5.2 Effective and Consistent Use
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Effective and consistent use Introduction to Household Water Treatment and Safe Storage, Module 5.2 Dr. Richard Johnston
Transcript of 5.2 Effective and Consistent Use
Effective and consistent use
Introduction to Household Water Treatment and Safe Storage, Module 5.2
Dr. Richard Johnston
Introduction
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Unsafe water
Consistent Use
Effective Option
● 768 million people used unimproved
drinking-water sources in 2011
● Many improved drinking-water
sources yield microbially
contaminated water ● Resource contamination
● Collection and storage
● Estimates of 1.8 billion people using
water that is faecally contaminated
Unsafe water
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Effective options
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● Efficacy: How well it works under
controlled conditions
● Effectiveness: How well it works in
the real world
● Household chlorination in Ecuador ● 2009: No significant difference in LRV seen
between households with and without
chlorination
● 2014: Faecal indicators in around 50% of
households practicing chlorination
● Turbidity, raw water contamination levels, post-
treatment contamination
Effective use
Sources: (McLaughlin, 2009), (Levy, 2014)
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● Effective use, objective indicators ● Residual chlorine
● LRV
● Consistent use, longitudinal studies ● Need repeat visits
● Long-term use ● One to five years after intervention
● Consistent use, compliance,
adherence
Effective and consistent use
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● Effective use, objective indicators ● Residual chlorine
● LRV
● Consistent use, longitudinal studies ● Need repeat visits
● Long-term use ● One to five years after intervention
● Consistent use, compliance,
adherence
Effective and consistent use
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Source: Brown J, Clasen T. High Adherence Is Necessary to Realize
Health Gains from Water Quality Interventions. PLoS One. 2012.
Efficacy and compliance
Source: Enger KS, Nelson KL, Rose JB, Eisenberg JN. The joint effects of efficacy and compliance: a study of household
water treatment effectiveness against childhood diarrhea. Water Research. 2013;47(3):1181-90.
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● Biosand filters in Cambodia ● 88% of households still using, 6 months-8 years
● Self-reported + inspection of BSF
● LifeStraw Family in Zambia ● 96% consistent users, 95% exclusive users
● Filter observed, reservoir contained water, +
self-report
● LifeStraw Family in Congo ● 68% consistent users after 8 months
● Nearly all reported drinking untreated water
Examples of high compliance
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● SODIS in Zimbabwe ● Self-reported, calculated, observed
● 65+% confirmed use after 26 months
● If received household visits
● Chlorine in Haiti ● 56% practicing, up to 8 years after intervention
● Free chlorine residual
● Biosand filters in Cambodia ● 88% of households still using, 6 months-8 years
● Self-reported + inspection of BSF
● LifeStraw Family in Zambia ● 96% consistent users, 95% exclusive users
● Filter observed, reservoir contained water, +
self-report
● LifeStraw Family in Congo ● 68% consistent users after 8 months
● Nearly all reported drinking untreated water
Examples of high compliance
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● Ceramic water filters in Cambodia ● 31% in regular daily use (interview + inspection)
● Highly dependent on time since intervention
● LifeStraw Personal in Ethiopia ● 34% reported use in last week, 13% consistent
● SODIS in Bolivia ● 32% compliance
● Self-reported confirmed by observation
Examples of low compliance
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● Combined treatment in Guatemala ● 6 months after intervention, 5% had purchased
sachets
● Ultraviolet radiation in Mexico ● 40% exclusive use of Mesita Azul
● Thermal disinfection in Bangladesh ● 21/101 reported use of chulli
● 17 reported inconsistent or wrong use
● Ceramic water filters in Cambodia ● 31% in regular daily use (interview + inspection)
● Highly dependent on time since intervention
● LifeStraw Personal in Ethiopia ● 34% reported use in last week, 13% consistent
● SODIS in Bolivia ● 32% compliance
● Self-reported confirmed by observation
Examples of low compliance
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● Personal factors ● Behavior change
● External factors ● Supply chains
● Supportive policy environment
● Etc…
● Different for different settings,
sub-populations
Factors impacting compliance
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● Five stages of innovation process
● Five attributes of innovation
Diffusion of Innovations
Knowledge
Persuasion
Decision
Implementation
Confirmation
Uptake Relative advantage
Compatibility
Complexity
Trialability
Observability
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Source: Rogers, 2003
Risks
• Perceived Vulnerability
• Perceived Severity
• Factual Knowledge
Attitudes
• Instrumental beliefs
• Affective beliefs
Norms
• Descriptive
• Injunctive
• Personal
Abilities
• Action knowledge
• Self-efficacy
Self-regulation
• Action control/planning
• Coping planning
• Remembering
• Commitment
RANAS psychological model
Source: Mosler, 2012
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● Three classes of factors ● Contextual
● Psychosocial
● Technology
● Five levels ● Societal/Structural
● Community
● Interpersonal/Household
● Individual
● Habitual
IBM-WASH
Source: Dreibelbis, 2013
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Behavior Change Reviews
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Monitoring and Evaluation Toolkit
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•Knowledge of correct use
•Demonstration of correct use
•Demonstration of safe water extraction
•Frequency of non-use by most vulnerable
•Consistently treating drinking water with HWTS
•Use of improved drinking-water source
Correct, consistent
use and storage
Monitoring and Evaluation Toolkit Indicators
Reported and observed use
Correct, consistent use and storage
Knowledge and behavior
Other environmental
health interventions
Water quality
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•Households effectively using HWTS method to improve quality of household drinking-water (“effective use”)
•Households with free chlorine residual in drinking-water
Water quality
Monitoring and Evaluation Toolkit Indicators
Reported and observed use
Correct, consistent use and storage
Knowledge and behavior
Other environmental
health interventions
Water quality
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Boisson, S. et al. (2009). "Randomized Controlled Trial in Rural Ethiopia to Assess a
Portable Water Treatment Device." Environmental Science & Technology 43(15): 5934-
5939.
Boisson, S., et al. (2010). "Field Assessment of a Novel Household-Based Water
Filtration Device: A Randomised, Placebo-Controlled Trial in the Democratic Republic of
Congo." PloS One 5(9): e12613.
Brown J, Clasen T. High Adherence Is Necessary to Realize Health Gains from Water
Quality Interventions. PLoS One. 2012.
Enger, K.et al. (2013). "The joint effects of efficacy and compliance: a study of household
water treatment effectiveness against childhood diarrhea." Water Res 47(3): 1181-1190.
Gruber, J. et al. (2013). "A Stepped Wedge, Cluster-Randomized Trial of a Household
UV-Disinfection and Safe Storage Drinking Water Intervention in Rural Baja California
Sur, Mexico." Am J Trop Med Hyg 89(2): 238-245
Gupta, S. et al. (2008). "The chulli water purifier: acceptability and effectiveness of an
innovative strategy for household water treatment in Bangladesh." American Journal of
Tropical Medicine and Hygiene 78(6): 979-984.
Harshfield, E., et al. (2012). "Evaluating the sustained health impact of household
chlorination of drinking water in rural Haiti." Am J Trop Med Hyg 87(5): 786-795.
Levy K, et al. Household effectiveness vs. laboratory efficacy of point-of-use chlorination.
Water research. 2014;54:69-77.
Luby, S. et al. (2008). "Difficulties in bringing point-of-use water treatment to scale in rural
Guatemala." American Journal of Tropical Medicine and Hygiene 78(3): 382-387.
Mäusezahl, D. et al. (2009). "Solar Drinking Water Disinfection (SODIS) to Reduce
Childhood Diarrhoea in Rural Bolivia: A Cluster-Randomized, Controlled Trial." PLOS
Medicine 6(8): e1000125.
McGuigan, K. et al. (2011). "High Compliance Randomized Controlled Field Trial of Solar
Disinfection of Drinking Water and Its Impact on Childhood Diarrhea in Rural Cambodia."
Environmental Science & Technology 45(18): 7862-7867.
McLaughlin L et al. An observational study on the effectiveness of point-of-use
chlorination. Journal of Environmental Health. 2009;71(8):48-53.
Mosler, H.-J., et al. (2013). "Achieving long-term use of solar water disinfection in
Zimbabwe." Public health 127(1): 92-98.
WSP (2010) Use of BioSand Filters in Cambodia.
WSP/UNICEF (2007). Use of Ceramic Water Filters in Cambodia.
Additional Resources: Compliance
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Dreibelbis R et al. The Integrated Behavioural Model for Water, Sanitation, and
Hygiene: a systematic review of behavioural models and a framework for
designing and evaluating behaviour change interventions in infrastructure-
restricted settings. BMC public health. 2013;13:1015.
Figueroa ME, Kinkaid DL. Social, Cultural and Behavioral Correlates of
Household Water Treatment and Storage. Baltimore: Johns Hopkins Bloomberg
School of Public Health, Center for Communication Programs, 2010.
Mosler, H.-J., et al. (2013). A guideline for behavior change. Eawag.
Mosler H-J. A systematic approach to behavior change interventions for the
water and sanitation sector in developing countries: a conceptual model, a
review, and a guideline. International Journal of Environmental Health Research.
2012;22(5):431-49.
Rogers E. The Diffusion of Innovations. 5th ed. New York: The Free Press; 2003.
Additional Resources: Behavior change
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● Health gains require effective and
consistent use (and unsafe water) ● Perceptions
● Effective use can be measured
● Consistent use is harder
● Frameworks ● Behavioural change
● Other factors
● Promote and monitor actual use
Conclusion
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