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5.2 Effective and Consistent Use
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
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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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