title: Impact on diarrhoeal illness of a community educational intervention to improve drinking water quality in rural communities in Puerto Rico.
abstract: BACKGROUND
  Waterborne disease is a major risk for small water supplies in rural settings. This study was done to assess the impact of an educational intervention designed to improve water quality and estimate the contribution of water to the incidence of diarrhoeal disease in poor rural communities in Puerto Rico a two-part study was undertaken.
  
  
  METHODS
  An educational intervention was delivered to communities relying on community water supplies. This intervention consisted of student operators and administrators supervising and assisting community members who voluntarily "operate" these systems. These voluntary operators had no previous training and were principally concerned with seeing that some water was delivered. The quality of that water was not something they either understood or addressed. The impact of this intervention was measured through water sampling for standard bacteriological indicators and a frank pathogen. In addition, face-to-face epidemiological studies designed to determine the base-line occurrence of diarrhoeal disease in the communities were conducted. Some 15 months after the intervention a further epidemiological study was conducted in both the intervention communities and in control communities that had not received any intervention.
  
  
  RESULTS
  Diarrhoeal illness rates over a four week period prior to the intervention were 3.5%. Salmonella was isolated from all of 5 distributed samples prior to intervention and from only 2 of 12 samples after the intervention. In the 15 months follow-up study, illness rates were lower in the intervention compared to control communities (2.5% vs 3.6%%) (RR = 0.70, 95%CI 0.43, 1.15), though this was not statistically significant. However, in the final Poisson regression model living in an intervention system (RR = 0.318; 95%CI 0.137 - 0.739) and owning a dog (RR = 0.597, 95%CI 0.145 - 0.962) was negatively associated with illness. Whilst size of system (RR = 1.006, 95%CI 1.001 - 1.010) and reporting problems with sewage system (RR = 2.973, 95%CI 1.539 - 5.744) were positively associated with illness.
  
  
  CONCLUSIONS
  Educational interventions directed both at identified individuals and the community in general in small communities with poor water quality is a way of giving communities the skills and knowledge to manage their own drinking water quality. This may also have important and sustainable health benefits, though further research preferably using a randomised control trial design is needed.
authors.affiliation: School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK. Paul.Hunter@uea.ac.uk
authors.forename: Paul R
authors.initials: PR
authors.lastname: Hunter
authors.forename: Graciela I
authors.initials: GI
authors.lastname: Ramírez Toro
authors.forename: Harvey A
authors.initials: HA
authors.lastname: Minnigh
mesh_terms: D000328:Adult; D003967:Diarrhea / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D060766:Drinking Water / Q000382:microbiology / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006266:Health Education / Q000379:methods; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011647:Puerto Rico / Q000453:epidemiology; D012424:Rural Population / Q000706:statistics & numerical data; D012475:Salmonella / Q000302:isolation & purification; D011795:Surveys and Questionnaires; D060753:Water Quality; D055815:Young Adult
chemical_list: D060766:Drinking Water