Impact on diarrhoeal illness of a community educational intervention to improve drinking water quality in rural communities in Puerto Rico
Open accessAbstract
BACKGROUND: Waterborne disease is a major risk for small water supplies in rural settings. This study was done to assess the impact of an educational intervention designed to improve water quality and estimate the contribution of water to the incidence of diarrhoeal disease in poor rural communities in Puerto Rico a two-part study was undertaken. METHODS: An educational intervention was delivered to communities relying on community water supplies. This intervention consisted of student operators and administrators supervising and assisting community members who voluntarily "operate" these systems. These voluntary operators had no previous training and were principally concerned with seeing that some water was delivered. The quality of that water was not something they either understood or addressed. The impact of this intervention was measured through water sampling for standard bacteriological indicators and a frank pathogen. In addition, face-to-face epidemiological studies designed to determine the base-line occurrence of diarrhoeal disease in the communities were conducted. Some 15 months after the intervention a further epidemiological study was conducted in both the intervention communities and in control communities that had not received any intervention. RESULTS: Diarrhoeal illness rates over a four week period prior to the intervention were 3.5%. Salmonella was isolated from all of 5 distributed samples prior to intervention and from only 2 of 12 samples after the intervention. In the 15 months follow-up study, illness rates were lower in the intervention compared to control communities (2.5% vs 3.6%%) (RR = 0.70, 95%CI 0.43, 1.15), though this was not statistically significant. However, in the final Poisson regression model living in an intervention system (RR = 0.318; 95%CI 0.137 - 0.739) and owning a dog (RR = 0.597, 95%CI 0.145 - 0.962) was negatively associated with illness. Whilst size of system (RR = 1.006, 95%CI 1.001 - 1.010) and reporting problems with sewage system (RR = 2.973, 95%CI 1.539 - 5.744) were positively associated with illness. CONCLUSIONS: Educational interventions directed both at identified individuals and the community in general in small communities with poor water quality is a way of giving communities the skills and knowledge to manage their own drinking water quality. This may also have important and sustainable health benefits, though further research preferably using a randomised control trial design is needed.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Only two studies were identified for the transition from improved water source on premises to improved source, on premises, and higher water quality, and one study for the transition to improved source, on premises, and continuous supply.
“We identified only two studies for the transition from improved water source on premises to improved source, on premises, and higher water quality,24, 95 and one study for the transition from improved water source on premises to improved source, on premises, and continuous supply.85”
In these interventions, drinking water was not free from microbial contamination and was still stored at household level after intervention implementation.
“In these interventions, drinking water was not free from microbial contamination24, 95 and was still stored at household level85 after intervention implementation.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Standard methods: For the examination of water and waste water
Water Environment Federation., Water Pollution Control Federation., American Water Works Association., & American Public Health Association. (1990) · Analytical Biochemistry · doi:10.1016/0003-2697(90)90598-4 · Cited by 72,107 · see citing works
Standard methods for the examination of water and wastewater
(2012) · Choice Reviews Online · doi:10.5860/choice.49-6910 · Cited by 14,300 · see citing works
Fewtrell, L., Kaufmann, R. B., Kay, D., Enanoria, W. T. A., Haller, L., & Colford, J. M. (2004) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(04)01253-8 · Cited by 1,688 · see citing works
Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992–2003
SMITH, A., Reacher, M. H., Smerdon, W., ADAK, G. K., Nichols, G. L., & Chalmers, R. M. (2006) · Epidemiology and Infection · doi:10.1017/s0950268806006406 · Cited by 276 · see citing works
Waterborne outbreaks reported in the United States
Craun, M. F., Craun, G. F., Calderon, R. L., & Beach, M. J. (2006) · Journal of Water and Health · doi:10.2166/wh.2006.016 · Cited by 250 · see citing works
Hunter, P. R. (2009) · Environmental Science & Technology · doi:10.1021/es9028217 · Cited by 246 · see citing works
Self-citationLiang, J. L., Dziuban, E. J., Craun, G. F., Hill, V. R., Moore, M. R., Gelting, R. J., Calderon, R. L., Beach, M. J., & Roy, S. L. (2006) · PubMed · Cited by 231 · see citing works
Water safety plans: managing drinking-water quality from catchment to consumer
Davison, A., Howard, G., Stevens, M. A., Callan, P., Fewtrell, L., Deere, D., & Bartram, J. (2005) · Bristol Research (University of Bristol) · Cited by 214 · see citing works
Arnold, B. F., Arana, B. A., Mäusezahl, D., Hubbard, A., & Colford, J. M. (2009) · International Journal of Epidemiology · doi:10.1093/ije/dyp241 · Cited by 136 · see citing works
Messner, M. J., Shaw, S., Regli, S. E., Rotert, K., Blank, V., & Soller, J. A. (2006) · Journal of Water and Health · doi:10.2166/wh.2006.024 · Cited by 133 · see citing works
Mahmud, S. G., Shamsuddin, S. A. J., Ahmed, M. F., Davison, A., Deere, D., & Howard, G. (2007) · Journal of Water and Health · doi:10.2166/wh.2007.045 · Cited by 87 · see citing works
Drinking Water and Infectious Disease
Hunter, P. R., Waite, M., & Ronchi, E. (2002) · CRC Press eBooks · doi:10.1201/9781420040524 · Cited by 80 · see citing works
Self-citationRichardson, H. Y., Nichols, G. L., Lane, C., LAKE, I. R., & Hunter, P. R. (2009) · Water Research · doi:10.1016/j.watres.2009.02.035 · Cited by 74 · see citing works
Self-citationHow Clean Must Our Drinking Water Be: The Importance of Protective Immunity
Frost, F. J., Roberts, M. H., Kunde, T. R., Craun, G. F., Tollestrup, K., Harter, L., & Muller, T. (2005) · The Journal of Infectious Diseases · doi:10.1086/427561 · Cited by 70 · see citing works
Hunter, P. R., Pond, K., Jagals, P., & Cameron, J. (2009) · The Science of The Total Environment · doi:10.1016/j.scitotenv.2009.03.013 · Cited by 61 · see citing works
Self-citationNaumova, E. N., Christodouleas, J., Hunter, P. R., & Syed, Q. (2005) · Journal of Water and Health · doi:10.2166/wh.2005.0017 · Cited by 60 · see citing works
Self-citationSwift, L., & Hunter, P. R. (2004) · European Journal of Epidemiology · doi:10.1023/b:ejep.0000020453.84296.f6 · Cited by 35 · see citing works
Self-citationEnvironmental Justice and Drinking Water Regulations
Pontius, F. W. (2000) · American Water Works Association · doi:10.1002/j.1551-8833.2000.tb08904.x · Cited by 12 · see citing works
Using Existing Surveillance-Based Data
Nichols, G. L. (2002) · CRC Press eBooks · doi:10.1201/9781420040524.ch12 · Cited by 8 · see citing works
Chalmers, R., Naumova, E. N., Woodhouse, S. J., Christodouleas, J., Hunter, P. R., & Syed, Q. (2005) · Cited by 7 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Prüss‐Ustün, A., Bartram, J., Clasen, T., Colford, J. M., Cumming, O., Curtis, V., Bonjour, S., Dangour, A. D., De France, J., Fewtrell, L., et al. (2014) · Tropical Medicine & International Health · doi:10.1111/tmi.12329 · Cited by 1,198 · see citing works
Self-citationStrunz, E. C., Addiss, D. G., Stocks, M. E., Ogden, S., Utzinger, J., & Freeman, M. C. (2014) · PLoS Medicine · doi:10.1371/journal.pmed.1001620 · Cited by 807 · see citing works
Interventions to improve water quality for preventing diarrhoea
Clasen, T., Alexander, K., Sinclair, D., Boisson, S., Peletz, R., Chang, H. H., Majorin, F., & Cairncross, S. (2015) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd004794.pub3 · Cited by 498 · see citing works
Wolf, J., Prüss‐Ustün, A., Cumming, O., Bartram, J., Bonjour, S., Cairncross, S., Clasen, T., Colford, J. M., Curtis, V., De France, J., et al. (2014) · Tropical Medicine & International Health · doi:10.1111/tmi.12331 · Cited by 461 · see citing works
Self-citationWolf, J., Hunter, P. R., Freeman, M. C., Cumming, O., Clasen, T., Bartram, J., Higgins, J. P. T., Johnston, R., Medlicott, K., Boisson, S., et al. (2018) · Tropical Medicine & International Health · doi:10.1111/tmi.13051 · Cited by 403 · see citing works
Self-citationWolf, J., Hubbard, S., Brauer, M., Ambelu, A., Arnold, B. F., Bain, R., Bauza, V., Brown, J., Caruso, B. A., Clasen, T., et al. (2022) · The Lancet · doi:10.1016/s0140-6736(22)00937-0 · Cited by 377 · see citing works
Loukas, A. C., Hotez, P. J., Diemert, D. J., Yazdanbakhsh, M., McCarthy, J. S., Corrêa‐Oliveira, R., Croese, J., & Bethony, J. M. (2016) · Nature Reviews Disease Primers · doi:10.1038/nrdp.2016.88 · Cited by 336 · see citing works
Arikpo, D., Edet, E. S., Chibuzor, M. T., Odey, F. A., & Caldwell, D. M. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011768.pub2 · Cited by 149 · see citing works
Chan, E. Y. Y., Tong, K. H. Y., Dubois, C., Mcdonnell, K., Kim, J. H., Hung, K. K. C., & Kwok, K. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182312268 · Cited by 51 · see citing works
Hu, G., Mian, H. R., Abedin, Z., Li, J., Hewage, K., & Sadiq, R. (2021) · Journal of Environmental Management · doi:10.1016/j.jenvman.2021.113937 · Cited by 44 · see citing works
Jain, M., Lim, Y., Arce-Nazario, J. A., & Uriarte, M. (2014) · PLoS ONE · doi:10.1371/journal.pone.0088059 · Cited by 42 · see citing works
Takanashi, K., Quyen, D. T., Hoa, N. T. L., Khẩn, N. C., Yasuoka, J., & Jimba, M. (2013) · PLoS ONE · doi:10.1371/journal.pone.0070654 · Cited by 31 · see citing works
Keenum, I. M., Crespo‐Medina, M., Garner, E., Pieper, K. J., Blair, M. F., Milligan, E., Pruden, A. J., Ramírez‐Toro, G., & Rhoads, W. J. (2021) · Environmental Science & Technology · doi:10.1021/acs.est.0c08814 · Cited by 30 · see citing works
Self-citationHunter, P. R., Risebro, H. L., Yen, M., Lefebvre, H., Lo, C., Hartemann, P., Longuet, C., & Jaquenoud, F. (2013) · BMC Public Health · doi:10.1186/1471-2458-13-1145 · Cited by 19 · see citing works
Self-citationKhan, M. M. H., Gruebner, O., & Krämer, A. (2013) · Natural Hazards · doi:10.1007/s11069-013-0829-1 · Cited by 19 · see citing works
Inequalities in Access to Water and Sanitation in Rural Settlements in Parts of Southwest Nigeria
Akoteyon, I. S. (2019) · Ghana Journal of Geography · Cited by 18 · see citing works
Systematic risk management approach of household drinking water from the source to point of use
Mudau, L. S., Mukhola, M. S., & Hunter, P. R. (2017) · Journal of Water Sanitation and Hygiene for Development · doi:10.2166/washdev.2017.029 · Cited by 17 · see citing works
Self-citationKhan, M., Zanuzdana, A., Burkart, K. G., & Krämer, A. (2013) · Population Space and Place · doi:10.1002/psp.1777 · Cited by 15 · see citing works
Domestic water quantity, service level and health, second edition.
Howard, G., Bartram, J., Williams, A. R., Overbo, A., Fuente, D., & Geere, J. (2020) · UEA Digital Repository (University of East Anglia) · Cited by 13 · see citing works
Knowledge–Behavior Gap in Tap Water Consumption in Puerto Rico: Implications for Water Utilities
Nelson, T. N. T., Poleacovschi, C., Ikuma, K., García, I., Weems, C. F., Rehmann, C. R., & Estes, K. W. (2023) · ASCE OPEN Multidisciplinary Journal of Civil Engineering · doi:10.1061/aomjah.aoeng-0005 · Cited by 13 · see citing works
Gunnarsdóttir, M. J., Gardarsson, S. M., Eriksson, M., Albrechtsen, H., Bergkvist, K. S. G., Rossi, P. M., Matilainen, R., Hansen, L. T., Jensen, P. E., Maréchal, J. Y. A., et al. (2023) · Journal of Water and Health · doi:10.2166/wh.2023.088 · Cited by 9 · see citing works
Akoteyon, I. S., Aliu, I. R., & Soladoye, O. (2020) · Journal of Water Sanitation and Hygiene for Development · doi:10.2166/washdev.2020.157 · Cited by 9 · see citing works
Community Forums as Amplifiers of Communities’ Voices: Isolated Communities in Puerto Rico
Colón, Y. M. S., Acosta‐Pérez, E., Rivera, M. L. R., Sánchez-Cesáreo, M., Diaz, C. M., Ortiz, G. L., González, J. C. M., Albino, V. M. S., & Lemus, L. M. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20146335 · Cited by 8 · see citing works
Critical Water Issues in Africa
Wandiga, S. O. (2015) · ACS symposium series · doi:10.1021/bk-2015-1206.ch006 · Cited by 8 · see citing works
Community level research on water health and global change: where have we been? Where are we going?
Karanja, D. M. S., Elliott, S. J., & Gabizon, S. (2011) · Current Opinion in Environmental Sustainability · doi:10.1016/j.cosust.2011.10.002 · Cited by 7 · see citing works
Detection of Shiga toxin-encoding genes in small community water supplies
Crespo‐Medina, M., Greaves, I., Hunter, P. R., Minnigh, H. A., & Ramírez‐Toro, G. (2020) · Journal of Water and Health · doi:10.2166/wh.2020.236 · Cited by 7 · see citing works
Self-citationMostafa, S., Camacho-Galván, M. N., Castelán-Martínez, H. E., Galdos-Balzategui, A., & Reygadas, F. (2020) · Environmental Engineering Science · doi:10.1089/ees.2020.0245 · Cited by 6 · see citing works
Educational interventions for improving complementary feeding practices
Arikpo, D., Edet, E. S., Chibuzor, M. T., Odey, F. A., & Caldwell, D. M. (2015) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011768 · Cited by 6 · see citing works
Rodrigues, A. J., Oyoo, W. S., Odundo, F., & Wambu, E. W. (2014) · Journal of Water and Health · doi:10.2166/wh.2014.039 · Cited by 6 · see citing works
Cryptosporidium in small water systems in Puerto Rico: a pilot study
Robinson, G., Minnigh, H. A., Hunter, P. R., Chalmers, R. M., & Ramírez‐Toro, G. (2015) · Journal of Water and Health · doi:10.2166/wh.2015.223 · Cited by 5 · see citing works
Self-citationVictor, C. P., Garn, J. V., Nalá, R., Manuel, J. L., Mangamela, M., McGunegill, S., Snyder, J. S., Hubbard, S., Fagnant-Sperati, C. S., Brown, J. M., et al. (2026) · Nature Water · doi:10.1038/s44221-026-00624-x · Cited by 3 · see citing works
ESTUDO BIBLIOMÉTRICO DA PRODUÇÃO CIENTÍFICA NACIONAL E INTERNACIONAL NO SETOR DE SANEAMENTO
Reis, D. A., Esperidião, F., Jorge, M. A., Ribeiro, L. C. D. S., Mota, T. S., Santos, J. C. N., & Silva, A. T. (2017) · Revista Gestão Inovação e Tecnologias · doi:10.7198/s2237-072220170001007 · Cited by 3 · see citing works
Public Mistrust of Drinking Water Quality in Puerto Rico Post Hurricane Maria
Nelson, T. N. T., Poleacovschi, C., Ikuma, K., García, I., Weems, C. F., Rehmann, C. R., & Estes, K. W. (2025) · Springer proceedings in earth and environmental sciences · doi:10.1007/978-3-031-81072-5_13 · Cited by 2 · see citing works
Qualidade das águas de nascentes na bacia hidrográfica do rio Paraguaçu, Cruz das Almas, Bahia
Barros, L., Cruz, C. L. D. C. V., & Silva, V. (2015) · Revista Brasileira de Recursos Hídricos · doi:10.21168/rbrh.v20n3.p668-676 · Cited by 2 · see citing works
Seasonal hazards and health risks in the Mekong Delta:a multi‐disciplinary approach
Few, R., Hunter, P. R., LAKE, I. R., Tran, P. G., Thien, V. T., & Tuấn, N. Q. (2010) · UEA Digital Repository (University of East Anglia) · Cited by 2 · see citing works
Self-citationAssessment of the water facilities in primary schools in the Niger Delta. WASH education series 1
Kotingo, E. L., Ayerite, A. L., & B, C. C. (2014) · IOSR Journal of Dental and Medical Sciences · doi:10.9790/0853-13935561 · Cited by 2 · see citing works
Social Development and Security for Smart Economic Development
Ndugwa, R. P., Opiyo, R. O., Mwaniki, D., & Odhiambo, O. (2016) · Advances in 21st century human settlements · doi:10.1007/978-981-10-1610-3_26 · Cited by 1 · see citing works
Rural health mapping the Reconcavo of Bahia
Barros, L. S. S. E. (2016) · Revista Brasileira de Higiene e Sanidade Animal · doi:10.5935/1981-2965.20160051 · Cited by 1 · see citing works
Ryan, M. O., Haas, C. N., & Betz, L. D. (2012) · doi:10.17918/etd-3994 · Cited by 1 · see citing works
Riani, P. N., Budiyono, B., & Nurjazuli, N. (2023) · Advances in health sciences research/Advances in Health Sciences Research · doi:10.2991/978-94-6463-324-5_51
Safely managed drinking water service use and child diarrhoea based on evidence from 24 countries
Greenwood, E. E., Freymond, M., Scheidegger, A., Lauber, T. B., Tussupova, K., Pickering, A. J., & Julian, T. R. (2026) · Nature Water · doi:10.1038/s44221-026-00647-4
- Authors
- Hunter, P. R., Ramírez Toro, G. I., & Minnigh, H. A.
- Affiliations
- University of East Anglia (GB)
- Corresponding author
- Hunter, Paul R
- ORCID
- Hunter, Paul R
- Venue
- BMC Public Health
- Published
- 2010-04-28
- Volume
- 10
- Issue
- 1
- Pages
- 219-219
- ISSN
- 1471-2458 (ISSN-L)
- PMC
- PMC2876105
- OpenAlex
- W1965300299
- Cited by
- 40
- References
- 20
- Citations by year
- 2026: 2 · 2025: 1 · 2023: 3 · 2022: 1 · 2021: 3 · 2020: 4 · 2019: 1 · 2018: 2 · 2017: 2 · 2016: 3 · 2015: 5 · 2014: 6 · 2013: 4 · 2012: 1
- FWCI
- 2.28
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Public Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Topics
- Physical Sciences › Environmental Science › Water Science and Technology › Water Resource Management and Quality
- Physical Sciences › Environmental Science › Water Science and Technology › Fecal contamination and water quality
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Keywords
- diarrhoeal diseases, drinking water quality, community water supply, rural communities, waterborne diseases, Salmonella, water quality management, dog ownership, sewer systems, bacteriological water quality, Puerto Rico, diarrhea prevention, water quality certification
- MeSH terms
- Adult, Diarrhea, Female, Follow-Up Studies, Health Education, Humans, Male, Middle Aged, Puerto Rico, Surveys and Questionnaires, Rural Population, Salmonella, Incidence, Young Adult, Water Quality, Drinking Water
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
