteers from TU supported the community in their efforts to secure a community-owned system and especially to ensure the success and sustainability of the hygiene program for improved health outcomes.
• PWFA, which was the lead volunteer technical group working on technical assessment, design, and implementation of the water system construction, as well as fund-raising. All of the project costs were financed by charitable donations. PWFA volunteers were concerned with constructing a high-quality, sustainable system to meet the needs of households. PWFA was under pressure to raise the rest of the money needed to finish the water system.
• Alianza de Sistemas de Agua Rural (ASAR), a Honduran nonprofit organization providing technical assistance to communities and their water systems. It offered community training in the areas of operation and maintenance of the water system; administration, like transparent bookkeeping, income/expense reports, and development of user fees; general and state laws governing potable water systems; protection and conservation of the water source; community empowerment and leadership as owners of the system; and participatory, democratic decision making. ASAR was interested in promoting the rights and best interests of communities constructing rural water systems and sought to protect communities in their partnerships with government and other agencies. In addition, ASAR received $0.08 for every dollar of collected water fees for each system. This fee supported its organization and services provided to communities. It wanted to have San Gabriel be part of its association, rather than having the water system managed by the municipality.
• The local municipal government, which provided tools, financial, and political support/influence for the project. The municipal government was interested in having ownership of the resultant water system, having control over its administration, and determining fees for users.
• The Honduran Ministry of Health (MOH). The MOH assisted with initial assessments, water testing, and additional training for the health promoters. An MOH health promoter serviced San Gabriel and oversaw the hygiene promotion project. The MOH was interested in having the household water fees finance the health promoter positions, since the MOH had limited resources and could only allocate one government-funded health promoter for each canton. Its main interest was the health of San Gabriel and health services provision.
• Engineers, Ltd., a Honduran for-profit engineering firm. The firm specialized in rural water systems and worked regularly with municipalities for the construction and management planning of these systems. Engineers, Ltd. approached the chief commissioner of San Gabriel and offered funds to start a water project in San Gabriel immediately. The approach that Engineers, Ltd. proposed resembled a consulting model, where the municipality would contract Engineers, Ltd. to build the system, which would be owned and operated by the municipality. It was interested in the municipality setting user fees and in acquiring more business contracts.
• Institution International, the primary funding agency for the project. It was interested in moving forward with the current plan of the household water delivery system. It had an intricate approval process for the disbursement of funds, and the project was being delayed because of this process. It had additional funds to donate, but these funds would only partially cover the completion of phase II of the project.
THE COMMUNITY MEETING
Community members stood, waiting under a Guanacaste tree to shield themselves from the oppressive sun. Men were wearing their cowboy hats with machetes strapped on their belts, and women wore their finest skirts and traditional aprons. Being foreigners, Virginia and Cassandra were easy to identify in the crowd. Virginia was mulling over what she would say to community members during the meeting. She was nervous and since the volunteers only visited a couple times a year, everyone showed up to the meetings to hear what they had to say. In terms of updates on progress of the project, she had many good things to report, but also had some news that might not be well received. She loved this community and did not want to disappoint them. Her thoughts were interrupted by Miguel calling the meeting to order.
After his regular, ceremonial introduction, he said, “We are all here today to discuss the water system and we have licenciada Virginia and licenciada Cassandra here from Springfield to tell us about the project’s progress. Also with us are Luís from the chief commissioner’s office, Jorge from ASAR, and Ana from the MOH.”
He announced that Virginia would speak first, and she stood in front of the crowd near a flip chart that she used to help explain the setup and process.
“Thank you, Miguel. I appreciate everyone being here and I have good news to report,” Virginia began. “As you know, TU has been working closely with ADC and PWFA in assessing the community’s needs and priorities, evaluating the resources we have available to us, monitoring the community’s health, and advising on decisions about this project. For 2 years, the health promoters have done an excellent job of educating homes and schoolchildren about hygiene and disease prevention. The community’s practices and health have improved significantly. Based on the data that we have collected, we have decided to continue the program. As you know, to have good hygiene, you need enough water, so we have been working hard on the water project,” she began.
Ana echoed Virginia’s comments, “It’s true. We’ve had less people coming to the clinic with diarrheal disease and parasitism. We’re very happy with the program so far.”
Virginia continued, “We have successfully finished phase I of the water project including the pump, tank, and chlorinator. We are ready to move to phase II of running the distribution network through the community and connecting homes. As decided by ADC, the current plan for the future of the system is as follows: operation, maintenance, chlorination, collection of fees, and administration will be managed by ADC. Each household will have a mandatory gray water soak pit to prevent standing water and will be responsible for the connection of the home to the main pipeline as well as the installation of the gray water soak pit. Each household will need to pay for the soak pit and the household connection. Service will cost $8 per household monthly. PWFA has worked with ADC to create a business plan so that the user fees will pay for system maintenance and salaries of the health promoters. Any extra money will be saved for future community development projects. In addition, eight cents on the dollar will pay the fee to ASAR, which will provide ongoing technical support and training, low-cost replacement parts, and electrical subsidies.”
She paused while the crowd stirred and people nodded in approval.
Virginia continued, “The only thing we’re waiting for is the processing of the additional funds from Institution International so we can start with phase II. Institution International manages its online donations by earmarking them for different projects. If the project is not specified by donors, the board of directors invests that undesignated money, waits for a return on the investment, and then uses it to support other projects. Since the economy has slowed, Institution International has not received much return on its investments, so it has to make tough decisions about what projects to support.”
Online? Earmarking? Board of directors? Investment? Virginia cringed after she heard herself explain all of this. She doubted community members would understand the ins and outs of Institution International’s funding scheme, the recession, or interest rates. Virginia looked out at the crowd and noted the confused looks on the community members’ faces. She wanted to be transparent about what was happening with the funding, but she couldn’t figure out a simpler way to explain it. She continued, trying to rephrase her explanation.
“Since the economy has entered a recession, things are getting expensive and people aren’t donating as much money.”
Community members nodded in agreement. One woman spoke up, “Yeah, corn is the most expensive I’ve ever seen it, and I can’t afford to buy meat any more at these prices.”
Although she felt conflicted about it, at this point, Virginia didn’t dare mention that although they had some funds promised for phase II, they didn’t have the full amount. They only had funds to complete part of phase II, and she felt discouraged about raising more funds during a recession. Since it had become increasingly difficult to acquire the rest of the funds, she didn’t want to promise any projected dates for system completion to avoid disappointment and mistrust.
“When will the project be finished?” a woman called out from the back of the group. This was exactly what Virginia feared. Prior to the meeting, Virginia had been informed by Miguel about the community’s restlessness and impatience to finish the project and avoid any more water shortages in the dry season and high levels of diarrheal disease in the wet season.
As Virginia started to …