Improving water quality in Nogales, Sonora, Mexico to decrease
Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. CPH 628: Program Planning & Evaluation Dr. John Ehiri Fall 2010 Felipe Caldeira Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Table of Contents Overview and Specific Aims .................................................................................................... 3 Background and Rationale ...................................................................................................... 4 Design and Methods ............................................................................................................... 8 Overall Study Design ................................................................................................................................................................ 8 Rationale ....................................................................................................................................................................................... 9 Frameworks ................................................................................................................................................................................. 9 Methods ....................................................................................................................................................................................... 10 Intervention ............................................................................................................................................................................... 12 Analysis ........................................................................................................................................................................................ 14 Monitoring and Evaluation .................................................................................................... 14 Inputs & Input Evaluation ................................................................................................................................................... 14 Processes & Process Evaluation ........................................................................................................................................ 14 Outcomes & Outcome Evaluation ..................................................................................................................................... 15 Impact ........................................................................................................................................................................................... 15 Logical Frameworks ............................................................................................................................................................... 16 Program Logistics .................................................................................................................. 21 Organizational Capacity ........................................................................................................................................................ 21 Budget .......................................................................................................................................................................................... 21 Reporting .................................................................................................................................................................................... 22 Sustainability ............................................................................................................................................................................. 22 Protection of Human Subjects ............................................................................................... 23 Risks to the subject ................................................................................................................................................................. 23 Adequacy of Protection Against Risk .............................................................................................................................. 24 Potential Benefits to Subjects and Others .................................................................................................................... 25 Importance of Knowledge to be Gained ........................................................................................................................ 25 Inclusion of Women, Children and Minorities ............................................................................................................ 25 Data and Safety Monitoring Plan ...................................................................................................................................... 26 Data Sharing Plan .................................................................................................................................................................... 26 Conclusions and Limitations .................................................................................................. 26 Appendices ........................................................................................................................... 28 References ............................................................................................................................ 47 Page 2 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Overview and Specific Aims This study proposes to reduce the prevalence of gastrointestinal disease and therefore the
morbidity and mortality associated with the disease in regards to people's consumption of potable
water in Nogales, Sonora, Mexico by conducting formative research and implementing a cost
Aim 1: To conduct formative research to assess the water delivery systems in Nogales, Sonora
and its potential impacts on people's health. Water sources in Nogales can come from
the groundwater such as the Santa Cruz Watershed, surface water such as the Santa Cruz
River, or piped in from the Los Alisos area. From there, water is then delivered to
people's homes either through the municipal water system, municipal water trucks,
private water trucks from owners with private wells, or bottled water. It's important to
analyze which source and delivery is used more so than others and how the water arrives
before it reaches the home.
Based on the literature18, we hypothesize that at least 60% of families in
communities that are not connected to the municipal water system rely on private
water trucks or pipas.
Aim 2: To assess the relationship between water safety and diarrheal diseases in Nogales,
Sonora by analyzing water sources at the point of use aka at point of consumption.
Based on the literature16, we hypothesize that the prevalence of diarrhea will be
higher in neighborhoods without access to pipe-borne water.
Based on the literature18, we hypothesize that the water will have more harmful
metals and minerals than microbes.
Aim 3: To design and implement a targeted intervention involving communities hypothesized to
be most at risk such as those not receiving piped water in order to decrease the
prevalence of diarrhea and exposure to harmful metals. Based on the literature3, the
intervention chosen to be implemented is a flocculent intervention that has shown to be
effective in eliminating microbes and metals from water without chlorination in
communities that don't have access to reliable water and must store their water in
Aim 4: To assess the effects of the intervention on the chosen intervention group by comparing
it to the control group at pre, mid (every four months), and post (end of the program).
Based on the literature2, 7, we hypothesize that the prevalence of diarrhea will
decrease by at least 50% by the end of the two year program.
We also hypothesize based on the literature2, 7 that reduction in diarrhea will be
positively correlated with reduction in microbial contamination of water sources.
Page 3 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Aim 5: To recommend to local authorities possible interventions, next step items, and policy
changes to improve the overall health of the Nogales, Sonora community for the future.
Cultural relevance is integral for understanding factors influencing any barriers.
Through qualitative research (focus groups & key informant interviews), informed
strategies can to targeted by the community, rather than at the community.
Background and Rationale People, businesses, industry and society can thrive only if there is a dependable source of high
quality water. It is well understood that water is essential for the maintenance of life. It functions
in digestion, absorption, circulation, and excretion, and plays a role in maintaining body
temperature. Water serves as a building material for growth and repair of the body, and it is part
of all body tissues and fluids. When it comes to public health, water holds a number of
significant implications for health. For instance, inadequate consumption of water is detrimental
to human health and contributes to mortality in developing societies. Numerous studies9 have
shown that dehydration will kill faster than starvation. Everywhere in the world special attention
to water needs should be given to special populations such as infants and to the sick, and in hot
environments, to all persons18. Also, chronic water shortages seriously compromise household
sanitation and personal hygiene which, in turn, can lead to a variety of health problems, most
notably gastrointestinal diseases and parasitic infections9. Shortages can also indirectly affect
health by causing water users to seek substitutes for household delivery. This practice often
results in chemical or microorganism contamination from the alternative source or from the
vessels used for storage or transfer25. Frequently, water is stored in 55-gallon drums usually
scavenged from local industries such as in Nogales, Sonora, Mexico.
The US-Mexico border is a stretch of land of about 3,000km that stretches East to West from the
Pacific Ocean to the Gulf of Mexico and stretches North and South 100km wide due the La Paz
Agreement14. Over the past 20 years, a unique dynamic of commerce and trade has affected the
region in part due to the North American Free Trade Agreement. Migration in Mexico has
heavily increased to the border region as industrial factories, or maguiladoras, provide financial
incentives to both migrant workers as well corporations in both countries for their cheap labor
and proximity to major cities for transport14.
However, this high influx of people migrating to the border has caused a significant strain on
local resources. Public services and systems have been heavily burdened by the increase demand
for resources which have not been improved significantly to respond to this pressure. This lack
of access to services and resources have created squatter communities in the region known as
colonias marginales or marginalized neighborhoods16. These are neighborhoods that have a very
low socio economic status and thus are vulnerable to the impacts of health. These neighborhoods
also lack transportation, roads, and even access to water and proper plumbing.
Page 4 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. This study will investigate the border region of Nogales, Sonora, Mexico. See Figure 1 for a
detailed map of the region including Nogales, Arizona. Nogales, Sonora, with a population of
approximately 350,00016 draws people throughout Mexico to the border with the hope of finding
jobs in the maquilidoras just like other regions on the border. The city has grown so rapidly, that
municipal water and sewerage systems have not kept up with growth23. Several neighborhoods or
colonias are not even connected to the local water system. Figure 2 illustrates Nogales, Sonora's
water system line and shortage. Water from approximately 41 wells are processed by filtration
before entering the domestic water supply delivered by pipe through the older portions of the
city. Most residents purchase bottled water for drinking due to fear of the local water quality13.
Parts of the city experience water delivered by “stand pipes” where resident bring containers and
fill them. In other areas, trucks may deliver water to residential or public tanks. Some residents
may even obtain water from the homes of friends or relatives. As mentioned earlier, this practice
of transporting and storing water leaves room for potential contamination25.
Figure 1. Map of Ambos Nogales Region24
Page 5 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Figure 2. Map of Nogales, Sonora Water System Distribution24
Nogales, Sonora has continuously been experiencing a water shortage. This is due to the natural
composition of the area as well as over use of the local water system. The mountain ranges
surrounding Nogales mostly comprise "impermeable Tertiary volcanic materials" that cannot
store groundwater18. The two cities themselves are built on top of a Quaternary alluvia, a bed that
can yield moderate amounts of water at relatively shallow depths. However, due to urbanization
and industrialization, the regional water balance has been altered. In consequence, growing
human demand has been rapidly depleting stores of subsurface water which is the only stable
water source. Given these pressures of population and development, "natural" recharge from
mountain-front and stream-channel recharge processes cannot adequately replenish the supply of
groundwater18. In order to compensate for this, the city of Nogales regularly shuts off water
supply to certain neighborhoods at certain hours of the day during certain days of the week5. This
shortage has also prompted concerns of why the water system should not be expanded.
There is also a concern for Nogales's local water system delivery. Mack and Varady18 state that
the sewers beneath the streets of Nogales, Sonora, are aging and poorly maintained. Therefore,
not only are entire zones and neighborhoods unserved or underserved as discussed previously,
but even sewered areas are problematic because of breaks and leaks. These breaches are
Page 6 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. exacerbated regularly by rushing floodwaters caused by the region's heavy rainfalls, during the
summer "monsoons"4. As a result, during such episodes sewer-line breaks are common and leaks
find their way to the aquifer, threatening groundwater quality in the long run. During these
periods of extreme flooding, moreover, health hazards increase due to open exposure of raw
sewage and post-flood surface accumulations create breeding ground for infectious disease18.
For the above reasons of water shortage and system delivery problems, residents of Nogales, like
those in other border communities, experience many of the health problems associated with
inadequate sewerage and the ensuing water contamination, primarily gastrointestinal diseases
and hepatitis9. A study conducted by the Ambos Nogales Water Project revealed that diarrheal
diseases, along with acute respiratory infections, were the principal causes of morbidity among
children from birth to four years of age18. The same study also found that gastroenteritis and
other infectious diseases were the seventh leading cause of mortality among the general
population in the region. The same study found an incidence rate for Hepatitis A of 27 cases per
10,000 people in Nogales, Arizona, and 18.67 cases per 10,000 people in Santa Cruz County.
These incidence rates were considerably higher than those for other Arizona border counties
such as Yuma and Cochise County. Hepatitis A is a virus transmitted through water and food by
This growing concern has prompted the U.S. Environmental Protection Agency (EPA) to
commission a report23 stating that "wastewater collection and treatment is the most pressing
infrastructural problems facing the urbanized portions of the U.S.-Mexico border." But
recognizing that it is not just an infrastructural problem, the report goes on to state that "its
solution would resolve many associated environmental and health problems in the large and
small population centers of the region."
The Ambos Nogales Water Project18 also conducted an investigation of water quality in the
region. They discovered that wells and wastewater lines in Nogales, Sonora, were generally
contaminated by bacteria. It is important to note that the Nogales International Wastewater
Treatment Facility reduces, but does not eliminate, bacteriologic contamination caused by
wastewater19. The water project also found elevated nitrate levels that exceeded Mexican
standards as well as detectable concentrations of volatile organic compounds (VOC's) in the
The Arizona Department of Environmental Quality (ADEQ) and the Arizona Department of
Health Services (ADHS) monitored ground water in the region and discovered amounts of the
carcinogen tetrachloroethylene or TCE in excess of the Arizona Based Guidance Levels (HBGL)
and maximum containment level (MCL)18. Fecal coliforms have also been continuously found in
excess of both national standards by various studies investigations19. It is important to note
however that fecal coliforms are not a health hazard per se but their presence are good indicators
of potential health problems, such as gastroenteritis and hepatitis because of fecal contamination
in the water.
Page 7 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Needless to say, there is enough evidence to suggest that there are health concerns in Nogales,
Sonora that need to be addressed. An aging water delivery system allows for contamination
during flood seasons and other microbes and carcinogens have been discovered in the water in
the region due to the influx of factories. A recent comprehensive review of 100 studies
evaluating the health impact of improvements in water supplies and sanitation in developing
countries found that improvements in water supply alone were associated with a median
reduction of 25% in diarrheal morbidity1. The same study also revealed that, in these same areas,
improvements in both water and sanitation have an even greater impact on mortality than on
illness, with a median reduction of 60% in deaths from diarrheal diseases. Just a slight
improvement in water quality plays a major role in improving a community's health and quality
To put things into perspective, the prevalence of diarrhea in the United States is approximately
10-15%2. In Mexico, particularly in the border region, the prevalence of diarrhea is about 25%1, 6,
. Some have attributed this spike in prevalence across the border to inadequate infrastructure
while others blame contaminated sources such as rivers and ground water. Not much research
has been published about water quality in the border town of Nogales, Sonora Mexico. Most the
literature available on the topic shows that sampling was done sporadically at different sources
from wells to washes20. Almost no published research is available in terms of water quality at
point of use20.
Design and Methods Overall Study Design This project will be quasi experimental with a non-equivalent group design (NEGD). Three
different communities will be investigated in this project to look at how water quality varies
along socioeconomic status (SES). Low, middle, and high SES neighborhoods or colonias will
be selected. From there, promotoras and research assistants will recruit 200 households to be
recruited in the study. Therefore, 66 households from each colonia will be recruited into the
study and represent changes in water quality along SES. Because we hypothesize that the colonia
with the lowest SES will have the lowest water quality since they are not connected to the city’s
municipal water system, half of those recruited in the low SES colonia will be a part of the
flocculent intervention while the other half will be the control of the flocculent intervention. In
other words, of those approximately 66 in the low SES colonia, 33 will be a part of the flocculent
intervention and the other 33 will be the control and will therefore not receive the flocculent
intervention. A pre, mid, and post assessment will be done at each household for water quality
and prevalence of diarrhea. Water samples will be collected and surveys investigating the rate of
diarrhea in the household during the past month will be done at the start of the program and
every four months for two years or in other words, when the study will end. The last collection of
data will be the post assessment. Those recruited for the intervention will have data (water
quality analysis and survey) taken on a monthly basis in order to observe a better trend over time
Page 8 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. of the effectiveness of the flocculent intervention. Table 1 illustrates the NEGD model chosen
for this project.
Table 1. Non Equivalent Group Design Model
Rationale Although the NEGD for this project does no allow for complete random assignment of groups, it
does however offer a close structure to a randomized design. Because the control group and the
intervention group will be from the same neighborhood or colonia in Nogales, Sonora, Mexico, it
is expected that they will be similar in regards to access to water, water use, disinfection
practices, water storage, and therefore water quality. In the NEGD method, even though the two
chosen groups are not randomly assigned and therefore not equivalent, they must be as similar as
possible. Because the control and intervention groups will be from the same colonia, we believe
this design method will be sufficient.
Frameworks The Ecological Model is based on the concept that there is a multi-factoral causation to disease
and health related behavior. The ecological model assumes that the problem is not always
behavior related but rather has social, economic, cultural, organizational, institutional, and even
environmental components. Each of these components are encapsulated within the other
therefore the flow of influence can go from the bottom up or vice versa. When using the
ecological model to find solutions to problems, it is important that interventions seek to address
problems across the spectrum and employ a range of strategies that will operate on multiple
levels. Because there are multiple factors that influence the overall quality of water at the point
of consumption, we believe that the ecological model best illustrates the situation in Nogales,
Sonora, Mexico. Figure 3 is a representation of the ecological model as it applies to this region.
Page 9 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Figure 3. Conceptual Framework of Water Quality in Nogales, Sonora, Mexico As discussed in the Background and Rationale sections of this proposal, the US-Mexico region
fueled by economics, trade, and government interests have lead to water inequities,
environmental vulnerability and decreased enforcement and regulation of the environment due to
maquiladoras, and caused a greater divide in SES. This in turn has created inequitable
neighborhoods or colonias that lack basic resources and hindered involvement among
themselves. Finally, it trickles down to the individual level and how it shapes individual values,
beliefs, knowledge, and attitudes when it comes to water quality. For instance people may
mistrust the water they receive and therefore spend money on bottled water rather than investing
in infrastructure or lack of knowledge and awareness of the current water and environmental
situation can lead to apathy in seeking out cleaner better water. We believe that our interventions
and assessments will ultimately come out of each component but the results will go back to the
Societal level and trickle down to cause change.
Methods In order to fulfill specific aim 1, an in depth review and analysis of the water delivery system of
Nogales, Sonora, Mexico will have to be done. It is imperative to know which neighborhoods in
Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Nogales, Sonora have access to water; how does water get to their home; what are the national,
statewide, and local laws, regulations, and enforcements for clean water; what are the limitations;
etc. These questions can be answered by conducting a formative literature review but most
importantly, meeting with local authorities experienced in this topic such as the municipal water
company (OOMAPAS16), international water commission (CONAgua16), bottled water
companies, water truck distributors, and any others involved in the complex system. Water
samples will be collected by researchers from each identified source and analyzed for microbes
such as total fecal coliforms, E.coli, enterococci as well as metals such as arsenic, lead and
Specific aim 2 will be fulfilled by conducting a water quality analysis study and
prevalence of diarrhea in various neighborhoods in Nogales, Sonora of all economic levels: poor,
middle class, and rich. 66 homes from each socioeconomic status will be recruited for the study
for a total of 200 homes. Each home will have water sampled from point of use whether that be a
kitchen sink or plastic storage tank i.e., tinaco14, 16, and will be analyzed for microbes such as
total fecal coliforms, E.coli, enterococci as well as metals such as arsenic, lead and mercury. A
survey will be implemented inquiring about each household’s prevalence of diarrhea, diarrhea
treatment methods, water sanitation practices, drinking habits, among others. The survey will be
implemented and samples will be taken by a team of community health workers or promotoras.
Samples and the survey will be implemented twice a year, once during the summer and once
during the winter to test for seasonal variability. Evidence has shown3 that water quality
decreases during rainy or wet seasons also known as monsoon season such as the summer in this
region and water quality improves during the dry season or winter season.
Specific aim 3 will also be conducted with the use of promotoras. Promotoras will
instruct participating households that have been identified as having water quality that poses a
threat to the participant's health on how to properly use flocculent and clean their water storage
units. Households under this intervention will continue to have their water analyzed and a
diarrheal survey implemented on a monthly basis rather than on a biyearly basis. The
effectiveness of the intervention will be evaluated by comparing water quality and health
outcomes during pre, mid, and post intervention implementation. This analysis and evaluation
will fulfill specific aim 4.
Once all the research as been gathered and analyzed on how water is delivered, the health
outcomes of the community because of the water quality, the success or failure of the flocculent
intervention, recommendations can be made for the city of Nogales, Sonora. Meeting with local
health officials and political officials on the findings will help disseminate information better and
help fulfill specific aim 5. Promotoras can provide input from their observations in the field and
limitations they encountered with their one on one interaction with participating households.
With the information obtained, the City of Nogales, Sonora can make informative decisions on
how to best improve the access to water to its citizens, improve the water quality to its citizens,
and improve the overall health of its citizens. For instance, should the city invest in expanding its
piped water or should the city enforce harsher regulations for illegal dumping, cleaner water
trucks, and contaminated wells?
Page 11 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Intervention Rather than investigate the current water quality at the point of use or consumption and compare
over time how it might have changed, an intervention will take place that we hypothesize will
improve water quality for those that we hypothesize will have poor water quality due to lack of
infrastructure. The intervention consists of maintenance of their water storage container whether
that be an industrial metal tank (tambo), a plastic container on top of the house with plumbing
(tinaco) or any other device as well as the use of flocculent. Flocculent is a disinfectant powder
that is added to drinking water to remove microorganisms, organic matter and heavy metals3.
The flocculent disinfectant includes many chemicals used in commercial water treatment but has
been specially formulated to work quickly on small volumes of water. All ingredients in the
flocculent disinfection are used in commercial water treatment or in food products and are
generally recognized as safe. Other similar alternatives have existed such as adding chlorine
tablets to stored water however several microorganisms are chlorine resistant such as
Cryptosporidium and users have expressed dissatisfaction with the intervention due to the
residual taste of chlorine in their water3.
The flocculent disinfectant combines precipitation, coagulation and flocculation with
chlorination. The procedure is simple: a sachet of flocculent added to a container of water and
stirred vigorously for 5 minutes, let stand for another 5 minutes and then filtered through a cloth
to another storage vessel and finally, waiting an additional 20 minutes is all it takes for clean
drinking water. 4 sachets are enough for a week's worth of water consumption and each sachet
costs $0.035. A recent World Health Organization study3 found that in total, there was a 40%
reduction in the longitudinal prevalence of diarrhea among people using the flocculent that did
not have access to a potable water system. The study also showed a 39% reduction in diarrheal
incidence among individuals less than 5 years of age, the most vulnerable population, and an
astonishing 72% percent reduction in individuals greater than 15 years of age3. Because of this
high rate of success and low cost high benefit factor of flocculent use, we believe that this
intervention if conducted correctly could provide a great benefit to the city of Nogales as it
decides to build infrastructure for its poor by keeping them healthy when consuming one of life’s
most necessary items.
Personnel will consist of two teams; a research team and a community team. The research team
will consist of the Principal Investigator (PI), a Co-Principal Investigator (CoPI), a doctoral
student, a program coordinator, and research assistants. The community team will consist of a
team of promotoras (approximately 25). The PI will be responsible for all aspects of the study
including ensuring that all specific aims are met and outcomes become realized. The CoPI will
be responsible for assisting the PI and will act as the second in command. A doctoral student will
be added to be an intermediate between all personnel as well as develop his or her own research
interest and thesis from this project. The program coordinator will be responsible for
coordinating promotoras and handling all administrative duties and data management. Research
assistants will be employed to handle remedial tasks.
Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Promotoras will be personnel but will not be on salary as the others. Promotoras will incentivized
with a cash reward for every household they recruit into the study by $100 for each household.
Promotoras that successfully recruit households into the intervention trial will receive another
$100 cash incentive. Promotras will be responsible for recruiting households in the
neighborhoods chosen for the project, administering and collecting surveys, collecting water
samples, instructing on the intervention procedure, and acting as a referral in case any household
has any questions or concerns about their case of gastrointestinal disease.
Quantitative methods consist of data gathered from water samples, epidemiologic indicators
from the survey and success rates from the intervention. Quantitative methods from water
samples will indicate number, concentration, and rate of E.coli, total fecal coliforms, enterococci,
as well as concentrations of chosen metals arsenic, lead, and mercury. Quantitative methods from
the survey will illustrate rates and prevalence of gastrointestinal disease. The same methods will
also prove or disprove the success of the flocculent intervention.
Qualitative methods will consist of information gathered from surveys and field notes from
promotoras as well as significant information obtained from stakeholder meetings. Although the
survey will have structured questions such as “has anyone in the household had an episode of
diarrhea in the past week – yes or no” there will also be open ended questions to asses
individuals’ impact on their community such as “how do you think water quality can be
improved?” and “how much more would you be willing to pay for better quality water and
why?” Even without open-ended questions in the survey, we believe a questionnaire provide up
to the minute primary source statistics that public health records cannot provide. Field notes
gathered from the promotoras based on their monthly experience with the intervention group will
also be used to analyze some challenges households faced with the intervention as well as any
comments, questions, or concerns they might have had. This information will then be used to
improve the intervention if possible for any wider implementation in the future. Using this mix
method approach, we believe the data gathered and our results will portray a more accurate
representation of the local water resources and its impact on human health.
Recruitment into the study will be done at random after the three neighborhoods or colonias are
chosen. From there, promotoras will go door to door in each colonia and ask a consenting
member of the household, preferably a woman, if they would be willing to participate in the
study. Promotoras will educate them on the procedures and times when data will need be
gathered and present the consenting household member with a consent form. The consent form
will have to be signed and the family member must be aware that they can choose to end the
study at any time as well as understand the risks and benefits. The only exclusion criteria for the
study is that they must live in one of the three colonias selected and the head of the household
member must be 18 years or older. Inclusion criteria would be anyone else that does not meet the
Page 13 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Informed Consent
Informed consent will be obtained from every participating household. All consenting materials
will be translated into their native Spanish and a copy will be given to them with contact
numbers to the researchers as well as the university’s human subjects protection hotline. When
informed consent is being given, participants will understand that there is little to no risk being
involved in the study even if they are a household enrolled in the intervention program and that
their answers and results will be kept confidential. Informed consent and study approval will be
obtained from the university’s human subjects protection department before the start of the
Analysis Analysis will be done using a suite of software. The questionnaire will be analyzed using SPSS
software and Envivo software. SPSS is ideal for analyzing structured questionnaire and N Vivo
provides better tools for analyzing open-ended questions, which the survey will contain, and
field notes taken by the promotoras and staff. Water quality data will be analyzed using SAS,
which is commonly used for biostatistical data. Each household will be given a unique identifier
so that names and other personal identifiable information will not be used. Data for each
household will illustrate rate of diarrhea over time as well as water quality over time such as
number of E.coli colonies at each point of collection. As mentioned earlier, houses not part of the
intervention will have data collected every four months for 2 years where as houses as part of the
intervention will have data collected every month for 2 years. ArcGIS will also be used for
mapping the results. For instance to illustrate where colonias are in relation to one another; if
they receive piped water, from where; prevalence of diarrhea for the neighborhood, during what
season; rates of E.coli, rates of metals etc. Ultimately, we want to observe trends over time for
water quality and diarrhea in relation to location and resources.
Monitoring and Evaluation This project will involve multiple inputs and processes that will produce outcomes and overall
impacts. For a detailed illustration on how these components interact, see Figure 4 and Table 2.
Inputs & Input Evaluation Inputs include staff, promotoras, number of stakeholder meetings as well as funds and lab
materials. The program coordinator will be responsible for assessing the status of each of these
inputs every 6 months to see if the study is where it needs to be or if resources need to be
allocated elsewhere. Processes & Process Evaluation Page 14 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Processes associated with the project include a water quality analysis, a questionnaire, the
flocculent use intervention, and education on flocculent use and proper disinfection practices.
Evaluation of these processes such as if goals have been met will include number of promotoras
enrolled in the program, number of participating households, number of people partaking in the
intervention, and number of samples collected to name a few.
Outcomes & Outcome Evaluation We believe that this project will produce certain outcomes. These outcomes include, reduced rate
of diarrhea; reduced exposure to contaminated water; increased flocculent use; a reduction in
illegal dumping; increase in water truck or pipa inspection; increase in well inspection. These
outcomes will be evaluated by observing trends in the data gathered based on the water samples
and questionnaires from each group and if the project is meeting these outcome objectives.
Impact We hope that after all these objectives are successfully met, the project will have achieved
improved health; healthier more productive workforce; expanded infrastructure; reduced social
inequities; improved costs for the city of Nogales. We understand that these impacts may be
difficult to achieve as well as difficult to measure during the length of the study. However we
believe that if these inputs and outcomes are met and evaluated for as described in Table 2, then
these impacts well be met later along the road especially with the help from the published results
from this study, which we plan to disseminate. In order to achieve program sustainability, we
hope to hire a doctoral student who will plan their dissertation on the impacts of this study or
implementing the intervention, if successful, on a larger and self-sustaining level so that
generations may benefit if the city of Nogales chooses or delays in building infrastructure for
communities that lack it. More information on program sustainability is available in the
sustainability section of this document. Figure 4 below illustrates how inputs and outputs from
this program will be monitored and evaluated as discussed.
Page 15 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Figure 4. Flowchart of Monitoring and Evaluation
Logical Frameworks Logical Frameworks are a common way to help provide a structured approach to priority setting as well aid in planning, implementing and evaluating projects. Table 2. Project Logical Framework, below, summarizes the activity design. Program objectives are displayed vertically and are depicted hierarchically: Goal →Outputs → Activities. The ways in which progress against each objective is assessed is displayed horizontally. External factors that might influence the achievement of objectives, assumptions and risks, are listed in the last column. Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Table 2. Project Logical Framework Narrative Summary Objectively
Prevalence data on
local morbidity and
To contribute to
mortality as it relates
quality in the Nogales,
water legislation for
reduced rate of
To implement an
intervention aimed at contaminated water;
quality and decreasing use; a reduction in
increase in water
truck or pipa
inspection; increase in
1. To conduct
formative research Public records
to assess the water available
Sonora and its
on people's health.
2. To assess the
and water quality
results presafety and
department will value
the project and invest
resources into its
Records and data are
available and of use
Analysis of trends in
the data based on
water sample tests,
department data and
including public and
private sectors will
value the project and
rally around it to
(including scale up)
Records are available
Provide a valuable
Collect water samples
for microbes and
Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. sources at the
point of use aka at
3. To design and
hypothesized to be
most at risk such
as those not
water in order to
4. To assess the
effects of the
intervention on the
by comparing it to
the control group
at pre, mid (every
four months), and
post (end of the
5. To recommend to
step items, and
policy changes to
overall health of
community for the
related morbidity and
pre, mid, and post
survey and water
Reduce exposure to
Intervention will be
Flocculent use has no
Reduction in diarrhea
Increase in flocculent
Reduction in exposure
and water quality
Collect water samples
for microbes and
Reduction in illegal
legislation pre and
Increase in water
Increase in well
regulate and enforce
Legislation will pass
Page 18 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. document
re review of water
availability in the
Number of meetings
Sign in sheets
Number of people
Number of people in
1.c: Water quality
Records of all
2.a: Survey of
Rate of diarrhea in the
2.b: Water quality
standards for the
2.c: Recruitment in
field notes on
Number recruited in
the study (N=198)
participating in the
Number of usable
People will want to
Reports of findings
Pre, mid, and post
Results will be
People will want to
Pre, mid, and post
People will want to
flocculent in the
Attendees will grant
Permission will be
granted to collect
samples from public
sources (rivers, wells,
People will want to
Promotoras will want
Field notes will
Page 19 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. households
flocculent use by
4.a: Water quality
households in the
project to undertake
Promotoras will take
adequate notes on
People will conduct
Pre, mid, and post
People will want to
4.b: Survey of
Rate of diarrhea
Pre, mid, and post
Significant trend over
5.a: Create a final
Number of reports
A physical bilingual
People will read the
Number of meetings
5.c: Submit findings
Attendees will use
Sign in sheets
Number of people
Conflicts may arise
Findings will get
Number of people in
Copies of publications Several backtracking
Receipts of attendance Available venues to
Page 20 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Program Logistics Organizational Capacity Esperança is a non-profit organization based in Phoenix, Arizona that was started by Father
Luke Tupper in 1972 to help communities in rural Brazil receive medical attention and assist
with disease prevention8. Today, it provides "health and hope to the world's poor" through
health projects and even surgery run by volunteers and community health workers in 14
countries around the world and the United States8. Esperança's mission is to "improve health and
provide hope for families in the poorest communities of the world through sustainable disease
prevention, education and treatment"8.
Esperança as a whole operates mainly on the foundation and power of volunteers educating
community members on health education to empower them to make correct health decisions and
disseminate that information to others for generations to come. For their project in Mexico, they
have used the power of promotoras or community health workers to help disperse health
education and prevention messages in impoverished communities. Promotoras are often women
from the communities in which they serve and have given up their time and life's to provide
community health education and advocacy services for the uninsured and underserved in the
community. Numerous studies have shown that the use of promotoras has been more effective
in getting health education and prevention across than doctors, social workers, or other strangers
as these volunteers are often more personable and have better community ties8. As well as
providing health services to various communities around the world, Esperança also coordinates
numerous health festivals, educational workshops, capacity building initiatives, and has
representatives attend important and cultural community meetings and events to establish a
presence in communities and form close community ties. These activities are significant as they
are vital for the success of promotora programs in these communities as they feel that
promotoras are one of them and accessible people. Esperança is looking to expand their
successful promotoras program into the Southeastern Arizona region with the help of this grant.
Budget Funds for salaries will be used to pay for the PI, the Co-PI, a doctoral student, and a program
coordinator. The PI will be responsible for all aspects of the study, ensuring that all specific aims
are met, and being the main in command. The Co-PI will assist the PI in any way possible and
will be second in command. The doctoral student will assist and be an intermediate between the
PI, Co-PI and Program Coordinator and will be responsible in developing his or her thesis
around this project with a focus on project sustainability. The Program Coordinator is
responsible for all administrative duties and coordinating and organizing among the promotoras.
To help the recruitment numbers and assist the work of the promotoras, each promotora will
receive $100 for each participating household they successfully recruit plus an additional $100
for each household they recruit to be a part of the intervention. Materials will be needed for
sample collection and delivery. Analysis of samples will be conducted at a contracted laboratory
Page 21 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. at $50 a sample. Intervention equipment includes flocculent, cloth and other materials given
regularly to each household identified having poor water quality.
Project Title: Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease.
Budget Period: 06/01/2010 - 05/31/2012
Promotora reimbursments for travel and meals @ $100 a month
Travel from university to Nogales @ $300 a month
Office Supplies @ $75 a month
Field Equipment @ $100 a month
Lab Analysis @ $50 a sample
Intervention Equipment @ $10 a household
Conference Travel @ $3000 twice a year
Total Direct Costs
IDC Base: MTDC
UA Indirect Cost @ 51.5% off campus 24 months
165 homes analyzed twice a year plus 33 homes analyzed monthly
$100 for each participating household plus and additional $100 for
each house in the intervetnion
200 households + 33 in the intervention
Reporting Reporting on our findings and disseminating the information we believe are critical for research
altruism. Reporting, or publishing, will begin during the 4th quarter of the last year of funding
for the study. The Principal Investigator along with the Co-Principal Investigator and the
doctoral student will work on publishing their findings in peer reviewed journals, presenting in
conferences, publishing in proceedings, getting media coverage, and working with government
leaders in properly utilizing information and disseminating it. Final stakeholder meetings will
also be conducted to report on the findings and disseminate information. Executive summaries
and fact sheets will be developed and distributed on the successes and limitations of the program
for community leaders, advocates, and legislators in order to promote the expansion of the
program within the city and throughout the state and elsewhere.
Sustainability It is important that programs that are implemented outlast their funding sources. One way to
accomplish this is with a sustainability component. The first two years of the program will rely
heavily on funding in order to gather information about the Nogales, Sonora region, build
Page 22 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. relationships and test the intervention. When the intervention is proven to be successful and cost
effective for the city, Nogales can establish a citywide program of flocculent use and tinaco
disinfection practices with the help of promotoras. This component will be a form of
sustainability as the city will be implementing the intervention long after the program and study
The process of ensuring that such a sustainable program will be established will be the
responsibility of the doctoral student employed in the program. He or she will be responsible for
establishing relationships with community leaders and members, forming a coalition, providing
training, designing a program, implementing, and disseminating any information obtained. Doing
so will allow the city of Nogales to improve the health of its citizens by providing tools and
education for proper water sanitation practices while the city continues to seek resources for
expanding its water delivery system. Although we strongly believe and the evidence suggests
that the best method to provide clean and accessible water to the citizens of Nogales is through a
direct piped system with proper waste water disposal and treatment, this accomplishment may
take years if not generations to achieve due to the vast amount of costs and complex
governmental systems. Therefore having a simple, community led program such as the one
discussed will help Nogales reach better community health through clean water at an inexpensive
cost for the time being.
Protection of Human Subjects Risks to the subject Human Subject Involvement and Characteristics
The purpose of this study is to reduce the rate of gastrointestinal disease in Nogales, Sonora,
Mexico as it pertains to water quality. Therefore, the involvement of human subjects is
imperative. The population of the Nogales, Sonora, Mexico region is diverse. Therefore this
study will include men, women, pregnant women, children, people will disabilities, and
minorities. This study does not target specifically any of the characteristics above but instead any
representative from the household. Human subject involvement will be two fold. One consists of
sharing information about the health status of the family within the household. The other consists
of voluntarily undertaking a flocculent intervention and appropriate water sanitation practices.
Another component that will not require human subject involvement but will require their
consent is the collection of water samples from their home.
It is an ethical and necessary practice to protect human subjects from risks associated with
research. Because of this, all materials associated with this project such as survey and project
proposal will go through and be approved by the University of Arizona’s Human Subjects
Protection Program. The institution will be advised of any changes in procedures and any new
risks associated in accordance with their policies. Since this is a project that will take in a foreign
Page 23 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. country, investigators will seek out human subjects approval with a Mexican institutional
counterpart whether it be through another university or governmental office.
Sources of Material
Sources of materials for this study include information gathered from a survey analyzing
prevalence of diarrhea in the household, water samples and secondary data collected for a needs
assessment of current resources as explained earlier.
The potential risks identified as part of this study include privacy and exposure. Because
personal and private information will be collected from participants such as rate of diarrhea in
the household, demographic information, sanitation practices, quality of life, and others, there is
always a slight chance of breach of privacy by investigators or outsiders. Risks associated with
exposure include flocculent use. Although no adverse affects have been identified with
flocculent use, there is a potential that new research will prove otherwise. However, although
these potential risks have been identified, we believe them to be minimal and a discussion of
protection from these risks is presented later.
Adequacy of Protection Against Risk Recruitment and Informed Consent
Households will be recruited at random by the promotoras voluntarily involved in the study. A
total of 200 households will recruited from 3 different neighborhoods that represent 3 different
socioeconomic status levels (rich, middle and poor). Promotoras will introduce themselves to the
chosen household, briefly explain the study, ask if they would be willing to participate, then read
the informed consent with the head of household and finally obtain a signature. The promotora
will provide her contact information to the head of household in case they have any questions.
The promotora will make clear that the household may stop participating at any time and that the
information they use will not be used against them and will not be identifiable.
Protection Against Risk
This research can be classified as minimal risk since it will only entail the sharing of household
information, collection of water, and an intervention involving flocculent use which has been
characterized by the World Health Organization3 as safe. However, since no research is free from
risk, this project will take necessary steps to protect subjects from any risk. Foreseeable risks in
being a participant in this project include privacy concerns and exposure to the flocculent.
Privacy will be managed by keeping data locked and encrypted within campus grounds and
according to campus policies for protection of human subjects. Identifiable information such as
name and address will be given a unique code so that they are unidentifiable to outside
investigators. Also, any publication will include results as a culminating analysis and not
individual case studies. For risks associated with flocculent exposure, we believe them to be
minimal according to the World Health Organization since the concentration in flocculent is
Page 24 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. minimal and consumption in water will not increase. However, if researchers learn of any
adverse affects of the flocculent use or any of the accompanying procedures, the intervention
will halt and intervention equipment will be repossessed to prevent further use. Any data
gathered until that point will be used for research analysis. Participants will be informed of
adverse affects and be treated for by medical staff provided by funding from the university’s
Human Subjects Protection Program. Mexican counterparts and stakeholders involved the study
will also be notified.
Potential Benefits to Subjects and Others Although subjects will not be compensated for participating in the study, they will have several
benefits. For one, the information they provide will be used for the greater Nogales community
and will help key decision makers and stakeholders make informed decisions about issues
surrounding water quality, health and infrastructure. For some subjects the study will provide the
benefit of clean water. Because we believe many receive poor quality water because of several
sources for contamination, this study will provide some subjects with tools and knowledge to
receive better, healthier water no matter how the water reaches them provided by the city thanks
to the intervention of flocculent use discussed earlier. Therefore, the results from all aspects of
this study (assessment and intervention) will benefit the city of Nogales if not other border
Importance of Knowledge to be Gained The knowledge to be gained from this project is invaluable. The information willingly obtained
and analyzed will provide the city of Nogales with a tool for combating its high rate of
gastrointestinal morbidity. The knowledge gained will also allow future researchers to
adequately assess US-Mexico border issues, Nogales water quality issues, and what interventions
can alleviate those issues.
Inclusion of Women, Children and Minorities Although women, children and minorities will not be specifically recruited for this project, their
information will be a culmination of the head of household’s reporting information. For instance,
the head of household for one of the participating homes may report that their child under the age
of 18 had an episode of diarrhea within the past week which they claimed was a result of
drinking water. This information will be treated as an indirect account of events and not a direct
account from a minor which would require separate consent. It is safe to assume that because this
project will take place in Mexico, majority if not all respondents will be of Hispanic origin which
is not a minority in the country. The involvement of women will be a major part of this study.
Not only will all the promotoras be women but we believe that the female head of household
will also be more likely to share information about her household and health. Therefore several
Page 25 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. women, whether knowingly pregnant or not, will be recruited in the study but will not entail any
more risks than discussed earlier or require separate authorization.
Data and Safety Monitoring Plan Adverse events will be immediately reported to the PI. The PI will be available to discuss
adverse events to community health workers and other research staff when necessary. The PI
will inform the University of Arizona Institutional Review Board of any adverse events within
48 hours of receiving the report. The PI is also responsible of reporting any adverse events to
community leaders and officials involved in the project or who had provided input.
Data Sharing Plan Data from this intervention will be stored in locked file cabinets and electronically. Any items
that could identify participants from the data will be removed, along with any items that could
lead to the deductive disclosure of any participants’ identities. We plan to publish the results
from this intervention and will consider all requests for data sharing by other researchers
working with community health worker interventions and water quality research in the USMexico border region. The requests for data sharing will be decided by the PI, Co-PI and
doctoral student, if necessary. If an agreement for data-sharing is made, applicants will only
have access to the non-identifiable data and the principal investigator would require a copy of all
drafts for publishing as well as successfully published research results from the data.
Conclusions and Limitations In the context of Nogales, Sonora, Mexico having inequitable water resources and inequitable
water quality with accompanying health disparities and the evidence supporting domestic
flocculent use to combat poor water quality and better health we believe that the program we
propose is important. Among the anticipated outcomes, both short term and long term, of our
Reduce diarrheal related morbidity and mortality by 50%;
Reduce exposure to harmful metals such as arsenic, lead, and mercury by 50%;
Increase flocculent use and hygienic practices by 50%;
Reduce illegal dumping of wastes;
Increase water truck inspections;
Increase private and public well inspection
Dissemination of results will ensure replication of good practices in other parts of
city, the country and elsewhere.
Page 26 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. There are inevitable limitations to every study. Identified limitations to this intervention include
With a violent drug warfare taking place in Mexico, especially in border
communities, its possible that residents will be weary in participating in a study
supported by Mexican government officials. With that said, the safety of the staff and
volunteers like the promotoras are also in risk and a surge in violence could affect
pause the study or halt further investigation all together.
Because we expect people receiving the intervention to conduct the intervention on a
regular basis, there is a possibility that they will not conduct the intervention or report
falsely that they did which in turn will affect the results of the water quality analysis.
Discussing gastro intestinal disease and other private and potential uncomfortable
information to strangers can be difficult. Due to cultural norms, we believe the female
head of the household would be willing to report on her family’s health to another
woman (promotora) rather than the male head of household. But even taking this
cultural approach can still cause underreporting of diarrhea.
Based on literature and personal communication, we are assuming that there is a
consensus that there are problems with the water delivery systems in Nogales.
However, we run the risk of discovering during stakeholder meetings that officials
don’t see this as a problem and that conducting such a project can be perceived as
intrusive, offensive, and placing blame.
With Nogales’s booming industry and industrial growth, the population is growing exponentially
and resources, both environmental and infrastructural have not been able to keep up with
demand. Because of this, communities have been receiving inadequate or poor quality water,
which in turn affects their health acutely (diarrhea from microbial exposure) and even
chronically (cancer from metal exposure). Working collaboratively with community health
workers or promotoras, community leaders, state officials, will help ensure participation and
individual behavior change in the promotion of treating water at home as well as expanding
infrastructure to eliminate health disparities. This unique collaboration will improve people’s
health since water is essential for life. Finally, in spite of the sometimes difficult cultural
circumstances and obstacles in a foreign country such as Mexico, we are confident that it is
feasible for us to execute this endeavor.
Page 27 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Appendices A. CONSENT FORM (ENGLISH) B. CONSENT FORM (SPANISH) C. INITIAL SURVEY (ENGLISH) D. INITIAL SURVEY (SPANISH) C. FOLLOW UP SURVEY (ENGLISH) D. FOLLOW UP SURVEY (SPANISH) Page 28 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Project Title: Water Quality and Health Analysis in Two Different Colonias of Nogales, Sonora, Mexico You are being invited to take part in a research study being conducted by The University of
Arizona and asked to read this form so that you know about this research study. The
information in this form is provided to help you decide whether or not to take part. If you
decide to take part in the study, you will be asked to sign this consent form. If you decide
you do not want to participate, there will be no penalty to you, and you will not lose any
benefit you normally would have.
The purpose of this study is to investigate the quality of life, access to water, and water quality in your
neighborhood and any potential connections to your health.
You are being asked to participate in this study because you live in Nogales, Sonora, Mexico.
A total of 200 households will participate in this study.
If you choose to participate, you will partake in two surveys and water will be collected.
The first survey will take place now and should last 30 minutes. The second survey will take place in the
winter and should last about 10 minutes.
If you are selected to participate in an intervention, water will be collected from your house once a month
and a short survey too.
The intervention consists of cleaning your water storage container and using a flocculent every 2 weeks.
A promotora will assist you and be your guide through this process
The things that you will be doing have no more risk than you would come across in everyday life.
There is no direct benefit to you by being in this study. What the researchers find out from this study may
help the community of Nogales, Sonora discover ways to improve their water quality and delivery.
Aside from your time, there are no costs for taking part in the study. You will not be paid for being in this
Information about you will be stored in locked file cabinet; computer files protected with a password. This
consent form will be filed in an official area.
Information about you will be kept confidential to the extent permitted or required by law. People who
have access to your information include the Principal Investigator and research study personnel.
Representatives of regulatory agencies such as the Office of Human Research Protections (OHRP) and
entities such as the University of Arizona Human Subjects Protection Program may access your records to
make sure the study is being run correctly and that information is collected properly. The agency that funds
this study (Udall Center for Public Policy) and the institutions where study procedures are being performed
(The University of Arizona and the United States Geological Survey) may also see your information.
However, any information that is sent to them will be coded with a number so that they cannot tell who you
are. Representatives from these entities can see information that has your name on it if they come to the
study site to view records. If there are any reports about this study, your name will not be in them.
You can call the Principal Investigator to tell him about a concern or complaint about this research study.
Page 29 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. The Principal Investigator, XXXXXXX, can be called at (520) 626-XXXX. You may also contact the Co
Principal Investigator, XXXXXXX, at (520) 626-XXXX.
For questions about your rights as a research subject; or if you have questions, complaints, or concerns
about the research and cannot reach the Principal Investigator or want to talk to someone other than the
Investigator, you may call the University of Arizona Human Subjects Protection Program office at (520)
626-6721 or visit their website at http://orcr.vpr.arizona.edu/irb/contact
You have the choice whether or not to be in this research study. You may decide to not begin or to stop the
study at any time.
Any new information discovered about the research will be provided to you.
STATEMENT OF CONSENT I agree to be in this study and know that I am not giving up any legal rights by signing this form. The procedures, risks, and benefits have been explained to me, and my questions have been answered. I know that new information about this research study will be provided to me as it is available and that the researcher will tell me if I must be removed from the study. I can ask more questions if I want, and I can still receive medical care if I stop participating in this study. A copy of this entire, signed consent form will be given to me. ___________________________________ ____________________________________ Subject's Signature Date INVESTIGATOR'S AFFIDAVIT: Either I have or my agent has carefully explained to the subject the nature of the above project. I hereby certify that to the best of my knowledge the person who signed this consent form was informed of the nature, demands, benefits, and risks involved in his/her participation. ___________________________________ Signature of Presenter ___________________________________ Signature of Investigator ____________________________________ Date ____________________________________ Date Page 30 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Título del proyecto: Análisis de Calidad del Agua y la Salud en dos colonias diferentes de Nogales, Sonora, México Ha sido invitado a participar en un estudio de investigación conductado por la Universidad
de Arizona y le pide que lea este formulario para que usted sepas de este estudio. La
información en esta forma se proporciona para ayudarle a decidir si desea o no participar.
Si usted decide tomar parte en el estudio, se le pedirá que firme este formulario de
consentimiento. Si decide que no quiere participar, no habrá sanción para usted, y usted no
perderá ningún beneficio que tendría normalmente.
El objetivo de este estudio es investigar la calidad de vida, acceso al agua, y la calidad del agua en su barrio
y las conexiones potenciales a su salud.
Se le pide a participar en este estudio porque usted vive en la colonia de Lomos de Fátima o el área que
contiene colonia Marguerita Maza de Juárez y la colonia Luis Donaldo Colosio.
Un total de 40 familias participarán en este estudio, 20 de cada área.
Si decide participar, usted participará en dos encuestas y agua será recogido por un total de 6 veces, tres
veces provenientes de tres fines de semana en verano y tres veces provenientes de tres fines de semana en
el invierno acerca de principios de enero.
La primera encuesta se llevará hoy y tendrá una duración de 30 minutos. La segunda encuesta se llevará en
el invierno y debe durar unos 10 minutos.
Las cosas que se le hace no tendrá un riesgo más de lo que vendría a través de la vida cotidiana.
No hay ningún beneficio directo a usted por participar en este estudio. Lo que los investigadores averiguar
a través de este estudio puede ayudar a la comunidad de Nogales, Sonora descubrir maneras de mejorar su
calidad y entrega de agua.
Aparte de su tiempo, no hay costos para participar en el estudio. No será para participar en este estudio.
Información sobre usted serán almacenados en un gabinete de archivo bloqueado; archivos informáticos
protegidos con una contraseña. Este formulario de consentimiento se archivará en un área oficial.
Información sobre usted se mantendrá confidencial hasta el límite permitido o requerido por la ley. Las
personas que tiene acceso a su información incluye el Investigador Responsable y personales del estudio.
Representantes de las agencias reguladoras como la Oficina de Protecciones Humano de Investigación
(OHRP) y otras entidades como la Universidad de Arizona Sujetos Humanos Programa de Protección
puede acceder a sus registros para asegurarse de que el estudio se está ejecutando correctamente y que la
información se recoge correctamente. La agencia que financió este estudio (Udall Center for Public Policy)
y las instituciones en los procedimientos del estudio se llevan a cabo (la Universidad de Arizona y el
United States Geological Survey) también puede ver su información. Sin embargo, toda la información que
se envía a ellos se identifican con un número para que no se puede saber quién es usted. Los representantes
de estas entidades puede ver la información que tiene en ella su nombre, si llegan al sitio de estudio para
ver los registros. Si hay una publicación sobre este estudio, su nombre no estará en ellos.
Puede llamar al investigador principal para hablarle de un problema o queja en respecto a este estudio. El
investigador principal, Robert Varady Ph.D., puede ser contactado a (520) 626-4393. También puede
comunicarse con el investigador de posgrado, Felipe Caldeira, a (520) 921-0388.
Page 31 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Para preguntas acerca de sus derechos como sujeto de investigación, o si tiene preguntas, quejas o
inquietudes sobre la investigación y no puede llegar al investigador principal o quieres hablar con alguien
que no sea el investigador, puede llamar a la Universidad de Arizona Sujetos Humanos Oficina del
Programa de Protección a (520) 626 a 6721 o puedes ir a http://orcr.vpr.arizona.edu/irb/contact
Usted tiene la opción de aplicar o no estar en este estudio de investigación. Usted puede decidir no iniciar o
detener el estudio en cualquier momento.
Cualquier nueva información descubierta sobre la investigación serán proporcionados a usted.
DECLARACIÓN DE CONSENTIMIENTO Estoy de acuerdo en participar en este estudio y saber que no estoy renunciando a cualquier derecho legal al firmar este formulario. Los procedimientos, riesgos y beneficios fueron explicados a mí, y mis preguntas fueran contestadas. Sé que la nueva información sobre este estudio de investigación será proporcionada a mí, ya que está disponible y que el investigador me dirá si ha que ser retirado del estudio. Puedo hacer más preguntas si quiero, y todavía pueden recibir atención médica si dejo de participar en este estudio. Una copia de este firmado formulario de consentimiento será dado a mí. ___________________________________ ____________________________________ Firma del Sujeto Fecha DECLARACIÓN JURADA DEL INVESTIGADOR: Yo o mi agente ha explicado cuidadosamente al sujeto la naturaleza del proyecto mencionado. Certifico que a lo mejor de mi conocimiento la persona que firmó este formulario de consentimiento fue informado de la naturaleza, exigencias, beneficios y riesgos de su participación. ___________________________________ Firma del Presentador ___________________________________ Firma del Investigador ____________________________________ Fecha ____________________________________ Fecha Page 32 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Water Quality and Health Analysis in Two Different Colonias of Nogales, Sonora, Mexico Ask to see the male or female head of household over 18.
Introduce the project by saying something like:
“Hello, my name is ________. The University of Arizona is interested in conducting a study on
water quality and health in your neighborhood and also to determine what you think about your
life in Nogales. We were wondering if you would be willing to participate in this study. No one
will be told what you tell us. We will combine everyone’s answers and only report the combined
answer from all surveys.
There is about 40 questions altogether and it should take no more than 25 minutes for you to
answer them all. We would also like to collect water samples from your home. Would you be
willing to participate?”
1) If no, thank them for their time and move on.
2) If yes, thank them for participating, hand them the consent form for them to sign allowing
them time to read it.
3) Meanwhile fill out the starter questions.
4) Give them a copy of the survey to follow along and ask if they have any questions.
5) Read all questions exactly as worded so that each respondent is asked the same
questions. Instructions to interviewers are in italics and should not be read to the
Date : _______________________________________________
Start Time : __________________________________________
End time: ___________________________________________
Participant Household Data
Street address: __________________________________________
Nearest Cross street __________________________________________
Gender: Male Female
Please circle the appropriate answers.
First, I would like to ask questions about yourself.
Page 33 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 1. What is your age range?
a. 18 to 24 b. 25 to 34
c. 35 to 44
d. 45 to 54
e. 55 to 64
f. 65 or over
2. How long have you lived in Nogales, Sonora (in years)?
a. 0- 1 year b. 1-5 years c. 5-10 years d. 10-20 years e. all your life
3. How many people live in your household?
a. 1 b. 2 c. 3
d. 4 e. 5
j. more than 9
4. Do you have pets?
5. Do you rent or own your house?
c. Other: _____________________
6. How many cars does the household have?
a. 0 b. 1 c. 2
d. 3 e. 4
f. more than 4
Now I would like to ask you questions about living in Nogales. On a scale from 1-5 with 1 being
the lowest value and 5 being the highest value, how would you rate the following:
7. Satisfaction with your current housing (your house and this colonia)?
8. Satisfaction with the responsiveness of your local government to your needs?
9. Satisfaction with your personal quality of life in Nogales?
10. In general, how happy are you with your life?
11. How would you rate how you can get medical treatment in your community?
Now I would like to ask you questions about you and your family’s health. Everyone gets
episodes of diarrhea. Some have episodes more than others. Diarrhea can be defined as soft,
watery, bowel movement that is sometimes difficult to control and may occur more than once a
day. Tell me:
12. Do you see diarrhea as a problem or a natural occurrence?
b. Natural occurrence
Page 34 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 13. Did you or anyone in the household have episodes of diarrhea recently?
a. Yes (Go to #14 below)
b. No (Go to #18 below)
1) Under 18
3) 65 and
If Y, then #
of times in
If Y, then #
of times in
18. What would you say was the cause of the episode(s) of diarrhea experienced by you or
d. Not sure
e. Other: _____________________________
19. When someone in the house gets diarrhea, how is it normally treated? Mark all that
c. Other over the counter medication:________________
d. Prescription medication:____________________
f. Herbal remedies besides tea:____________________
Page 35 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 20. Do you think the water makes you sick?
a. Yes b. No
Water Use Questions
Now I would like to ask you questions relating to how you get your water and how you use it.
Please answer the following:
21. How do you get your DRINKING water?
a. Potable water
b. Bottled water
c. Private water truck
b. City water truck
c. Other (specify) _____________________________________
22. Is this house connected to the city’s water system through pipes?
a. Yes. b. No
23. If you receive water from the system, during what times is what delivered to you?
24. Do you store your water?
b. Yes. If yes,:
2. Tank on top of the house
3. Water tank or portable container
4. Underground tank
5. Plastic gallon or plastic bucket
6. Dishes (pots, etc.)
7. Others (specify)______________________________________
25. How does the water that reaches your house look?
c. With sand or dirt or particles
d. Other particles
26. Do you clean your water before using it to drink or cook?
b. Yes. If yes, which treatment:
Page 36 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 4. Other (specify)______________________________________
27. Would you be willing to treat your water any further than what you already do?
28. How many glasses of water (~237mL) do and your family drink a day?
e. more than 8
29. How do you obtain water for use other than drinking (baths, washing, etc.)?
Piped in/Potable water (water faucet)
Private water truck
City water truck
Other (specify) _____________________________________
30. How much money do you spend on water per month (water bill, supplies, etc.?)
a. Less than 100 pesos b. 100-300 pesos
c. 300-500 pesos
d. 500-700 pesos
e. 700-900 pesos
f. 1000-1300 pesos g. 1300-1500 pesos f. More than 1500
Water Quality Questions
Now I would like to ask you questions relating to water and the environment in Nogales. On a
scale from 1-5 with 1 being the lowest value and 5 being the highest value, how would you rate
31. The overall purity of potable water in Nogales?
32. The purity of piped water in your household, if it’s piped?
33. Satisfaction with your water service?
34. Your concern over the purity of potable water in your community?
35. Concern with flooding and drought in the region?
Policy Implication Questions
Now I would like to ask you questions about what you would like to see change and how you
think that can be achieved. These questions are your opinions and are not predetermined
answers. Tell me briefly:
36. How much more per month would you be willing to pay for better potable water?
37. What would you recommend so that potable water is improved?
Page 37 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 38. What could the citizens of Nogales and OOMAPAS do to improve potable water?
39. If you pay taxes, how much more would you be willing to pay for better potable water?
40. What could you do to improve potable water for the city?
Page 38 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Water Quality and Health Analysis in Two Different Colonias of Nogales, Sonora, Mexico Winter Survey Ask to see the female head of household over the age of 18.
Reintroduce yourself and remind them of the study and the interview they did by saying:
"Hello, my name is ________. We were here during the summer to collect water samples and ask
questions about water quality and health in your neighborhood and also to determine what you
think about life here in Nogales. We were wondering if we could finish the interview and collect
a final, water sample. Remember that no one will know what you tell us. We will combine
everyone’s answers and only report on the combined answers from the survey.
This time there are only 4 questions total and it should take no more than 5 minutes to respond.
Can we get started?"
If no, thank them for their time and ask if there’s a better time to finish the survey and collect
water samples. If yes, thank them for participating and begin the survey.
Read all questions exactly as worded so that each respondent is asked the same questions.
Instructions to interviewers are in italics and should not be read to the respondents.
Date : _______________________________________________
Start Time : __________________________________________
End time: ___________________________________________
Best time for collecting water samples :____________________
Everyone gets episodes of diarrhea. Some have episodes more than others. Diarrhea can be
defined as soft, watery, bowel movement that is sometimes difficult to control and may occur
more than once a day. Tell me:
1) Under 18
3) 65 and
If Y, then #
of times in
If Y, then #
of times in
Page 39 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Person 4
Análisis sobre la Calidad del Agua y la Salud en Nogales, Sonora, México. * La encuesta debe ser atendida por persona mayor de 18 años.
** Invitación a ser encuestado:
"Hola, mi nombre es ________. La Universidad de Arizona está interesada en la realización de
un estudio sobre la calidad del agua y la salud en su colonia y también para determinar lo que
usted piensa acerca de su vida en Nogales. Queremos saber si estaría dispuesto a participar en
este estudio. Toda la información que proporcione será confidencial y solo será utilizado para
fines estadísticos. Vamos a combinar las respuestas de todos y sólo informan de la respuesta
combinada de todas las encuestas. Queremos saber si estaría dispuesto a participar en este
El total de preguntas a responder son cuarenta, el tiempo de respuesta se estima en veinticinco
minutos como máximo. Para complementar el estudio, le estamos solicitando que nos permita
tomar muestras de agua de su casa; para nosotros es necesario hacer las tomas en tiempos
diferentes, que no tardará más de cinco minutos, por lo que le pedimos autorización para
recabarlas durante los próximos tres fines de semana y la misma cantidad de muestras en época
de invierno, antes del mes de enero. ¿Estaría dispuesto a participar?"
1).- En caso de negativa, agradecer tiempo brindado.
2.- En caso afirmativo, darles las gracias por participar, dan a ellos la autorización para que
firmen y le dan tiempo para leerlo.
3).- Mientras tanto, llene las preguntas primarias en la caja.
4).- Déles una copia de la encuesta y póngase a sus órdenes en caso de que tengan duda sobre
alguna de las preguntas.
5).- Lea todas las preguntas exactamente como está redactada de manera que cada encuestado
se le pide las mismas preguntas.
Hora de inicio: _______________________________________
Hora de finalización: ___________________________________
Datos de la casa:
Intersección más cerca___________________________________
Género: Femenino Masculino
Favor de encerrar las respuestas apropiadas.
Page 40 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Preguntas generales:
En primer lugar, me gustaría hacer preguntas acerca de usted.
1. ¿Cuál es su edad?
b. 18 a 24
b. 25 a 34
c. 35 a 44
d. 45 a 54
e. 55 a 64
f. 65 o más
2. ¿Cuánto tiempo ha vivido en Nogales, Sonora (en años)?
a. 0 - 1 año b. 1 – 5 años c. 5 – 10 años d. 10 – 20 años
e. Toda su vida
3. ¿Cuántas personas viven en su casa?
j. más de 9
4. ¿Tiene mascotas?
5. ¿Usted renta o es dueño de su casa?
c. Otro: ____________________________________
6. ¿Cuántos vehículos tiene la familia?
f. más de 4
Ahora me gustaría hacerle unas preguntas sobre su vida en Nogales. En una escala de 1 a 5, con
1 el valor más bajo y 5 el valor más alto, ¿cómo calificaría los siguientes?:
7. ¿Satisfacción con su residencia (su casa y esta colonia)?___
8. ¿Satisfacción con la capacidad de respuesta del gobierno municipal a sus
9. ¿Satisfacción con su calidad de vida personal en Nogales? ___
10. ¿En general, nivel de felicidad que tiene con su vida? ___
11. ¿Cómo califica el modo en que tiene acceso a cualquier tratamiento médico, en su
Page 41 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Preguntas sobre la salud.
Ahora me gustaría hacerle algunas preguntas sobre su salud y la de su familia. Todo el mundo
tiene episodios de diarrea. Algunos tienen episodios con más frecuencia que otros. La diarrea se
puede definir como evacuaciones íiquidas del intestino que a veces es difícil de controlar y que
ocurren más que una vezs en un mismo día. Dígame:
12. ¿Considera a la diarrea como un problema o un evento natural?
d. Ocurrencia natural
13. ¿Usted o alguien en su casa tuvo un episodio de diarrea recientemente?
c. Sí (Siga a 14 abajo)
d. No (Siga a 18 abajo)
de 18 años
3) 65 o más
diarrea en la
Sí, No, No
diarrea en el
Sí, No, No
do por causa
Sí, No, No
en el último
en el trabajo
o en la
Sí, No, No
en el último
18. ¿Cuál diría que fue la causa del episodio(s) de diarrea experimentada por usted y/o
algún miembro de su familia?
i. No está seguro
j. Otro: _____________________________
Page 42 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 19. ¿Cuando alguien en casa tiene diarrea, normalmente, cual tratamiento utilizan para
combatirla? Marque todas las opciones que apliquen.
l. Otro medicamento commercial sin receta:________________
m. Medicamento con receta:____________________
o. Remedios herbarios además de té:____________________
20. ¿Cree usted que el agua hace que usted o alguien de su familia se enferme?
Preguntas sobre el uso del agua
Ahora me gustaría hacerle unas preguntas relativas a cómo obtiene el agua y cómo la usa. Por
favor responda las siguientes:
21. ¿De dónde obtiene el agua para beber?
d. Agua potable.
e. Agua embotellada
f. Camión de agua privada
g. Camión de agua del municipio
h. Otros (especificar) _____________________________________
22. ¿Esta casa tiene drenaje (alcantarillado) conectado a las tuberías de la calle?
23. ¿Si recibe agua del grifo, durante que horas recibe de la red? _____________________
24. ¿Almacena agua?
d. Sí. ¿en qué recipiente lo almacena?
3. Depósito de agua o contenedores portátiles.
5. Galón de plástico o cubeta.
6. Olla u otro utensilio de cocina.
7. Otros ______________________.
25. ¿Cómo es la apariencia del agua que llega a su casa?
Page 43 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. e.
De color amarillento.
Con arena o tierra.
26. ¿Aplica algún tratamiento para limpiar o purificar el agua antes de usarla para beber o
d. Sí. ¿qué tratamiento utiliza?
1. Uso de cloro.
4. Otros (especificar)______________________________________
27. ¿Estaría dispuesto a tratar o limpiar su agua, más de lo que ya lo hace?
28. ¿Cuántos vasos de agua (~237mL) bebe usted y su familia cada día?
b. 2-4 c. 4-6 d. 6-8 e. Más de 8.
29. ¿Cómo obtiene agua para otros usos, que no sea beber?
a. Agua potable.
b. Agua embotellada.
c. Camión de agua privada
d. Camión de agua del municipio
i. Otros (especificar) _____________________________________
30. ¿Cuánto dinero gastas en agua por mes (factura de agua, suministros, etc.)?
b. Menos de 100 pesos b. 100-300 pesos
c. 300-500 pesos
d. 500-700 pesos
e. 700-900 pesos
f. 1000-1300 pesos g. 1300-1500 pesos f. Más que 1500 pesos
Preguntas sobre la Calidad del Agua
Ahora me gustaría hacerle unas preguntas relacionadas con el agua y el medio ambiente en
Nogales. En una escala de 1 a 5, con 1 el valor más bajo y 5 el valor más alto, ¿cómo calificaría
31. ¿Qué tan pura considera el agua potable en Nogales? ____
32. ¿La pureza de agua potable entubada en su hogar, si la llevan? ____
33. ¿Satisfacción con su servicio de agua? ____
34. ¿Tiene preocupación por la pureza del agua potable en su comunidad? ____
Page 44 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. 35. ¿Preocupación por inundaciones y/o la sequía en la localidad? _____
Cuestiones Sobre Implicación Política
Ahora me gustaría hacerle unas preguntas acerca de lo que le gustaría ver cambiar y cómo cree
que se puede lograr. Estas preguntas son sus opiniones y las respuestas no están
predeterminadas. Dime brevemente:
34. ¿Qué cantidad mensual estaría dispuesto a pagar por recibir el servicio de agua más
35. ¿Que recomendaría para que el agua sea más potable?
36. ¿Qué podrían hacer los nogalenses y el Organismo Operador de Agua en Nogales para
mejorar el agua potable?
37. ¿Si usted paga impuestos, cuanto más estaría dispuesto a pagar por que le brinden el
servicio de agua más potable en el municipio?
38. ¿Qué podría hacer usted para que el agua sea más potable para el resto de la ciudad?
Page 45 | 49 Caldeira Improving water quality in Nogales, Sonora, Mexico to decrease prevalence of gastrointestinal disease. Calidad del Agua y Análisis de Salud en dos colonias diferentes de Nogales, Sonora, México Encuesta de Invierno Pida ver la jefa de la familia mayor de 18 años.
Presentarte nuevamente ante quien atienda la encuesta y recordarle de su entrevista anterior
"Hola, me llamo ________. Estuvimos aquí en el verano para recoger muestras de agua y hacer
preguntas acerca de la calidad del agua y la salud en su vecindario y también para determinar
lo que usted piensa acerca de su vida en Nogales. Queremos saber si podríamos terminar la
entrevista y recoger otra, final, tres muestras en los próximos tres fines de semana. Recuerda
que nadie se le dirá lo que nos dicen. Vamos a combinar las respuestas de todos y sólo informan
de la respuesta combinada de todas las encuestas.
Esta vez solamente se trata de 4 preguntas en total, y debe llevar no más de 5 minutos para que
usted pueda responder. ¿Podemos empezar? "
Hora de inicio: _______________________________________
Hora de finalización: ___________________________________
La mejor hora para la recogida de agua :____________________
Todo el mundo tiene episodios de diarrea. Algunos tienen episodios más que otros. La diarrea se
puede definir como evacuaciones liquidas del intestino que a veces es difícil de controlar y
ocurre más que es normal para un día. Dime:
de 18 años
3) 65 o más
diarrea en la
Sí, No, No
diarrea en el
Sí, No, No
o por causa
Sí, No, No
en el último
en el trabajo
o en la
Sí, No, No
en el último
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