Why poor children stay sick : Water sanitation hygiene and child health in rural Malawi

Abstract: The impact of an improved method of drinking water supply upon child health was evaluated in a rural area in southern Malawi. A prospective cohort srudy was made before and after the intervention with a gravityfed,piped water and a sanitation and health education programme using intervention and comparison groups. Water handling and hygiene behaviour of people were studied together with people's knowledge andperception regarding water quality. The morbidity, growth and mortality of 1178 children under five years of age were investigated. The bacteriological quality of both the traditional water sources and the piped water as well as that of stored household water was examined during dry and rainy seasons.The piped water was of considerably better bacteriological quality than that of the traditional water sources. However, during storage at home water from both types of sources became heavily contaminated. The deterioration was particularly pronounced during the rainy season. After intervention with piped water, all households, also those using traditional water, used significantly more water. The perception of people regarding the quality of their water was closely related to the bacteriological quality.There was significantly lower total morbidity and a tendency toward lower mortality for children in households using the improved method of water supply compared to children in households relying upon traditional water sources. On the other hand, there was no statistically significant impact upon any of the water-related diseases. Considering the poor environmental and personal hygiene as well as deficiencies in food supply, the lack of a significant impact is not surprising. Despite this, there was a conspicuous tendency of a decline in the prevalence of diarrhoea! diseases after intervention both among children in households using the improved water and in households not using it. There was thus a certain "spill-over" effect. All households, both those in the intervention and those in the comparison group, actively participated in the work of the water project, which resulted in an increased awareness of health related issues in both groups. This implies serious diffuculties when using a quasi-experimental design, which relies on before and after evaluations with comparison groups.There were strong inter- and intra-seasonal variations of all diseases. Eye- and skin-infection co-varied closely with variations in rainfall. The prevalence of diarrhoea! diseases was lowest during the beginning ofthe dry season, then gradually increased to reach a peak at the onset of the rains when total morbidity was lowest and after that decreased towards the end of the rainy season. The results indicate that accessibility to water as well as pesonal hygiene are relatively more important than the quality of the environment and the food supply. Children born during the beginning of the dry season had the lowest rates of diarrhoea diseases during their first 18 months, while those born during the beginning of the rains had the highest. The implications of climatic seasonality are thus of paramount importance when planning and implementing development programmes.