Monday, January 28, 2013

Safe Drinking Water: Changing lives and fulfilling dreams one hand pump at a time- Cristina Los


Safe Drinking Water:  Changing lives and fulfilling dreams one hand pump at a time- Cristina Los
Introduction
What is a basic human right, lack of it can cause 6,000 deaths in children a day, and is unavailable to 884 million people in the world?  (1)  The answer is interestingly one of the things that many of us in the developed world take for granted; access to clean and safe drinking water.  The lack of access to this basic necessity in life has been brought to the attention of world leaders almost 40 years ago.  In the 1970’s access to safe drinking water became a “cornerstone of the public health agenda” and formally became known as a basic human right.  When it was realized that almost a quarter of the world’s population did not have, what was now considered a basic human right, it started a world-wide movement (2).  The decade starting in 1981 became known as the International Drinking Water Supply and Sanitation Decade (3).   This spurred world leaders to being to discuss this topic and devise strategies and goals to tackle the problem.  In 1990 it was estimated that 23% of the population did not have access to clean drinking water, and while some progress was being made, it was slow and not enough governments around the world were taking the problem seriously (4). 
In September of 2000, the United Nations created the Millennium Development Goals.  In these goals, Target 7.C was to halve, the proportion of the population without sustainable access to safe drinking water and basic sanitation, by 2015 (3). To meet this goal meant that the percentage of people without improved access to safe drinking water in 2015 would be 12% (4).  While we are currently on target to meet this goal if the development of clean water access continues, there are some roadblocks to consider.  First, the constant increase in the world’s population means that while we may hit our target percentage, the number of people who need to be served in order to reach that goal also increases (4).  While this is positive, because more people will have access to clean drinking water, it also means that the programs and solutions which are implemented need to be sustainable, so they can accommodate the growing population. 
Current Interventions
            Because this is a worldwide problem, there have been thousands of groups which are all working to create interventions to increase safe water access.  Across the board, there have been some commonalities that most groups follow.  First, outside groups give a financial contribution to help communities gain access to clean water.  These financial investments are usually funded through international assistance programs or private investors (5; 6).  The bulk of the money goes to buying the technology to create a way to harvest the clean water from the ground.  Across the years, the most popular method to bring safe drinking water to a community is to create boreholes.  The boreholes are created with drilling machines which drill down through the ground until they reach a water table.  A hand-pump can then be attached to the hole to bring water to the surface (7).  In the early 90’s, the drilling of these holes were much more expensive as the equipment was much more cumbersome and hard to use.  In more recent years, this process has been reduced in cost as the technology for drilling has been advanced and the process became more user-friendly for those not skilled in drilling (8). 
An additional component to most programs is the addition of some type of education system.  These education campaigns usually cover topics such as hygiene, sanitation, and the importance of drinking safe, uncontaminated water, and are usually based on current research and data from surrounding areas (9).  They also may include information on how disease, sanitation, hunger and poverty are all connected through the importance of drinking safe water (10).  While these are all important concepts to learn, these programs are also all very short in duration, and do not spend a great amount of detail discussing the maintenance of the new water system (11).   
            In trying to educate the communities, a common campaign seen across the board is the Global WASH campaign.  This campaign was started in 2001 in response to making a move on the MDGs that were established in 2000.  WASH represents a renewed emphasis on global water, sanitation and hygiene.  Branded in several ways over the years, from “The Big Issue” and “Hurry Up”, the campaign focused on spreading awareness of water, sanitation and hygiene, and trying to change policy makers (14).  While components of this program have been used in isolation or as a whole, many of the groups implementing clean water solutions have some components of the WASH campaign in their education system. 
            Two examples of groups that have used the described method of intervention include the country of Kenya and UNICEF.  In Kenya the government has partnered with many international groups, rotary clubs and relief agencies to build boreholes and hand pumps in their communities.  They then use components of the WASH program to teach the importance of hygiene and sanitation (5). 
The Water, Environment and Sanitation (WES) sector of UNICEF has also been using a similar method of bring safe drinking water to communities around the world.  Their projects include the same basic premise as the Kenyan intervention program, and also incorporate field research based practices into their programs.  In their plan to help minimize the water crisis, they focus on bringing in the technology to build bore holes, the tools to install hand pumps, and education lectures and trainings to help people become knowledgeable of the importance of clean water, sanitation and hygiene.  In their planning, UNICEF is focused on “promoting behavioral change” so their efforts are focused on bringing the “best available information and new research on the issue” to the communities they are serving.  UNICEF also understands the importance of connecting with the community members in order for their campaign to be a success.  To this end, they use a model of assessment, analysis and action and focus their evaluation on knowledge, attitudes and practices.  In this way UNICEF feels they have the best chance of making a lasting impact on these communities (9).
While some of these interventions have helped to reduce the numbers of people in the world without access to clean water (2), they have not provided a sustainable solution and there are still over 700 million people without access to clean and safe water (15).  Unfortunately, the impact of these programs has been minimized due to some of the following reasons. 
Critique 1
The first major critique of the existing intervention is that the program does not inspire or develop a sense of community interest.  This can be seen in both the technology and education parts of the existing interventions. For example, external companies and funders come in with a funding source, and neither the source nor the money is linked to the community (11).  In this way, community members do not have interest in the project monetarily.  This also means that when the company and the money leave, the communities are left with no supplies or money to maintain the technology.  Maybe in a few more months when the hand pump breaks, they don’t have any spare parts, and there is no one to fix it, because the community members were not trained in pump maintenance (8).  The people who put it in in the first place cannot come back, no one has interest about the project, and then again, people regress back to their old state of gathering water and no forward progress is made. 
Additionally, the education program that is included does not promote community interest and sustainability.  When the new water sources are created, the communities are flooded with new tools and education, where they were taught how important it is that they maintain the new sources of water and how practicing safe sanitation and hygiene will reduce the risk of disease and increase their quality of life.  However, they have no means to sustain these new practices.  For example, in the education program, they learned the importance of washing your hands with soap after using the bathroom, and how it can minimize diarrheal cases of disease by up to 45% (12).  However, if they do not have any soap to wash their hands with, because they have no money to buy soap (13), this can create cognitive dissonance.  They would buy more soap if they had the money, or make soap if they knew how, but because they do not have access to these resources (11), they stop practicing the behavior.  Additionally, the education of hand washing was given based on data to show how it is a more healthy practice (5), but because their education about hand washing was relatively new, and was not shown to them in a way that it would be embedded in their core values, the hand washing routine will be easily dropped and forgotten.  In these ways, the program as it currently stands does not inspire community interest and therefore is not sustainable by the communities it seeks to help.   
Critique 2
The second reason these implementation methods are not successful is because the education component does not create lasting change.  This is because the educational lessons are framed around the core value of health.  Core values are the critical values that are fundamental to a culture and help them define who they are as a community.  Also, because these values are so important to the members of the community, people choose to make decisions and conduct behaviors that are congruent with these values (16).   In close conjunction with core values is the technique of framing.  Framing is a technique used to provide an overarching theme to a set of arguments and to capture all the information under one larger umbrella (17).  Framing can be thought of in terms viewing different issues through a camera.  If you look through a camera you will see a scene.  If you change the lens on the camera it changes the way you see the scene, it can become black and white, or inverted or all green.  Using this analogy, framing using core values is an important part of sending a message to the public that people will listen to, remember, and adopt into daily practice.             When giving a message to a community or in this case, delivering health education, it is useful to use framing to deliver your idea.  Within current interventions, in delivering these trainings, the emphasis is currently on health, safe water and sanitation.  The lessons are based on data and facts from studies done in the area (9), and promote behaviors such as hand washing because it will improve one’s health (10).  The trainings are delivered using the frame of health.   However, this may not me the most effective way to promote safe water practices and sanitation.  If health is not a core value of the community, people will be less likely to adopt those behaviors.  Conversely, the more they can relate to the core value being presented the more likely they are to agree with that frame, and they will be more likely to adopt that behavior.  This is related to Schon and Rein (1994)’s definition of a frame in which they describe a frame as a culture’s beliefs, values and perspectives, which the members of that community then use to bring meaning to their thoughts and actions (18).   The education programs that are being used such as WASH (14) emphasize the importance of hygiene because it is good for your health and to fight hunger and poverty (10).  This may not be the best approach as health is generally not a strong core value, and specifically in the water scare populations.           
Critique 3
 The third and most important critique is that there is no sustainability of the intervention, and this is due to the fact that there is no community buy in into the project.  The lack of community buy in can be attributed to the lack of ownership in the project.  In the social sciences it has been shown that ownership of an item or program can have a substantial impact on how much people value that thing, and how much they are invested in protecting it (19).  In the case of the water crisis, in the current interventions communities who are getting access to clean water are not valuing the project enough to have ownership of it.    This is due to lack of monetary contributions, lack of maintenance education and not targeting the write persons for education.  Firstly, in the design of the projects, the preferences of the community members were not considered (8).  This could be detrimental to the project, as sometimes some of these practices may interfere with community values or religious beliefs, and therefore are not internalized by the community, and the interventions are quickly forgotten or not used (11).  Additionally, community members were not required to contribute monetarily to the project (4). While this was considered a benefit of the programs, because people should not have to pay for water, this also minimized their possible feeling of ownership.
Another missed opportunity to create sustainability through ownership was in the education part of the projects.  Members of the community were not taught how to maintain the hand pumps, nor did they have equipment to fix them if they broke, which happened often as the technology was not made for the mass community use (11).  While this has become less of a problem as the technology becomes simpler, the lack of education and showing them how to maintain the tools is a lost opportunity to create a sense of ownership. 
An additional critique of the education system is that it did not target women and children.  In order to be most effective with the message of drinking safe water and sanitation, in order to see the biggest impact, the intervention should target those people who are most involved in gathering the water, because these are the people who will be most affected by this intervention.  In most cases, the women and children, especially young girls are responsible for this task (4; 8).  For these reasons, the lack of ownership in the project has put a significant damper on the possible impact these interventions could have on minimizing the water crisis. 


Proposed Intervention
            In the past few years, renewed emphasis has been placed on continuing to improve the interventions that are put in place to continue to reduce the number of people in the world who are without access to safe drinking water.  Researchers now realize the importance of working with the community (2) when building a program that can be implemented successfully and which can be sustained.  A model program in this new movement is the work of Water.org.  This organization understands the importance of getting the community members involved in all steps of the process in order to make their efforts worthwhile and sustainable, and this is at the forefront of their minds in planning new interventions.  Water.org specifically targets projects in communities where there is an interest with strong buy in from community leaders.                 They first get communities involved by working with local partners to set up a loan for that community.  These local partners who provide the money are thought to better know the needs, values and political issues within that specific community, and can build a closer relationship from the start.  It gives all parties involved a feeling of togetherness and ownership rather than one person helping another.  With this small microloan, community members are able to work to drill a bore hole and put in a water pump, but they need to work together as a community, to make enough money to pay back the loan (20).  The community is then actively involved in digging the hole and putting in the water pump.  In order to make sure that the project can be sustained, Water.org specifically makes sure that the women and children (whose main job is to bring water to the site) are involved in learning about how the new system works and how it can be sustained (2).   
            For my proposed intervention, I am going to suggest a plan that further develops the model that Water.org is currently implementing.  Many of their improvements are key elements of a successful campaign, and I would like to suggest even more ways to strengthen the impact of this campaign.
Intervention 1
The first suggestion for improvement is to help gain community interest and buy-in which will create ownership and sustainability.  I propose to achieve this using social norms and agenda setting theory (21).  Water.org has done a great job of recognizing the need to work with communities who are truly interested, and who have the members and the teams who are interested and ready to work.  By working with these teams, the company is already at an advantage because they have something that these communities want, and therefore when they get it, they will show more ownership of their program (19) and try harder to sustain it. 
            In trying to create a greater sense of community interest I suggest that we use agenda setting theory and social norms theory.  Both these theories are based on group decision making and suggest that more impact can be made in groups.  For this reason they try to move important ideas onto the public agenda and help them to become social norms so they are easily adapted by the community. 
            The goal of agenda setting theory is to bring the issue you care about to the public’s attention (21).  In this case, we want to have people in the community care about having safe drinking water.  Because children are such an integral component in the water gathering process, I suggest that we start integrating this new agenda in schools with the children.  In conjunction with Water.org on this particular project, I propose that students in school be assigned a project to help make a movie.  The goal of the movie will be to help all members of the community think about their aspirations and dreams, and then help show the connection between drinking safe water and achieving your dreams. 
This movie will consist of two parts.  The first part will be about the family.  The children will film their family in their daily lives and then interview their family about how they  gets water, what they use the water for, and their thoughts about what they could do if they had access to safe water.  The second part will be short personal interviews of all the children of what they want to be when they grow up.  In filming this video, the hope is that families would start talking about the water crisis.  Perhaps, children who are not able to attend school because they need to harvest clean water every day, will start to think about their aspirations and what they could do if it was easier and less time consuming to gather water for their family.  
With this video, we can then make the connection to family and what they know and are familiar with, and how drinking safe water can make these dreams come true.  By having everyone interview their families, hopefully the families will start talking about what they wish they had, and possibly think about how water can help.  If we can make this connection between their dreams and drinking clean water, this will help bring the issue of drinking clean water to the forefront of discussions. 
We will then compile all of the videos and start projecting the product into the community.  We will show it on TV, have screenings of it at the local library, and write about it in the newspapers.  Using agenda setting theory, we will push this issue into the consciousness of the whole community.  Hopefully when enough people see the video, they will begin to see social norms theory (22) take hold as more community members know that many of their other community members care about this issue, and they will start to care as well.   The hope is that this topic will spread throughout their community, especially to the government officials and this will eventually increase community interest in being proactive in bringing safe drinking water to their families and children.   
Intervention 2
The second improvement we can make to previous interventions is to start using a different frame.  Instead of educating the community about how important it is to wash your hands, and to drink clean water and to practice good hygiene because it is healthy for you, I propose that the lessons focus on selling autonomy.  The focus on autonomy rather than health goes back to our earlier discussion about the power of a frame.  In terms of focusing on core values, autonomy and choice are much stronger core values than health because they are more strongly valued across a wider range of people (16).  Also, since almost everyone would say that choice and autonomy are already important to them in other areas of their lives, by connecting clean water and sanitation with autonomy, you are not introducing new concepts or asking them to change their opinions.  It makes your information a much easier sell, and greatly increases the number of people who will accept your new information. 
            As an actual mechanism to bring autonomy into the education conversation I propose to start a campaign using advertising and marketing theory.  In advertising theory a promise is made to an audience in which they  believe that if they use the product or in this case, continue to gain access to safe drinking water , they will be able to reach the promise or goal described (23). This promise is then backed up by support, which can range from images, movies, sound clips, or songs, all of which can be tied to emotions and core values.  A similar concept using marketing theory posits that you know what the deepest desires of the population are and create a message that links directly to those desires. 
            In the case of the water crisis, this would be very easy to fit in.  Because with Water.org the communities are already working with local partners, the local partners will know what values are important and what political or religious views the community holds.  With this information we will be able to know what are the goals and aspirations of the group.  We will also know more about the aspirations of the group, from the interviews we conducted for the videos.   We will then create a tailored lesson so drinking safe water is linked to achieving their aspirations.  In this case, as an example, I will focus on school girls.  I propose that we use flyers and commercials and even local plays and skits to show girls that if they drink safe water and practice good hygiene than they will be able to choose what they can do with their lives.  Instead of being delegated to get water every day and be denied the opportunity to become educated, if you stick with these practices you can choose who you want to be and you can become anything you want.  Also the education lessons should include a component about pump maintenance.  If we can teach them how to fix it independently, we can further build on the autonomy frame, as we literally give them the tools to be autonomous in maintaining this new lifestyle.
Intervention 3
My final suggestion for improving the current intervention would be to create sustainability and ownership in the project.   These fixes are mostly already components of the Water.org project, so they should be easier to implement on a wider scale.    I would suggest that the program put a large emphasis of making sure that the program will be able to run once the main teachers and implementers have left the site.  In order for this to happen, the community needs to have a sense of ownership.  The community needs to feel that they own a piece of the project, and in order to do this, they need to be actively involved in the planning, creating and maintenance of the project (19).  To reach this goal, I propose first that we continue the practices of Water.org and partner with local banks and loan agencies to finance small microloans for the communities to that they can have monetary buy in into the project (20).  This will be an easy first step into the process, because if the community is very interested in bringing safe drinking water to their sites via the other two intervention suggestions, then once they are able to purchase the equipment to set up a pump, they will value their fresh water even more (19), and they will be invested in keeping it working which will allow them to pay back the loan eventually. 
Second, I propose specific hands-on learning tools for the women and children of each community.  Because the women and children are the ones who spend the most time going on long journeys to get safe water, their time is the one most affected by this new improvement of safe and clean water.  As shown at the website (10), having clean water in a village can greatly improve the life and aspirations of women and children.  If safe drinking water is more readily available, the women and children of the village will have more time to tend to their families, and then children, especially the girls will have an opportunity to stay in school longer.  In order to help strengthen their feeling of ownership, they will be working hands on with each step of the water process.  All the people who usually gather water will be trained in how to use the pump, they will be given some tools to fix it and they will be shown what to do if something goes wrong.  By doing this training, the impact long term will be exponential.  By giving them practice and lessons in how to gather water and fix any problems, they will begin to gain self-efficacy and empowerment that they can sustain this project (4).  The time and money spent on teaching them is a minimal but worthwhile investment, as their ownership in the project will grow exponentially, because they know how to maintain the technology and contribute to bettering the future of their community.  
Conclusion
            Clearly, there is much progress being made toward completing the MDG of halving the number of people in the world who are without access to clean water by 2015.  However, as we continue to drill down and bring safe drinking water to communities we will face new challenges.   The constantly increasing world population will encourage us to make our efforts more sustainable, and as we continue to work with willing and able sites, the number of sites who have fewer resources and who are more remote will increase.  These dilemmas call in the need for more widespread and sustainable interventions.  By creating an intervention that can be adopted into a communities’ core values, and if we can work side by side with each site to empower them to take on ownership of this project and also their future, we can hope to go beyond the scope of the MDGs and bring clean and safe drinking water to everyone on the planet.


References

1.  World Vision:  Building a better world for Children.  Safe drinking water, sanitation and hygiene initiatives.  Retrieved from http://www.worldvision.org/content.nsf/learn/ways-we-help-wsh#projects
2. Graham, J. Sanitation and hygiene:  Taking stock after three decades (pp. 17-27).  In: Selendy, J.M.H., ed. Water and Sanitation-related Diseases and the Environment:  Challenges, Interventions and Preventive Measures, Singapore: Wiley-Blackwell, 2011b.
3. United Nations Millennium Development Goals.  Goal 7:  Ensure environmental sustainability.  Retrieved from http://www.un.org/millenniumgoals/environ.shtml
4.  Graham, J. Tacking the water crisis:  A continuing need to address spatial and social equity (pp. 3-15).  In: Selendy, J.M.H., ed. Water and Sanitation-related Diseases and the Environment:  Challenges, Interventions and Preventive Measures, Singapore: Wiley-Blackwell, 2011a.
5. World Vision Kenya.  Mobilizing Communities:  Managing Resources. Focusing on Children.  Waterm Sanitation & Hygiene (WASH). Annual Report. 2009. 
6.  Moe, C.L., & Rheingans, R. D. (2006).  Global challenges in water, sanitation and health.  Journal of Water and Health, 4, 41-57.
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8.  Wood, M. Are handpumps really affordable? (pp. 155-157).  In:  Pickford, J. Barker, P., & Coad, A., ed.  Affordable Water Supply and Sanitation, Southampton Row, London:  IT Publicationas, 1995.
9.  United Nations Children’s Fund (UNICEF).  UNICEF Handbook on Water Quality. New York, NY: United Nations Children’s Fund (UNICEF), 2008. 
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11. Black, M. & Talbot, R.  Water: A Matter of Life and Health.  Oxford, NY: Oxford University Press, 2005.
12. Selendy, J.M. H.,& Aagaard-Hansen, J. Introduction (pp. xv-xvii).  In: Selendy, J.M.H., ed. Water and Sanitation-related Diseases and the Environment:  Challenges, Interventions and Preventive Measures, Singapore: Wiley-Blackwell, 2011b.
13.  Hayes, J.  Facts and Details: Toilets and sanitation in the developing world (Third World). 2008 updated January 2012.  Retrieved from http://factsanddetails.com/world.php?itemid=2168&catid=57&subcatid=379
14.  Water Supply & Sanitation Collaborative Council (WSSCC).  Global wash campaign.  Retrieved from http://www.wsscc.org/wash-advocacy/campaigns-events/global-wash-campaign
15. Water.org. Facts.  Retrieved from http://water.org/facts/
16.  Smolicz, J. Core values and cultural identity.  Ethnic & Racial Studies,1981, 4(1), 75-91.
17. Certain Trumpet Program. Framing memo: The affirmative action debate. Washington, DC: Advocacy Institute, September 1996.
18.  Schon, D. A., & Rein, M., Frame reflection:  Toward the resolution of intractable policy controversies.  New York:  Basic Books. 1994.  as sited in: Menashe, C. L., & Siegel, M. The Power of a Frame:  An analysis of newspaper coverage of tobacco issues- United States, 1985-1996.Journal of Health Communication 1998; 3(4): 307-325. 
19.  Ariely, D. Predictably Irrational:  The Hidden Forces that Shape our Decisions. New York, NY:  HarperCollins, 2008.
20.  Water.org.  Solutions.  Retrieved from http://water.org/solutions/
21.DeFleur, M. L., Ball-Rokeach, S. J. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plaines, NY: Longman Inc., 1989.
22. Wisconsin Clearinghouse for Prevention Resources.  Best practices: Social norms.  Retrieved from http://wch.uhs.wisc.edu/13-Eval/Tools/Resources/Social%20Norms.pdf
23. While, G. E. Creativity:  The x factor in advertising theory. Journal of Advertising 1972, 1(1), 28-32. 


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