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Project in Tanna, Vanuatu

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Project in Tanna, Vanuatu An Evaluation of a World Vision Water, Sanitation, and Hygiene (WASH) Project in Tanna, Vanuatu Alexandra Morrison A thesis submitted for the degree of Master of Public Health University of Otago, Dunedin, New Zealand 29th February 2016 ii Abstract Background In 2013, World Vision Vanuatu and World Vision New Zealand implemented a three-year water, sanitation, hygiene (WASH), and nutrition project (the Project) in south west Tanna, Vanuatu. The overall goal of the Project was to reduce child undernutrition, with short- and medium-term objectives to increase WASH infrastructure, and improve caregiver WASH and nutrition knowledge and practices. In January 2015, after two completed years of the Project, we designed and undertook an evaluation. Methods For households with children aged under five years of age in the Project villages we conducted: WASH and child health surveys; WASH infrastructure observations; anthropometric measurements of children under five years of age and their mothers; and microbiological drinking water testing. We compared our data with those gathered at baseline and at the end of year one of the Project. We undertook logistic regressions to investigate associations between: child health outcomes and WASH and nutrition factors; and household microbiologic water safety and WASH factors. Results Complete enumeration of households with children under five years of age was attempted. Overall, 220 households and 320 children participated in the evaluation. There was a significant increase over time in the proportion of households with access to improved latrines, from 39 (26.4%) of 148 households in 2013, to 202 (97.1%) of 208 in 2015 (p<0.001); and in the proportion of handwashing facilities from 31 (21.0%) of 148 in 2013, to iii 172 (82.7%) of 208 in 2015 (p<0.001). Caregiver WASH knowledge improved over the course of the project. A total of 12 (4.0%) of 303 children were wasted (<-2 Z-score weight-for-height), 145 (48.8%) of 297 children were stunted (<-2 Z-score height-for-age), and 59 (19.1%) were underweight (<-2 Z-score weight-for-age). In the two weeks prior to the survey 35 (11.6%) of 303 children had diarrhoea. Factors associated with a lower prevalence of stunting included using improved water sources (PR: 0.69, 95% CI:0.56–0.85, p=0.001) and a greater maternal height (PR: 0.95, 95% CI: 0.91–0.99, p=0.006). Using an improved water source was associated with a lower prevalence of being underweight (PR: 0.45, 95% CI: 0.27–0.74, p=0.002). Of the 201 households with microbiological water testing, 10 (5.0%) had E. coli levels safe for drinking at <1/100 mL, whereas 145 (72.1%) had E. coli levels indicating very high health risk at >100/100 mL. Factors associated with lower odds of very high risk drinking water included the source being rainwater (OR: 0.10, 95% CI: 0.02–0.59, p=0.009), and having a water container with a spigot (OR: 0.34, 95% CI: 0.13–0.77, p=0.010). Additionally, households with severely stunted children or underweight children had higher odds of having very high risk drinking water (OR: 3.02, 95% CI: 1.13–8.03, p=0.027 and OR: 2.51, 95% CI:1.02–6.19, p=0.045. Conclusions We found that the Project achieved most of its short- and medium-term objectives to improve WASH and nutrition infrastructure, knowledge, and practices. Microbiologic testing indicated that most drinking water in the Project households was unsafe. Undernutrition remained high in the Project population and was associated with having very high risk drinking water. Providing the Project population with improved drinking water as planned in the third Project year, is likely to contribute to achieving the Project’s overall goal to reduce child undernutrition. iv Preface The World Vision Tanna integrated WASH Project (the Project) was originally a three-year project beginning in 2013. This was later extended to four years due to the devastation caused by cyclone Pam in March 2015 to the island of Tanna. The Project was funded by World Vision New Zealand through the New Zealand Aid Programme (NZ Aid), and implemented by World Vision Vanuatu. According to the Project design, monitoring on a number of project outcomes was to occur annually. A memorandum of understanding exists between World Vision and the University of Otago and the Centre for International Health, University of Otago initiated talks regarding a possible mid-term evaluation of the Tanna WASH Project. Alex Morrison, Master of Public Health (MPH) candidate from the Centre for International Health began working on the evaluation on November 2014. World Vision New Zealand stipulated the evaluation should take place in January–February 2015 in Tanna, Vanuatu, to align with their reporting requirements to NZAID in April 2015. The roles of the candidate and others involved in the evaluation are outlined below: Alex Morrison, MPH candidate. Determined the objectives of the evaluation based on the original aims of the Project. Prepared and gained University of Otago Research Advisory Committee (RAC) approval and University of Otago Human Ethics Approval. Prepared survey questionnaires for the evaluation and with the assistance of the World Vision Tanna team contextualized the survey questions so they were appropriate for the population of south west Tanna. Programmed the questionnaires into the smartphone data collection platform FieldTask (Smap Consuting, Niel Penman, VIC, Australia). Prepared training material for the Smartphone application. v Trained the World Vision Tanna survey team on how to use the FieldTask data collection application Prepared consent forms and information sheets for participants. Assisted in training the World Vision Tanna survey team in anthropometry techniques. Made sure all necessary preparation for data collection was undertaken. Supervised the data collection component of the evaluation. During the survey, assisted in conducting anthrompetric measurements of children, observation questionnaires, and water testing. Led a debriefing session every day after data collection. Was responsible for quality control of survey questionnaires during data collection. After data collection extracted preliminary results for the Tanna World Vision team. Manually cleaned and pre-processed datasets. Conducted statistical analyses of the data with advice and assistance from a statistician. Wrote a report of preliminary results for World Vision New Zealand to assist in their reporting requirements. Wrote a report of preliminary results to NZ Aid as part of the NZ Aid Postgraduate Field Research Award. Write up of thesis. Writing of a paper for publication. vi Professor John Crump (candidates primary supervisor) contributed to preparing the University of Otago RAC application and Human Ethics Committee application, as well as contributing to the design of the evaluation and giving advice during field work. Prof. Crump reviewed drafts of the candidate’s reports and thesis. Dr Susan Jack (candidate’s supervisor) led the initial discussions with World Vision that resulted in the evaluation, and liaised with World Vision New Zealand throughout the evaluation. Dr Jack contributed significantly to the planning of the evaluation and gave advice during data collection. Post data collection she contributed to analyzing and collating preliminary data for reports. She also reviewed drafts of the candidate’s reports and thesis. Associate Professor Katrina Sharples (candidate’s statistics supervisor) gave advice during the planning of the evaluation and undertook initial sample size calculations. Assoc. Prof. Sharples also gave advice to the candidate during data collection and post data collection and assisted the candidate with statistical methods for analysing the data. She also checked the candidates resulting outputs and interpretations for accuracy and reviewed drafts of the candidate’s thesis. Associate Professor Lisa Houghton, Senior Lecturer of Human Nutrition at the University of Otago, contributed to planning the child nutrition and anthropometry sections of the evaluation. Assoc. Prof. Houghton prepared the training material for anthropometric measuring, and led the training of the World Vision Tanna team on these techniques prior to data collection. She also reviewed the nutrition questions included in the child health survey and helped to ensure other aspects of the evaluation were prepared prior to the survey. Ms. Hanneke Lewthwaite, University of Otago medical student and Centre for International Health summer scholarship student assisted the MPH candidate in the preparation and data collection stages of the evaluation. Specifically, pre data collection Ms. Lewthwaite researched Compartment Bag Tests (CBTs) (Aquagenx, NV, USA) for water microbiological quality testing, undertook positive and negative controls for each batch of CBTs, and tested CBTs at variable room temperatures. She also helped to prepare water quality related household questions and trained three Tanna World Vision team members on CBT survey methods. Throughout data collection she undertook and supervised the water quality vii testing, and post data collection was responsible for preparing preliminary water quality results for use by the Tanna World Vision team. World Vision New Zealand funded the evaluation. Elise Bryce-Johnson (World Vision New Zealand, Grants Programme Manager, Papua New Guinea and Vanuatu) facilitated contact between World Vision Vanuatu and the University of Otago. Dr Raul Schneider (World Vision Regional Health Adviser) assisted in obtaining
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