The Promotora de Salud Model Predominant Salvadoran strategy for provision of basic health care and health promotion in rural communities is typically through ‘promotores de salud,’ or health promoters. - HP model taps into existing community networks to provide health education and promotion in a culturally sensitive manner for hard-to-reach populations.[i] - HP programs are cost effective and appropriate for rural settings. - Clients are more likely to trust and relate to members of their own community than they would an outsider, leading to an effective solution for promoting behavior change. This is a model with which the community of Santa Clara is very familiar: they currently have one MOH-employed promoter allocated to the community, Ms. Josefa Jurado. MOH-employed promoters are typically responsible for promotion, prevention, treatment, and environmental sanitation in seven areas: child health, reproductive health, dental health, basic health assistance, first aid, basic sanitation, and health education. However, in Santa Clara, Ms. Jurado is the only promoter. She is often pressed to meet the most basic needs of all households, almost exclusively in the area of maternal and child health. This intervention seeks to complement ongoing health promotion activities in Santa Clara by supplementing promotion and education in the areas of personal and domestic hygiene, which is currently lacking. [i] Lewis M, Eskeland GS, Traa-Valerezo X. Challenging El Salvador’s rural health care strategy, Volume 1. The World Bank. 2000.

Promoters and the Intervention Community members consider the issues of hygiene and sanitation to be both household and community matters. Consequently, the program has been designed to address these issues on both levels. The promoters have three major functions: hygiene promotion and education; 2) demonstrations/assistance to achieve proper hygiene practices; and 3) evaluating the intervention. Their efforts focus on building necessary knowledge and skills to adopt and maintain proper hygiene practices; they also serve as role models of these practices. In addition, through community-based participatory research methods, the promoters collect data for evaluating the inputs and outcomes of the program. Training of Promoters The promoters were recruited from Santa Clara based on certain characteristics, such as leadership skills, minimum literacy and educational requirements, permanent residence in Santa Clara, and long-term interest in the program goals. Nineteen applicants applied for the positions and the final candidates were selected by community vote. The promoters received an initial 5-day training by the GWU/EWB/Santa Clara team, and receive follow-up trainings from the MOH and PCV on a regular basis. They were trained with skills in the areas of: leadership, communication and hygiene promotion, time management, problem solving, participatory learning, and data collection/instrumentation. A training manual was created and translated by the GWU team, Ms. Putzer and Ms. Jurado (available upon request).

240 gpm/48hrs Test. Water depth actually increased. Well is 327’ Deep.

$43,000 in labor $6500 for land; free community donated land for the well ADESCO will own the project and manage the administrative duties of the public health promoters

Rotary Club of Glen Burnie, MD Rotary Club of San Miguel El Chapparistique Engineers Without Borders – Washington DC George Washington University – Public Health Santa Clara, El Salvador - Water Distribution & Public Health Project

Non-profit 501(c)(3) humanitarian organization established to partner with developing communities worldwide in order to improve their quality of life. This partnership involves the implementation of sustainable engineering projects, while involving and training internationally responsible engineers and engineering students. Over 350 projects in 45 developing countries. Started in 2002 and now has over 250 chapters and more than 12,000 members in the US.

EWB Public Health A new endeavor Recognized need for public health aspect of EWB projects More effective methods for community assessment and ensuring sustainability Interest from engineers Emerging favor for multi-disciplinary projects

Community Location

Santa Clara, El Salvador Santa Clara (Pop. 3,165): Is a rural community within the municipality of San Rafael Oriente (Pop. 16,929), in the Eastern region of San Miguel Local Organizations: Associacion de Desarrollo Comunitario (ADESCO) Asociacion Nacional para la Defensa, Desarrollo y Distribucion del Agua a Nivel Rural (ANDAR) Peace Corps Ministry of Health Local municipal government

Background The people of Santa Clara suffer many hardships, as the majority live in suboptimal conditions without adequate housing, education, or an improved water source. Households contract local drilling companies to construct raw water wells. Most wells access the same shallow aquifer contaminated by community pit latrines. The contamination of wells has been confirmed through bacteriological testing of samples throughout the community that were positive for excessive levels of fecal coliform bacteria. High rate of morbidity associated with water-borne pathogens and related illnesses. Average Family spends 2-4 hours getting water every day. Every family member is involved.

Transport water with wagons Use of horsepower to draw buckets from well Water Collection - Today Carry water in large containers

Objectives A comprehensive approach to preventing illness by improving the water supply and Improving key hygiene behaviors, especially ensuring safe water storage & handling, food, personal and domestic hygiene, trash disposal, and improved sanitation. Clean water for the Santa Clara community: 250 Households, expandable to 400. The Community prefers piped water delivery to each individual household. It had already located a semi-remote, deep well from which to extract the raw water for their system.

9 Assessment & Implementation Trips

Lodging

Public Health

Hygiene Promotion/Education Program Health promoters Complement ongoing health education & promotion efforts by MOH (only maternal child health) Enhance local capacities for sustainable program Maximize health impact of water system

Health Promoters Household visits School hygiene Materials Assistance Role models/leaders Community mobilization (dengue, & trash clean-up) Upcoming: Water Management Education

Before Public Health Solid Waste

After Public Health Solid Waste

Your New Water System Handbook for households to understand: How the water system works Do’s and don’ts of system use How to use/store it properly How to conserve the resource How to prevent standing water (Dengue) How to understand their bill/quantity used

Still Some Work To Be Done… Water quality/quantity Water storage/handling Grey water disposal Child hygiene/care Open defecation of children Trash disposal Proximity of domesticated animals to homes

Technical Design    Water system components include: Water Board Office Water Pump & Storage Shed Chlorination System Control System Storage Tank Distribution Network Household Connection Grey Water Pits  

Water Board Office

Well and Pump Well Casing Diameter: 8” Design Point: 95 gpm @ 425ft Control System and VFD Minimum Pressure: 1psi Maximum Pressure: 100 psi Distribution System Number of Homes: 230 Gallons per home per day: 160 Maximum Pipe Diameter: 6” Minimum Pipe Diameter: 2” Maximum Pressure: 80 psi Minimum Pressure: 20 psi Chlorine Tablet Feeder Desired Chlorine Residual: 0.5 – 0.8 mg/L Tablet Feeder Design Ground Storage Tank Tank Storage: 100 m3 (25,000 Gallons) Tank Diameter: 6.8m (22’-4”) Tank Height: 3.9m (12’-10”) Potable Water System Schematic 4” PVC Well Fill Line Grade at well = 200m

Well Site & Pump Chlorine Tablet Feeder Pump

Power for Pump Changed from 3 Phase to 1 Phase Added VFD to Pump Mayor Paid for Design & Installation of Power Lines

Pump House

Pump Installation

Pump Controls

Storage Tank Design

Soil Test

Storage Tank Excavation

Tank Construction

Tank Construction(Cont.)

Tank Construction (Cont.)

Distribution System

Distribution (Cont.)

Pump to Tank Supply Line

Distribution to School

Mock-up House Hookup

Mock-up Grey Water Pit

Community Ownership The planning, development and implementation of this initiative has been community-driven, and the resultant water system and health promotion program will be community-owned and operated. What kind of help is the community providing? Unskilled labor for approximately 8,300 m3 of trenching for an estimated contribution of $43,000 USD (1 m3/person/day, $5/day) Free lodging for volunteers Transportation Equipment includes shovels, wheelbarrows, pickup trucks, etc. The local water board has already collected $6,500 for land (central well and tank locations) and $6,000 for individual household connections

Sustainability ANDAR & EWB provide ongoing community training Administration (Transparent bookkeeping, end of year income/expense reports & development of user fees) General and state laws governing potable water systems Protection and conservation of the water source Empowerment to encourage leadership as owners of the system Management of the Water Board (ADESCO), including participatory, democratic decision-making, roles of leadership Health Promoters continue to train community and ensure proper use of water system ADESCO to hire and train a system engineer from the community to operate and maintain the system EWB has and will continue to update its business plan for the self sustaining system to ensure affordability

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