Childhood mortality in relation to nutritional status and water supply--a prospective study from rural Malawi.

In connection with the introduction of an improved method of water supply in rural Malawi, the nutritional status, morbidity, and mortality among 1,178 children under five were studied during three rainy and three dry seasons. Data were collected at fortnightly home interviews. Nutritional assessment was made twice a year. One hundred and thirty-seven of the children died during the study period, and the probability of dying before the age of five was estimated to 270 per 1,000 children. The mortality risk was related to weight for height (p less than 0.001) and height for age (p less than 0.01) as well as to upper arm circumference (p less than 0.001) and triceps skinfold (p less than 0.05). Mortality among children living in households using the new, piped-water supply tended to be lower than mortality for those using traditional water sources, although the difference was not statistically significant (relative risk 0.4, 95% confidence interval 0.1-1.3).

Bacteriological contamination of water in rural areas: an intervention study from Malawi.

The bacteriological quality of drinking water sources and of stored household water was examined in a rural area of Malawi, before and after improvement of the method of water supply. Among the traditional water sources, water quality was better in springs than in wells and rivers. During the rainy season, there was a considerable deterioration of water quality, which was most pronounced in wells. The improved water supply system consisted of piped, untreated surface water from an uninhabited mountain area. This water contained a mean value of 54 faecal coliforms per 100 ml which can be regarded as acceptable in this setting. During collection of drinking water and during household storage, there was considerable contamination, which mirrored the unhygienic environment. Contamination was worse during the rainy season than during the dry season. Technical interventions aimed at improving water supply in rural areas of developing countries will probably not become effective unless combined with comprehensive health education programmes for the population concerned.

Child health and household water supply: a longitudinal study of growth and its environmental determinants in rural Malawi.

The growth of 1029 children under 5 years of age, in rural Malawi, was studied during 1 year before and 1 year after the introduction of a piped water supply system. The study was performed to evaluate the effect of socio-economic and environmental factors, especially water supply, on growth. In general, the first 2 years of life were highly liable to nutritional impairment. The seasonal variation of growth rate was most pronounced in children under 2 years. It was found that crowding, measured both as population density and as members per household, had a negative impact on the growth of younger children. In households utilizing piped water, children did not display significantly better growth when compared with children in households using traditional water sources. Although clean water in itself is vital, it was not enough to improve the growth of young children under the conditions that we have studied. It is suggested that, when providing an improved water supply, sanitation and hygiene education are necessary additions. Other ways of reducing recurrent infections, in combination with effective nutrition during and after episodes of disease, should also be given increased consideration in order to improve growth.

Water supply, sanitation and health education programmes in developing countries: problems of evaluation.

There are several methodological problems related to evaluating the impact that improved water supply, sanitation and health education projects have on public health. Fifteen studies of intervention programmes, one by the present authors, are discussed. Since non-intervention studies of water supply are difficult to assess, a valid study design must include an intervention programme, even though such studies are more costly and time-consuming. Detailed descriptions of programmes, study plans, and analytical methods are often lacking, and different studies reach greatly diverging conclusions. It may be proposed that studies based on "weak" methodology give a more positive impression of improved public health after improvement of water supply than do before-after studies using comparison groups.