1. 2015 UNC Water and Health Conference October 29, 2015 Jason Rosenfeld, MPH University of Texas Health Science Center at San Antonio Michael Goodman, MPH, DrPH University of Texas Medical Branch at Galveston

2.  Background  Methods  Results  Discussion  Limitations  Next Steps

3.  Demographic & Health Surveys  Bio-Sand Filter programs/evaluations

4.  Establish prevalence of WASH knowledge, norms and behaviors in Buen Samaritano bateyes  Establish prevalence of self-report WASH diseases in Buen Samaritano bateyes  Explore predictors of self-report diarrhea in children under the age of 5  Baseline for eventual community-based WASH promotion intervention (Community Health Clubs)

5.  Community selection ◦ Served by Buen Samaritano ◦ Buen Samaritano water or health promoter ◦ Rural batey (barrios excluded) Stratified by: filter, promoter, ownership, and proximity to town 10 Bateyes

6. 35 50 Agua Blanca 30 Bermejo Higueyana Copey Lima Solano Guerrero 80 203 Estante Alto San German SEYBO LA ROMANA HIGUEY

7. Sampling  Sample size=230 HH ◦ Proportional to estimated population ◦ Heads of household over 18 years; verbal consent  Systematic sampling began in NE corner  318 HH sampled / 184 completed Instrument  Direct interview  132 questions & observations ◦ Knowledge ◦ Behaviors ◦ Perceived norms (adaptations of RANAS) ◦ Health outcomes ◦ Social capital

8. -Avg Age: 43 -Avg HH size: 4.2 -Avg Children<5: 1.5/HH -56% ≠ Child<5 -Avg Years in Community: 13 Filter Non- Filter Total P- Value N (%) 102 (55.7)81 (44.3)183 Community Ownership Central Romana 88 (86.3)72 (88.9)160 (87.4)0.658 Private14 (13.7)9 (11.1)23 (12.6) Gender Male23 (22.8)36 (46.8)59 (33.1)0.001 Female78 (77.2)41 (53.2)119 (66.9) Education None28 (29.2)28 (35.4)56 (32.0)0.099 Primary45 (46.9)42 (53.2)87 (49.7) Secondary +23 (24.0)9 (11.4)32 (18.3)

9. Mean=1.68 Mean=2.57 Hand Wash Knowledge 6.0% = 0 correct 3.8% = 5+ correct Filter: 2.75 Non-Filter: 2.35 p=0.16 Diarrhea Knowledge 26.4% = 0 correct 3.2% = 5+ correct Filter: 1.74 Non-Filter: 1.60 p=0.68

10. Water Treatment 73.4% of all households treat their drinking water Chlorination (63.8%) Filters (29.1%) Respondents w/no education are more likely to report not treating their drinking water (p=0.006) Primary Drinking Water Source 88% use an improved water source Households in non-filter communities (p=0.001) and in privately owned communities are more likely to report using an unimproved source (p=0.02) Perceived Treatment Norms 68.3% and 73.3% agreed the majority of households and friends, respectively, treat water

11. Of those with a latrine (n=154)  38.3% observed to be dirty  21.5% observed to be covered/sealed Sanitation Facilities 13% of all households openly defecate Households in non-filter communities are more likely to report using an unimproved facility [χ2 (1,N=177)=9.78, p=0.002] Perceived Defecation Norms 51.9% agreed the majority of households use an improved facility

12. -68.3% reported using soap for hand washing -88.5% use bar soap How Wash Hands

13.  46.4% of households had at least 1 child <5 ◦ Total # Children < 5: 76 children  27% of all children < 5 reportedly had diarrhea in past 48 hours

14. VariableOR95% CIP-Value Zone 10.4050.083 1.978 Zone 21REF Zone 30.2050.059 0.708* Filter community0.2580.084 0.795* Female respondent9.6821.901 49.325** Children under 5 years3.4152.001 5.830*** Education0.5510.265 1.145 Intercept0.0860.012 0.606 Likelihood ratio (p)42.14 (<0.001) Logistic regression of reported household diarrhea *less than 0.05 **less than 0.01 ***less than 0.001

15.  Acute Respiratory Illnesses in children<5: 18% ◦ 19% filter vs 16% non-filter  Chikungunya: ◦ 29.5% (n=69 people) of households had at least 1 person with symptoms in previous 48 hours.  76% had 1 person with symptoms  24% had 2 or more people with symptoms

16. DHS & Batey DHS  Access to improved water for rural areas = 77% ◦ Nationally, 78% HH use bottled water ◦ Water treatment in rural areas = 19.5% ◦ Bateyes:  25% =piped, public network (18% outside of house)  54% = bottled water  57% do not treat drinking water  Access to improved sanitation for rural areas = 74% ◦ OD = 8% ◦ Bateyes: 24% = private toilet ◦ 27.9% = private latrine & 14.3% = shared latrine (42.2% = latrine) ◦ 30.9% = nothing (OD?)  28.9% <5 with diarrhea in bateyes (2 week recall); compared to 18% national

17.  Diarrhea risk factors in Santo Domingo (2000)-knowledge high, behavior low ◦ No measurement of diarrhea  Cholera risk study (2015): urban/rural geography & SES have greater role than nationality  RCT of Concrete BioSand Filters in Bonao (2009 & 2011) ◦ BSF households had 0.39 to 0.53 odds of diarrhea compared to those without

18. Research  Explore behavioral determinants ◦ Knowledge-Attitudes-Norms-Behaviors  Social Capital analysis Programmatic  Possible Community Health Club intervention

19.  Time ◦ Household Sampling ◦ Community Sampling  Normative measures  Self-report measures  Student enumerators

20.  Hospital Buen Samaritano  Central Romana  Center for Medical Humanities & Ethics  Project Hispaniola Student Group

21.  Aiken, B., Stauber, C., Ortiz, G., and Sobsey, M. (2011). An assessment of continued use and health impact of the concrete biosand filter in Bonao, Dominican Republic. American Journal of Tropical Medicine and Hygiene, 85(2): 309-317.  Centro de Estudios Sociales y Demográficos (CESDEM) y ICF International (2015). Encuesta Sociodemográfica y sobre VIH/SIDA en los Bateyes Estatales de la República Dominicana 2013. Santo Domingo, República Dominicana: CESDEM y ICF International.  Centro de Estudios Sociales y Demográficos (CESDEM) y ICF International (2014). Demographic health survey 2013. Santo Domingo, Dominican Republic: CESDEM yICF International.  Lund, A., Keyes, H., Leventhal, S., Foster, J, and Freeman, M. (2015). Prevalence of cholera risk factors between migrant Haitians and Dominicans in the Dominican Republic. Pan American Journal of Health, 37(3): 125-32.  McLennan, J (2000). Prevention of diarrhea in a poor district of Santo Domingo, Dominican Republic: Practices, Knowledge and Barriers. Journal of Health and Population Nutrition 18(1): 15-22.  Stauber, C., Ortiz, G., Loomis, D., and Sobsey, M. (2009). A randomized controlled trial of the concrete biosand filter and its impact on diarrheal disease in Bonao, Dominican Republic. American Journal of Tropical Medicine and Hygiene, 80(2): 286-293.  WHO/UNICEF Joint Monitoring Program. (2015). Dominican Republic: Estimates on the use of water sources and sanitation facilities (1980-2015). Accessed on 10/23/2015: http://www.wssinfo.org/fileadmin/user_upload/ resources/Dominican_Republic.xls

22. Questions?