The Acceptance & Adoption of Household Based Treatment And Safe Storage Of Drinking Water (HWTS)

1. The evidence & learning from field application in the developing world The Acceptance & Adoption of Household Based Treatment And Safe Storage Of Drinking Water (HWTS) BongiMoyo-Maposa Water & Asset Management Group CSIR Built Environment

2. Presentation Outline • Introduction • The safe water challenge & The case for HWTS • Scaling up HWTS • A review of the field evidence (literature and field examples) • Conclusions: • Implications for practice, advocacy and policy • Limitations of the evidence base & further work

3. The Safe Water and Health Challenge • Globally, approx 3% of deaths, 4% of DALYs due to unsafe water, sanitation and hygiene • Diarrhoeal illness in Africa, Asia and Latin America • 90% due to environmental sanitation • Diarrhoea still a public health issue of concern in South Africa

4. The Case for HWTS • Focus on personal & domestic hygiene in diarrhoeal disease control • The rise of HWTS: • Early reviews of the efficacy of interventions (Water Quantity & availability> sanitation>water quality) • Shift in the paradigm (quality more important): post –collection contamination &HWTS • Prospects for universal access to safe water and sanitation

5. The Case for HWTS A cost effective strategy: • Relative risk estimates for diarrhoea • Water quality(0.69), sanitation (0.68) and hygiene (0.63) • Source water quality (0.89) compared to point of use (0.65) • Independence of HWTS • $1 investment = $60 in reduced DALYs • WHO endorsement- HWTS Network

6. Scaling-Up HWTS What are the factors that have influenced the acceptance and adoption of household based water treatment and safe storage in the target contexts? • Scaling up strategies • Areas for further work

7. Review of the field evidence Querying the evidence • Review of the literature • Inclusion & Exclusion criteria • Data sources • Thematic analysis

8. 1: Compatibility with existing social and cultural norms • Intervention might interfere and cause disease • Using disinfectant might interfere with the cooling of water in clay pots • Water is culturally associated with purity

9. 2: Convenience • Convenient method to use • Easy to use/ ease of use • Preferred bleach to the flocculant disinfectant because the process was simpler

10. 3: Time • Women already have a heavy workload • Treating water took too much time • Bleach vsflocculant disinfectant

11. 4:Taste & appeal of the treated water • Volume of treated water - almost always to little • Taste and smell of ‘WaterGuard’ • Visible effects of using flocculant disinfectant

12. 5: Cost or Affordability • SODIS economical but bottles were a problem, cheaper than boiling • No money to buy disinfectant etc

13. 6: Need for water treatment • Source water contaminated • Aware of importance of treating water • Aware of the link between water and disease • Water traditionally associated with purity, already clean

14. 7: Self Efficacy & Knowledge • Aware of the link between water and disease • Know how to prevent diarrhoea • Have access to the treatment technology

15. 8: Motivation • Cues to action initiate behaviour change • Trusted and competent information sources (social marketing & motivational interviewing) • Prestige

16. 9: Access to the technology/ intervention • Intervention not readily available in the home • Cheaper locally available alternatives

17. 10: Perceived efficacy of the intervention • Know about the germicidal effects of the sun and chlorine • Previous experience

18. Knowledge/Self Efficacy Perceived Efficacy of Intervention Compatibility Need for water treatment Motivation Convenience Acceptance Adoption Time Taste & Visual Appeal Accessibility Affordability

19. Review of the field evidence(1) In a community survey of communities around De Hoop Dam (2009) • 95% of the households interviewed stored drinking water after collecting it • 75% storage containers reportedly covered • 62% reported treatment • >80% used JIK (a household disinfectant) and soda • Soda only, chlorine and boiling

20. Review of the field evidence(2)

21. Review of the field evidence(2) In a community survey of 35 randomly selected households in Tsambonkhulu, Mpumalanga (2012): • Community relies on 3 unprotected wells although there a number of boreholes and a piped water scheme • All collection and storage containers were made of • plastic • Most of the collection containers had narrow mouths and were not covered

22. Review of the field evidence(2) • Appears most household do some kind of treatment • Only a quarter (23%) did not report treating their drinking water • Range of treatment methods reportedly used

23. Review of the field evidence(3) Potter for Peace Ceramic Water Purifiers were distributed to communities in the E. Cape as part of the ASWSD I project (2010) • Community trained in the use of the filters at distribution • Acceptability to users: Happy to have the filter but dissatisfied with its performance (too little water, too slow, clogs within a few days) • Learnings: Understanding of context is key • To deployment of appropriate intervention, • Shed light on the relevant elements of context

24. Review of the field evidence(3)

25. Review of the field evidence (3)

26. Review of the field evidence (3)

27. Review of the field evidence (3)

28. Review of the field evidence (3)

29. Review of the field evidence (4) The AmDrum in the E.Cape (2009) • A 50L flocculant- disinfectant system designed by the CSIR, piloted in 2009 and subsequently redesigned • Issues with the original design: • Technical problems – loose parts, leaking taps, taps breaking, smelly sand column • Unavailability of spares and chemical refills

30. Review of the field evidence (4)

31. Review of the field evidence (5) The rise and rise of HWTS in urban Harare (2007-2008) • Breakdown in the municipal water supply services • Cholera and diarrhoea outbreak • Boiling previously common, chlorination became the method of choice • Chlorination preferred over SODIS in an informal settlement in peri-urban Harare

32. A deep well

36. Meanwhile....

37. Review of the field evidence (5) To treat … motivation, resources, knowledge, health concerns, taste and acceptability of treated water, trust placed in authorities, availability & accuracy of information Or not to treat…. concerns about time, labour constraints, unwillingness to take up the responsibility, religious beliefs, and conviction about the necessity of treatment

38. Review of the field evidence (5) Health concerns Resources Motivation TREAT Taste and acceptability of treated water Knowledge

39. Conclusion • HWTS is an option to secure access to safe water for households • Available field evidence can provide a framework to understand HWTS implementation: • Implications for practice • Direction of future research • Policy and advocacy

40. Conclusion Limitations and gaps in knowledge • Limitations • Wide geographical coverage • Short term nature of the studies • More work on acceptability and adoption • Issue addressed as a secondary objective • Settings • Technologies • chlorination & solar disinfection • The role of the researcher