Going to scale with safe water – what changes are needed to remove the barriers to scale? 2014.
By Urs Heierli and Paul Osborn, Discussion paper for 300in6.
Event the most successful projects – as described in the Hystra study: “Access to Safe Water for the Base of the Pyramid” look more like oases in the middle of a huge desert. It is unlikely that scaling these projects will lead to universal access. What is badly needed are not more oasis, but a greening of the desert in-between, and this requires significant changes from business as usual.
This discussion paper attempts to sketch out a change agenda and will describe what is needed to go to scale. Scaling-up is not a linear process of replicating successful models or pilot projects at a larger scale: it means to apply a much more holistic, better coordinated and orchestrated approach involving not only project partners but mainstream institutions of the society.
Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion. Appl Psychol Health Well Being. 2014 Mar;6(1):96-118. doi: 10.1111/aphw.12018.
Authors: Huber AC1, Tobias R, Mosler HJ.
Two hundred million people worldwide are at risk of developing dental and skeletal fluorosis due to excessive fluoride uptake from their water. Since medical treatment of the disease is difficult and mostly ineffective, preventing fluoride uptake is crucial. In the Ethiopian Rift Valley, a fluoride-removal community filter was installed. Despite having access to a fluoride filter, the community used the filter sparingly. During a baseline assessment, 173 face-to-face interviews were conducted to identify psychological factors that influence fluoride-free water consumption. Based on the results, two behavior-change campaigns were implemented: a traditional information intervention targeting perceived vulnerability, and an evidence-based persuasion intervention regarding perceived costs.
The interventions were tailored to household characteristics. The campaigns were evaluated with a survey and analyzed in terms of their effectiveness in changing behavior and targeted psychological factors. While the intervention targeting perceived vulnerability showed no desirable effects, cost persuasion decreased the perceived costs and increased the consumption of fluoride-free water. This showed that altering subjective perceptions can change behavior even without changing objective circumstances. Moreover, interventions are more effective if they are based on evidence and tailored to specific households.
Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda. PLoS One, March 2014.
Authors: Christina K. Barstow, Fidele Ngabo, Ghislaine Rosa, Fiona Majorin, Sophie Boisson, Thomas Clasen, Evan A. Thomas
Background – In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges.
Methods and Findings – This paper describes the design, implementation and outcomes of a pilot program in 1,943 households across 15 villages in the western province of Rwanda to distribute and monitor the use of household water filters and improved cookstoves. Three key program design criteria include a.) an investment in behavior change messaging and monitoring through community health workers, b.) free distributions to encourage community-wide engagement, and c.) a private-public partnership incentivized by a business model designed to encourage “pay for performance”. Over a 5-month period of rigorous monitoring, reported uptake was maintained at greater than 90% for both technologies, although exclusive use of the stove was reported in only 28.5% of households and reported water volume was 1.27 liters per person per day. On-going qualitative monitoring suggest maintenance of comparable adoption rates through at least 16 months after the intervention.
Conclusion – High uptake and sustained adoption of a water filter and improved cookstove was measured over a five-month period with indications of continued comparable adoption 16 months after the intervention. The design attributes applied by the implementers may be sufficient in a longer term. In particular, sustained and comprehensive engagement by the program implementer is enabled by a pay-for-performance business model that rewards sustained behavior change.
Video Surveillance Captures Student Hand Hygiene Behavior, Reactivity to Observation, and Peer Influence in Kenyan Primary Schools. PLoS One, March 2014.
Authors: Amy J. Pickering, Annalise G. Blum, Robert F. Breiman, Pavani K. Ram, Jennifer Davis
Background – In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.
Methods – Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.
Findings – Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio = 1.14 [95% CI 1.01–1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.
Conclusion – Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs.
Solar Disinfection of Pseudomonas aeruginosa in Harvested Rainwater: A Step towards Potability of Rainwater. PLoS One, Mar 2014.
Authors: Muhammad T. Amin, Mohsin Nawaz, Muhammad N. Amin, and Mooyoung Han
Efficiency of solar based disinfection of Pseudomonas aeruginosa (P. aeruginosa) in rooftop harvested rainwater was evaluated aiming the potability of rainwater. The rainwater samples were exposed to direct sunlight for about 8–9 hours and the effects of water temperature (°C), sunlight irradiance (W/m2), different rear surfaces of polyethylene terephthalate bottles, variable microbial concentrations, pH and turbidity were observed on P. aeruginosa inactivation at different weathers. In simple solar disinfection (SODIS), the complete inactivation of P. aeruginosa was obtained only under sunny weather conditions (>50°C and >700 W/m2) with absorptive rear surface. Solar collector disinfection (SOCODIS) system, used to improve the efficiency of simple SODIS under mild and weak weather, completely inactivated the P. aeruginosa by enhancing the disinfection efficiency of about 20% only at mild weather.
Both SODIS and SOCODIS systems, however, were found inefficient at weak weather. Different initial concentrations of P. aeruginosa and/or Escherichia coli had little effects on the disinfection efficiency except for the SODIS with highest initial concentrations. The inactivation of P. aeruginosa increased by about 10–15% by lowering the initial pH values from 10 to 3. A high initial turbidity, adjusted by adding kaolin, adversely affected the efficiency of both systems and a decrease, about 15–25%; in inactivation of P. aeruginosa was observed. The kinetics of this study was investigated by Geeraerd Model for highlighting the best disinfection system based on reaction rate constant. The unique detailed investigation of P. aeruginosa disinfection with sunlight based disinfection systems under different weather conditions and variable parameters will help researchers to understand and further improve the newly invented SOCODIS system.
A global brief on vector-borne diseases, 2014. World Health Organization.
Vector-borne diseases cause more than one million deaths each year. But death counts, though alarming, vastly underestimate the human misery and hardship caused by these diseases, as many people who survive infection are left permanently debilitated, disfigured, maimed, or blind.As vectors thrive under conditions where housing is poor, water is unsafe, and environments are contaminated with filth, these diseases exact their heaviest toll on the poor – the people left behind by development. Measures that control the vectors, the agents of disease, provide an excellent, but underutilized opportunity to help these people catch up.
Why “improved” water sources are not always safe. WHO Bulletin, April 2014.
Authors: Ameer Shaheed, Jennifer Orgill, Maggie A Montgomery, Marc A Jeuland & Joe Brown
Existing and proposed metrics for household drinking-water services are intended to measure the availability, safety and accessibility of water sources. However, these attributes can be highly variable over time and space and this variation complicates the task of creating and implementing simple and scalable metrics. In this paper, we highlight those factors – especially those that relate to so-called improved water sources – that contribute to variability in water safety but may not be generally recognized as important by non-experts.
Problems in the provision of water in adequate quantities and of adequate quality – interrelated problems that are often influenced by human behaviour – may contribute to an increased risk of poor health. Such risk may be masked by global water metrics that indicate that we are on the way to meeting the world’s drinking-water needs. Given the complexity of the topic and current knowledge gaps, international metrics for access to drinking water should be interpreted with great caution. We need further targeted research on the health impacts associated with improvements in drinking-water supplies.
The challenge of global water access monitoring: evaluating straight-line distance versus self-reported travel time among rural households in Mozambique. Journal of Water and Health, Vol 12 No 1 pp 173–183, 2014.
Jeff C. Ho, Kory C. Russel and Jennifer Davis. Department of Civil and Environmental Engineering, Stanford University, 473 Via Ortega, Stanford, CA 94305, USA. E-mail: jennadavis@stanford.edu
Woods Institute for the Environment, Stanford University, 473 Via Ortega, Stanford, CA 94305, USA
ABSTRACT – Support is growing for the incorporation of fetching time and/or distance considerations in the definition of access to improved water supply used for global monitoring. Current efforts typically rely on self-reported distance and/or travel time data that have been shown to be unreliable. To date, however, there has been no head-to-head comparison of such indicators with other possible distance/time metrics. This study provides such a comparison. We examine the association between both straight-line distance and self-reported one-way travel time with measured route distances to water sources for 1,103 households in Nampula province, Mozambique.
We find straight-line, or Euclidean, distance to be a good proxy for route distance (R2 = 0.98), while self-reported travel time is a poor proxy (R2 = 0.12). We also apply a variety of time- and distance-based indicators proposed in the literature to our sample data, finding that the share of households classified as having versus lacking access would differ by more than 70 percentage points depending on the particular indicator employed. This work highlights the importance of the ongoing debate regarding valid, reliable, and feasible strategies for monitoring progress in the provision of improved water supply services.
Household Water Treatment Uptake during a Public Health Response to a Large Typhoid Fever Outbreak in Harare, Zimbabwe. Am Jnl Trop Med Hyg, Mar 2014.
Authors: Maho Imanishi, et al.
Locally manufactured sodium hypochlorite (chlorine) solution has been sold in Zimbabwe since 2010. During October 1, 2011–April 30, 2012, 4,181 suspected and 52 confirmed cases of typhoid fever were identified in Harare. In response to this outbreak, chlorine tablets were distributed. To evaluate household water treatment uptake, we conducted a survey and water quality testing in 458 randomly selected households in two suburbs most affected by the outbreak.
Although 75% of households were aware of chlorine solution and 85% received chlorine tablets, only 18% had reportedly treated stored water and had the recommended protective level of free chlorine residuals. Water treatment was more common among households that reported water treatment before the outbreak, and those that received free tablets during the outbreak, but was not associated with chlorine solution awareness or use before the outbreak. Outbreak response did not build on pre-existing prevention programs.
Social Marketing of Water and Sanitation Products: A Systematic Review of Peer-reviewed Literature. Soc Sci Med, Mar 2014.
Authors: WD Evans, et al.
Highlights
• Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT) can be marketed like commercial products
• There has been no systematic review of theory, research, and practice in this area
• We identified 32 articles over a 22 year period that met search criteria
• Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change
• The quality of evaluations varied and more randomized controlled studies are needed
• Social marketing is a promising strategy to improve water and sanitation programs worldwide
Like commercial marketing, social marketing uses the 4 “Ps” and seeks exchange of value between the marketer and consumer. Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT), can be marketed like commercial products in developing countries. Although social marketing in these areas is growing, there has been no systematic review of the current state of practice, research and evaluation.
We searched the literature for published peer-reviewed studies available through major online publication databases. We identified manuscripts in the health, social science, and business literature on social marketing that used at least one of the 4 Ps of marketing and had a behavioral objective targeting the behaviors or products related to improving water and sanitation. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 117 articles and reviewed a final set of 32 that met our criteria.
Social marketing is a widespread strategy. Marketing efforts have created high levels of awareness of health threats and solutions, including behavior change and socially marketed products. There is widespread use of the 4 Ps of marketing, with price interventions being the least common. Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change.
Interventions have successfully used social marketing following widely recommended strategies. Future evaluations need to focus on mediators that explain successful behavior change in order to identify best practices and improve future programs. More rigorous evaluations including quasi-experimental designs and randomized trials are needed. More consistent reporting of evaluation results that permits meta-analysis of effects is needed.
