PLoS One. 2011;6(10):e26132.

What Point-of-Use Water Treatment Products Do Consumers Use? Evidence from a Randomized Controlled Trial among the Urban Poor in Bangladesh.

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Luoto J, Najnin N, Mahmud M, Albert J, Islam MS, Luby S, Unicomb L, Levine DI. RAND Corporation, Santa Monica, California, United States of America.

BACKGROUND: There is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why.

METHODS: We gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a
combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water’s contamination with E. coli (compared to 200 control households).

FINDINGS: Households reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls.

CONCLUSION: Traditional arguments for the low adoption of POU products focus on affordability, consumers’ lack of information about germs and the dangers of unsafe water, and specific products not meshing with a
household’s preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such
efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users,
household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.