Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India. BMC Public Health, July 30, 2015.

Mark Rohit Francis, Guru Nagarajan,  et al.

Background – Acceptance and long-term sustainability of water quality interventions are pivotal to realizing continued health benefits. However, there is limited research attempting to understand the factors that influence compliance to or adoption of such interventions.

Methods – Eight focus group discussions with parents of young children – including compliant and not compliant households participating in an intervention study, and three key-informant interviews with village headmen were conducted between April and May 2014 to understand perceptions on the effects of unsafe water on health, household drinking water treatment practices, and the factors influencing acceptance and sustainability of an ongoing water quality intervention in a rural population of southern India.

Results – The ability to recognize health benefits from the intervention, ease of access to water distribution centers and the willingness to pay for intervention maintenance were factors facilitating acceptance and sustainability of the water quality intervention. On the other hand, faulty perceptions on water treatment, lack of knowledge about health hazards associated with drinking unsafe water, false sense of protection from locally available water, resistance to change in taste or odor of water and a lack of support from male members of the household were important factors impeding acceptance and long term use of the intervention.

Conclusion – This study highlights the need to effectively involve communities at important stages of implementation for long term success of water quality interventions. Timely research on the factors influencing uptake of water quality interventions prior to implementation will ensure greater acceptance and sustainability of such interventions in low income settings.


The paradigm shift in the approach to household water treatment systems, 2015.

Urs Heierli, social marketing expert and advisor to the Safe Water II project, talks about the necessary paradigm shift to household water treatment systems. Visit:… to read more about Safe Water Phase 2, a three year initiative (2015-2018) aiming to increase access to safe water particularly for people living at the base of the economic pyramid (BOP).

Effectiveness of emergency water treatment practices in refugee camps in South Sudan. WHO Bulletin, Aug 2015.

Authors: Syed Imran Ali, Syed Saad Ali & Jean-Francois Fesselet

Objective – To investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March–April 2013.

Methods – For each of three refugee camps, we measured physical and chemical characteristics of water supplies at four points after distribution: (i) directly from tapstands; (ii) after collection; (iii) after transport to households; and (iv) after several hours of household storage. The following parameters were measured: free and total residual chlorine, temperature, turbidity, pH, electrical conductivity and oxidation reduction potential. We documented water handling practices with spot checks and respondent self-reports. We analysed factors affecting residual chlorine concentrations using mathematical and linear regression models.

Findings – For initial free residual chlorine concentrations in the 0.5–1.5 mg/L range, a decay rate of ~5×10-3 L/mg/min was found across all camps. Regression models showed that the decay of residual chlorine was related to initial chlorine levels, electrical conductivity and air temperature. Covering water storage containers, but not other water handling practices, improved the residual chlorine levels.

Conclusion The concentrations of residual chlorine that we measured in water supplies in refugee camps in South Sudan were too low. We tentatively recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of diarrhoeal disease outbreaks and the pH or turbidity of water supplies. According to our findings, this would ensure a free residual chlorine level of 0.2 mg/L for at least 10 hours after distribution. However, it is unknown whether our findings are generalizable to other camps and further studies are therefore required.

Determinants of Caregivers’ Use and Adoption of Household Water Chlorination: A Qualitative Study with Peri-urban Communities in the Peruvian Amazon. Am Jnl Trop Med Hyg, July 2015.

Authors: Jessica D. Rothstein, Elli Leontsini, et al.

The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination.

Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers’ understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.


Coping with household water scarcity in the savannah today: Implications for health and climate change into the futureEarth Interact. 2015 doi:10.1175/EI-D-14-0039.1, in press.

Authors: Amber L. Pearson, Jonathan D. Mayer, David J. Bradley

Even as millions live without reliable access to water, very little is known about how households cope with scarcity. The aims of this research were to: 1) understand aspects of water scarcity in three rural villages in southwestern Uganda; 2) examine differences by demographics and type of source; 3) assess relationships between different factors related to water access; and 4) explore coping strategies used. Health implications and lessons learned that relate to future climate change are discussed.

Over half of the households relied on seasonal water sources. Of those accessing ‘permanent’ sources, ~30% experienced inaccessibility within the past two weeks. Self-reported better access to water was correlated with minutes spent walking to source and to some degree with the source being more public or shared. Those without access to public sources tended to migrate as the primary coping strategy. Water sharing and reciprocity appears crucial between wealthy and poor households, however, those from outside ethnic groups appear to be partially excluded. Middle income households followed by the poorest had the largest reliance on purchasing water to cope. These findings underscore how access to water resources, particularly in times of insecurity, involves social networks.


Knowledge, Information, and Water Treatment Behavior of Residents in the Kathmandu Valley, Nepal. The Development Journal of the South, Vol. 1, No. 1, 2015.

Authors: Hari Katuwal, Mona K Qassim, José A. Pagán, Jennifer A Thacher, Alok K. Bohara

In this paper, we examine determinants of water treatment behavior using survey data (N=1200) from Kathmandu, Nepal. In particular, this paper focuses on the impacts of knowledge, exposure to information, and community participation on drinking water treatment behavior. Previous research has found that income, education level, awareness, and exposure to media are major factors that impact the individual-level decision to treat water before using it. We contribute to this literature by explicitly examining how knowledge about waterborne diseases, exposure to water quality information campaigns, and participation in community organizations impact drinking water treatment behavior.

The results from probit regression analyses suggest that either a one percentage increase in the knowledge index or community participation index both increase the likelihood of utilizing drinking water treatment methods by about 0.17 percentage points. Households connected to the distribution system are 31 percentage points more likely to treat water compared to those that are not connected to the system. Multinomial results indicate that wealthier households use more than one treatment method.

Silver Dissolution and Release from Ceramic Water Filters. Env Sci Tech, June 2015.

Authors: Anjuliee M. Mittelman, Daniele S. Lantagne, Justine Rayner, and Kurt D. Pennell

Application of silver nanoparticles (nAg) or silver nitrate (AgNO3) has been shown to improve the microbiological efficacy of ceramic water filters used for household water treatment. Silver release, however, can lead to undesirable health effects and reduced filter effectiveness over time. The objectives of this study were to evaluate the contribution of nanoparticle detachment, dissolution, and cation exchange to silver elution, and to estimate silver retention under different influent water chemistries. Dissolved silver (Ag+) and nAg release from filter disks painted with 0.03 mg/g casein-coated nAg or AgNO3 were measured as a function of pH (5–9), ionic strength (1–50 mM), and cation species (Na+, Ca2+, Mg2+).

Silver elution was controlled by dissolution as Ag+ and subsequent cation exchange reactions regardless of the applied silver form. Effluent silver levels fell below the drinking water standard (0.1 mg/L) after flushing with 30–42 pore volumes of pH 7, 10 mM NaNO3 at pH 7. When the influent water was at pH 5, contained divalent cations or 50 mM NaNO3, silver concentrations were 5–10 times above the standard. Our findings support regular filter replacement and indicate that saline, hard, or acidic waters should be avoided to minimize effluent silver concentrations and preserve silver treatment integrity.

Efficacy of Handwashing with Soap and Nail Clipping on Intestinal Parasitic Infections in School-Aged Children: A Factorial Cluster Randomized Controlled Trial. PLoS Medicine, June 2015.

Authors: Mahmud Abdulkader Mahmud, Mark Spigt, et al.

Background - Intestinal parasitic infections are highly endemic among school-aged children in resource-limited settings. To lower their impact, preventive measures should be implemented that are sustainable with available resources. The aim of this study was to assess the impact of handwashing with soap and nail clipping on the prevention of intestinal parasite reinfections.

Methods and Findings - In this trial, 367 parasite-negative school-aged children (aged 6–15 y) were randomly assigned to receive both, one or the other, or neither of the interventions in a 2 × 2 factorial design. Assignment sequence was concealed. After 6 mo of follow-up, stool samples were examined using direct, concentration, and Kato-Katz methods. Hemoglobin levels were determined using a HemoCue spectrometer. The primary study outcomes were prevalence of intestinal parasite reinfection and infection intensity. The secondary outcome was anemia prevalence. Analysis was by intention to treat. Main effects were adjusted for sex, age, drinking water source, latrine use, pre-treatment parasites, handwashing with soap and nail clipping at baseline, and the other factor in the additive model. Fourteen percent (95% CI: 9% to 19%) of the children in the handwashing with soap intervention group were reinfected versus 29% (95% CI: 22% to 36%) in the groups with no handwashing with soap (adjusted odds ratio [AOR] 0.32, 95% CI: 0.17 to 0.62). Similarly, 17% (95% CI: 12% to 22%) of the children in the nail clipping intervention group were reinfected versus 26% (95% CI: 20% to 32%) in the groups with no nail clipping (AOR 0.51, 95% CI: 0.27 to 0.95). Likewise, following the intervention, 13% (95% CI: 8% to 18%) of the children in the handwashing group were anemic versus 23% (95% CI: 17% to 29%) in the groups with no handwashing with soap (AOR 0.39, 95% CI: 0.20 to 0.78). The prevalence of anemia did not differ significantly between children in the nail clipping group and those in the groups with no nail clipping (AOR 0.53, 95% CI: 0.27 to 1.04). The intensive follow-up and monitoring during this study made it such that the assessment of the observed intervention benefits was under rather ideal circumstances, and hence the study could possibly overestimate the effects when compared to usual conditions.

Conclusions - Handwashing with soap at key times and weekly nail clipping significantly decreased intestinal parasite reinfection rates. Furthermore, the handwashing intervention significantly reduced anemia prevalence in children. The next essential step should be implementing pragmatic studies and developing more effective approaches to promote and implement handwashing with soap and nail clipping at larger scales.


Factors Determining Water Treatment Behavior for the Prevention of Cholera in Chad. Am Jnl Trop Med Hyg, Apr 2015.

Authors: Jonathan Lilje, Hamit Kessely and Hans-Joachim Mosler

Cholera is a well-known and feared disease in developing countries, and is linked to high rates of morbidity and mortality. Contaminated drinking water and the lack of sufficient treatment are two of the key causes of high transmission rates. This article presents a representative health survey performed in Chad to inform future intervention strategies in the prevention and control of cholera.

To identify critical psychological factors for behavior change, structured household interviews were administered to N = 1,017 primary caregivers, assessing their thoughts and attitudes toward household water treatment according to the Risk, Attitude, Norm, Ability, and Self-regulation model. The intervention potential for each factor was estimated by analyzing differences in means between groups of current performers and nonperformers of water treatment. Personal risk evaluation for diarrheal diseases and particularly for cholera was very low among the study population. Likewise, the perception of social norms was found to be rather unfavorable for water treatment behaviors.

n addition, self-reported ability estimates (self-efficacy) revealed some potential for intervention. A mass radio campaign is proposed, using information and normative behavior change techniques, in combination with community meetings focused on targeting abilities and personal commitment to water treatment.

Evaluation of Microbial Water Quality Tests for Humanitarian Emergency and Development SettingsProcedia Engineering, Volume 107, 2015, Pages 237–246. Humanitarian Technology: Science, Systems and Global Impact 2015, HumTech2015.

Authors: Susan Murcott, Megan Keegan, Alison Hanson, Akshay Jain, Jason Knutson, Shuyue Liu, Jenny Tanphanich, Teng Ke Wong

How do you know if drinking water is safe? Or which microbial indicator tests work best when few side-by-side performance evaluations exist in real-world field sites? This research compares bacterial indicator test products inlow-resource settings in Ahmedabad, India and Tamale, Ghana. In India, three hydrogen sulfide (H2S) bacteria test products were evaluated: laboratory-made H2S, TARA Aquacheck and ORlab H2S, and compared to an EPA-certified standard, the IDEXX Quanti-Tray® 2000. In Ghana, 3 M Petrifilm™, Aquagenx CBT and Easygel® Cards were included in addition toH2S and Quanti-Tray® 2000. Results are presented in a Consumer Reports-style for easy comprehension.