Bringing safe water to remote populations: an evaluation of a portable point-of-use intervention in rural Madagascar

Systematic Review of the Microbiological Performance of Household Water Treatment Technologies

Household water treatment (HWT) is a prevalent method for improving the safety of drinking-water. We conducted a systematic review of peer-reviewed literature from 1997 to 2021 on microbiological performance of common HWT technologies including porous ceramic filters, carbon block or membrane filtration, granular media filtration, thermal treatment, solar disinfection, UV irradiation, chemical disinfection, and combined coagulation-disinfectant products. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) best practices and searched SCOPUS, Web of Science, PubMed, and Agricola and further consulted an expert working group to add relevant publications reporting microbial performance of HWT (n = 396 peer-reviewed studies). Reported log10 reduction values (LRVs) varied widely across and within technology categories. We summarize microbial performance by technology type; pathogen class (bacteria, virus, protozoa); and study setting (field or laboratory). Combined coagulation-disinfectant products had the highest LRV performance for bacterial (6.3) and viral (5.3) classes, and porous ceramic had the highest LRV for protozoa (3) when n > 3. Findings can inform the selection of candidate HWT options, but factors such as product design, time burden of use, cost, and long-term maintenance requirements are important considerations in technological performance. Microbiological performance is meaningless if the technology is not used consistently, correctly, and sustainably.

Outcome evaluation of WASH intervention in rural households at Jawi district, Northwest Ethiopia: Mixed method design, goal based evaluation

BACKGROUND

The government of Ethiopia revealed that GTP II and SDG were achieved through one Water Sanitation and Hygiene (WASH) program. According to the 2016 Ethiopian Demographic and Health survey, the rural population was more affected by poor sanitation and hygiene. To address this Ethiopian government ratified Rural WASH sanitation and hygiene promotion through a community-centered approach, and to improve WASH service evidence on the effectiveness of an intervention at the household level is needed in developing countries. However, in our country one WASH in rural areas called community centered approach intervention was planned and delivered for 3 years (2018-2020) Nevertheless, as to our review and researchers knowledge, the outcome of this intervention is not evaluated yet in our country as well as in this evaluation study area.

METHOD

The evaluation was conducted in rural households of Jawi district by a Quasi-experimental design supplemented with a qualitative in-depth interview, from 01/14/2021-3/28/2021 and 4/22/2021-5/25/2021 for quanitative and qualitative study, respectively. Intervention groups were households that took WASH intervention while the controls did not. The evaluation approach was summative and counterfactual plus participatory and focuses on program outcome. A total of 1280 households were selected using two stage sampling with lottery method simple random sampling. We collected quantitative data through survey and structured observational checklist, while qualitative data through key informant interviews using a semi-structured questionnaire. We assessed program effectiveness and also the analytical study was conducted through propensity score matching to assess program effect through Stata 14.1. Qualitative data were transcribed and translated to English and thematic analysis was done using Atlas.ti.9.

RESULT

The overall program effectiveness was very good but the effectiveness in handwashing before eating using soap and water was poor. Also, this intervention increased water treatment utilization in 41.7% point (ATT=0.417, 95% CI= 0.356, 0.478), 24.3% point (ATT =0.243, 95%CI=0.180, 0.300) in exclusive latrine utilization, 41.9% point (ATT=0.419, 95%CI = 0.376, 0.470) in handwashing using water and soap before eating, 50.2% point(ATT=0.502, 95%CI=0.450, 0.550) in handwashing after defecation by using water and soap in intervention households. Our qualitative finding revealed that unable to afford soap and their working place far away from their home were the most frequent reason reported by the respondent for not using soap for hand washing and latrine utilization respectively CONCLUSIONS: This intervention should be scale-up and pay greater attention and deliver innovative strategies to the improvement of handwashing practice and exclusive latrine utilization.

AVAILABILITY OF DATA AND MATERIALS

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Chlorination for low-cost household water disinfection - A critical review and status in three Latin American countries

Chlorination has historically provided microbiologically safe drinking water in public water supplies. Likewise, chlorine has also been introduced as a low-cost disinfection method in rural and marginalized communities, both at community and household level, as well as during emergencies. Although this practice is common and well established for use as a household water treatment technology in the Global South, several challenges in effective and efficient implementation still need to be addressed. Here, we explored these issues by a literature review and narrowed them to the status of three Latin American countries (Mexico, Colombia, and Brazil). Overall, it was found that although guidance on household-based chlorination includes information on health risks and hygiene, this may not create enough incentive for the user to adapt the method satisfactorily. Physicochemical quality of the water influences chlorination efficiency and it is found that variations in quality are rarely considered when recommending chlorine doses during implementation. These are far more often based on a few measurements of turbidity, thereby not considering dissolved organic matter, or seasonal and day-to-day variations. Other factors such as user preferences, chlorine product quality and availability also represent potential barriers to the sustainable use of chlorination. For chlorination to become a sustainable household water treatment, more focus should therefore be given to local conditions prior to the intervention, as well as support and maintenance of behavioural changes during and after the intervention.

An Application of the Integrated Behavioral Model for Water, Sanitation and Hygiene to Assess Perceived Community Acceptability and Feasibility of the Biosand Filter among Maasai Pastoralists in Rural Tanzania

In addition to diarrheal disease risk, lack of access to safe water may have other indirect effects throughout one's life, such as school and workplace absenteeism, leading to less economic productivity. In contexts with scarce resources and unsafe drinking water, household water treatment and safe storage options such as the Biosand filter (BSF) allows households to directly reduce contamination and increase the quality of their drinking water. This study aimed to develop an understanding of perceived community acceptability and feasibility related to pre- and post-implementation of a BSF pilot project in rural Maasai households in the Ngorongoro Conservation Area (NCA), Tanzania. The study was guided by the Integrated Behavioral Model for Water Sanitation and Hygiene interventions (IBM-WASH) to understand the various factors influencing end-user perceptions of the BSF. In-depth interviews, group discussions and think tanks were conducted among a cross-section of community members, stakeholders, and other actors from May 2016 to September 2017. The data were analyzed using a thematic content analysis approach. A range of perceived contextual, technological, and psychosocial factors were found to potentially affect the acceptability and feasibility of BSF adoption in the NCA, highlighting the complex layers of influences in the setting. Whilst the BSF is seemingly an accepted option to treat water within the NCA, the community identified key barriers that may lower BSF adoption. The application of the IBM-WASH model served as a useful framework for evaluating the introduction of the BSF, identifying insights into contextual, technological, and psychosocial community factors.

Five-Year Follow-Up on the Prevalence and Intensity of Infections of Schistosoma mansoni in a Hard-to-Reach District of Madagascar

Schistosomiasis is a major public health problem in Madagascar. The WHO recommends preventive chemotherapy by mass drug administration (MDA) with praziquantel as the primary approach to control Schistosoma mansoni-related morbidity in endemic populations, alongside complementary interventions such as health education. The impact of annual MDA and health education programs was assessed in the hard-to-reach Marolambo district of eastern Madagascar, an area endemic for S. mansoni. Repeated cross-sectional studies undertaken 2015-2019 examined between 300 and 381 school-aged children (aged 5-14 years) annually. The prevalence and infection intensity of S. mansoni were assessed by urine-circulating cathodic antigen (CCA) dipsticks and coproscopy using Kato-Katz (KK) methodologies. After four rounds of annual MDA, a reduction in S. mansoni prevalence was seen in CCA (93.9% in year 1-87.7% in year 5; P = 0.007) and KK (73.9% in year 1-59.4% in year 5; P < 0.0001). The prevalence of heavy-intensity infections roughly halved from 23.7% to 10.1% (P < 0.0001), and the mean intensity of infection fell by 55.0% (480.2-216.3 eggs per gram of feces). A malacological survey found Biomphalaria pfeifferi snail intermediate hosts in multiple water contact sites including rice paddies, streams, and Nosivolo River. Despite reductions in infection prevalence and intensity, schistosomiasis still poses a significant public health challenge in Marolambo district. Twice yearly MDA cycles and/or community-wide MDA are suggested to better reduce infections. Expanding health education, improving standards of water, sanitation and hygiene, and attention on snail-related control will also be important, especially in rice paddy irrigated areas.

Engineering and characterization of gymnosperm sapwood toward enabling the design of water filtration devices

Naturally-occurring membranes in the xylem tissue of gymnosperm sapwood enable its use as an abundantly-available material to construct filters, with potential to facilitate access to safe drinking water in resource-constrained settings. However, the material’s behavior as a filter is poorly understood, and challenges such as short shelf life have not been addressed. Here, we characterize the operational attributes of xylem filters and show that the material exhibits a highly non-linear dependence of flow resistance on thickness upon drying, and a tendency for self-blocking. We develop guidelines for the design and fabrication of xylem filters, demonstrate gravity-operated filters with shelf life >2 years, and show that the filters can provide >3 log removal of E. coli, MS-2 phage, and rotavirus from synthetic test waters and coliform bacteria from contaminated spring, tap, and ground waters. Through interviews and workshops in India, we use a user-centric approach to design a prototype filtration device with daily- to weekly-replaceable xylem filters, and uncover indicators of social acceptance of xylem as a natural water filter. Our work enhances the understanding of xylem as a filtration material, and opens opportunities for engineering a diverse range of low-cost, biodegradable xylem-based filtration products on a global scale.

Gymnosperm sapwood is an abundantly available material to construct water filters but the material’s behaviour as a filter is poorly understood and challenges such as short shelf live have not been addressed. Here, the authors develop guidelines for the design and fabrication of xylem filters and demonstrate gravity-operated filters with a shelf life of more than two years for the removal of contaminants from spring, tap and ground water.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.

Impact of adding hand-washing and water disinfection promotion to oral cholera vaccination on diarrhoea-associated hospitalization in Dhaka, Bangladesh: evidence from a cluster randomized control trial

Background

Information on the impact of hygiene interventions on severe outcomes is limited. As a pre-specified secondary outcome of a cluster-randomized controlled trial among >400 000 low-income residents in Dhaka, Bangladesh, we examined the impact of cholera vaccination plus a behaviour change intervention on diarrhoea-associated hospitalization.

Methods

Ninety neighbourhood clusters were randomly allocated into three areas: cholera-vaccine-only; vaccine-plus-behaviour-change (promotion of hand-washing with soap plus drinking water chlorination); and control. Study follow-up continued for 2 years after intervention began. We calculated cluster-adjusted diarrhoea-associated hospitalization rates using data we collected from nearby hospitals, and 6-monthly census data of all trial households.

Results

A total of 429 995 people contributed 500 700 person-years of data (average follow-up 1.13 years). Vaccine coverage was 58% at the start of analysis but continued to drop due to population migration. In the vaccine-plus-behaviour-change area, water plus soap was present at 45% of hand-washing stations; 4% of households had detectable chlorine in stored drinking water. Hospitalization rates were similar across the study areas [events/1000 person-years, 95% confidence interval (CI), cholera-vaccine-only: 9.4 (95% CI: 8.3–10.6); vaccine-plus-behaviour-change: 9.6 (95% CI: 8.3–11.1); control: 9.7 (95% CI: 8.3–11.6)]. Cholera cases accounted for 7% of total number of diarrhoea-associated hospitalizations.

Conclusions

Neither cholera vaccination alone nor cholera vaccination combined with behaviour-change intervention efforts measurably reduced diarrhoea-associated hospitalization in this highly mobile population, during a time when cholera accounted for a small fraction of diarrhoea episodes. Affordable community-level interventions that prevent infection from multiple pathogens by reliably separating faeces from the environment, food and water, with minimal behavioural demands on impoverished communities, remain an important area for research.

Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review

BACKGROUND

Water, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear.

AIM

To examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts.

METHODS

A systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980-2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed.

RESULTS

Of 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence.

CONCLUSION

The current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships.

Microbial removals by a novel biofilter water treatment system

Two point-of-use drinking water treatment systems designed using a carbon filter and foam material as a possible alternative to traditional biosand systems were evaluated for removal of bacteria, protozoa, and viruses. Two configurations were tested: the foam material was positioned vertically around the carbon filter in the sleeve unit or horizontally in the disk unit. The filtration systems were challenged with Cryptosporidium parvum, Raoultella terrigena, and bacteriophages P22 and MS2 before and after biofilm development to determine average log reduction (ALR) for each organism and the role of the biofilm. There was no significant difference in performance between the two designs, and both designs showed significant levels of removal (at least 4 log10 reduction in viruses, 6 log10 for protozoa, and 8 log10 for bacteria). Removal levels meet or exceeded Environmental Protection Agency (EPA) standards for microbial purifiers. Exploratory test results suggested that mature biofilm formation contributed 1-2 log10 reductions. Future work is recommended to determine field viability.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh

OBJECTIVE

To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers.

METHODS

After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use.

RESULTS

Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level).

CONCLUSION

The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

What is the role of informal healthcare providers in developing countries? A systematic review

Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.

Building on success--potential to improve coverage of multiple health interventions through integrated delivery with routine childhood vaccination

BACKGROUND

Integrating delivery of nonvaccine interventions with childhood vaccinations has been suggested as a mechanism to accelerate progress toward Millennium Development Goals.

METHODS

Demographic health surveys from 28 sub-Saharan African countries were analyzed to determine potential coverage with 5 nonvaccine interventions that could be delivered to children, mothers, and families during routine infant vaccinations. Potential coverage levels were calculated among households with children aged 12-23 months, based on existing coverage of interventions and vaccinations.

FINDINGS

Most (>60%) children in families that had not received nonvaccine interventions had been vaccinated. If nonvaccine interventions could be delivered with vaccinations, the median percentage of households owning a bed net could increase from 46% to 92% and those with improved or treated sources of water from 55% to 91%. The median percentage of children who had received vitamin A supplementation could increase from 66% to 90%. Mothers who have been tested for human immunodeficiency virus could increase from 16% to 86%.

CONCLUSIONS

In Africa, vaccination programs could provide a platform to substantially increase coverage of nonvaccine interventions. Studies are needed to investigate programmatic approaches to optimize the selection, adoption, and long-term utilization of these interventions and to assess the impact on vaccination and other intervention coverage.

Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index

Point-of-use water treatment (i.e., water purification at the point of consumption) has proven effective in preventing diarrhea in developing countries. However, widespread adoption has not occurred, suggesting that implementation strategies have not motivated sustained behavior change. We conducted a systematic literature review of published behavioral research on factors influencing adoption of point-of-use water treatment in countries categorized as low- to medium-development on the United Nations Development Programme Human Development Index. We used 22 key words to search peer-reviewed literature from 1950 to 2010 from OVID Medline, CINAHL, and PsycINFO. Twenty-six (1.7%) of 1551 papers met our four inclusion criteria: 1) implemented a point-of-use water treatment intervention, 2) applied a behavioral intervention, 3) evaluated behavior change as the outcome, and 4) occurred in a low- or medium-development country. We reviewed these 26 publications for detailed descriptions of the water treatment intervention, theoretical rationales for the behavioral intervention, and descriptions of the evaluation. In 5 (19%) papers, details of the behavioral intervention were fully specified. Seven (27%) papers reported using a behavioral theory in the design of the intervention and evaluation of its impact. Ten (38%) studies used a comparison or control group; 5 provided detailed descriptions. Seven (27%) papers reported high sustained use of point-of-use water treatment with rates >50% at the last recorded follow-up. Despite documented health benefits of point-of-use water treatment interventions in reducing diarrheal diseases, we found limited peer-reviewed behavioral research on the topic. In addition, we found the existing literature often lacked detailed descriptions of the intervention for replication, seldom described the theoretical and empirical rationale for the implementation and evaluation of the intervention, and often had limitations in the evaluation methodology. The scarcity of papers on behavior change with respect to point-of-use water treatment technologies suggests that this field is underdeveloped.

Understanding why women adopt and sustain home water treatment: insights from the Malawi antenatal care program

In many settings in Africa, social marketing has proven more successful in generating brand recognition for chlorine water treatment products than in promoting their use. To promote household use of one such product in Malawi, WaterGuard, the Ministry of Health (MOH) and Population Services International (PSI) distributed free hygiene kits that included WaterGuard to pregnant women attending antenatal clinics in 2007. Follow-up surveys documented a sustained increase in WaterGuard use three years after the initial intervention. In 2010, PATH (www.path.org) conducted qualitative research on the factors motivating women to adopt, sustain, or discontinue use. To provide context, interviews were also conducted with their friends, relatives, and husbands. Interviews revealed that sustained use of WaterGuard does not necessarily imply consistent use. Most respondents reported switching back and forth between WaterGuard and stock chlorine distributed for free by the government, and many treated water seasonally rather than year-round. Qualitative findings suggest that two program strategies strongly influenced women's decisions to adopt, purchase, and continue using WaterGuard. First, positive, ongoing contacts with health care workers, especially during home visits, raised awareness of the need to treat water, encouraged trial use, and supported continuing use. Second, an extended free trial of the product overcame initial cost barriers and allowed women and their families to experience the health benefits of WaterGuard, appreciate its value and relevance to their lives, and get used to its taste. Social support-from like-minded relatives, friends, neighbors, health care workers, husbands, and children-was also a critical factor that promoted consistent, ongoing use of WaterGuard. The findings confirm the importance of interpersonal communication in prompting adoption of household water treatment and suggest that consumers assess the perceived value of a product, not simply its cost. Further research is planned to investigate questions raised about patterns of ongoing use.

Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature

BACKGROUND There is a growing interest in the role of private health providers in low- and middle-income countries (LMICs). Informal private providers (IPPs) provide a significant portion of health care in many LMICs, but they have not received training in allopathic medicine. Interventions have been developed to take advantage of their potential to expand access to essential health services, although their success is not well measured. This paper addresses this information gap through a review of interventions designed to improve the quality, coverage, or costs of health services provided by IPPs in LMICs. METHODS A search for published literature in the last 15 years for any intervention dealing with IPPs in a LMIC, where at least one outcome was measured, was conducted through electronic databases PubMed and Global Health, as well as Google for grey literature from the Internet. RESULTS A total of 1272 articles were retrieved, of which 70 separate studies met inclusion criteria. The majority (70%) of outcomes measured proximate indicators such as provider knowledge (61% were positive) and behaviour (56% positive). Training IPPs was the most common intervention tested (77% of studies), but the more effective strategies did not involve training alone. Interventions that changed the institutional relationships and contributed to changing the incentives and accountability environment were most successful, and often required combinations of interventions. CONCLUSION Although there are documented interventions among IPPs, there are few good quality studies. Strategies that change the market conditions for IPPs-by changing incentives and accountability-appear more likely to succeed than those that depend on building individual capacities of IPPs. Understanding the effectiveness of these and other strategies will also require more rigorous research designs that assess contextual factors and document outcomes over longer periods.

Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala

BACKGROUND

The promotion of household water treatment and handwashing with soap has led to large reductions in child diarrhoea in randomized efficacy trials. Currently, we know little about the health effectiveness of behaviour-based water and hygiene interventions after the conclusion of intervention activities.

METHODS

We present an extension of previously published design (propensity score matching) and analysis (targeted maximum likelihood estimation) methods to evaluate the behavioural and health impacts of a pre-existing but non-randomized intervention (a 3-year, combined household water treatment and handwashing campaign in rural Guatemala). Six months after the intervention, we conducted a cross-sectional cohort study in 30 villages (15 intervention and 15 control) that included 600 households, and 929 children <5 years of age.

RESULTS

The study design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics. The intervention led to modest gains in confirmed water treatment behaviour [risk difference = 0.05, 95% confidence interval (CI) 0.02-0.09]. We found, however, no difference between the intervention and control villages in self-reported handwashing behaviour, spot-check hygiene conditions, or the prevalence of child diarrhoea, clinical acute lower respiratory infections or child growth.

CONCLUSIONS

To our knowledge this is the first post-intervention follow-up study of a combined household water treatment and handwashing behaviour change intervention, and the first post-intervention follow-up of either intervention type to include child health measurement. The lack of child health impacts is consistent with unsustained behaviour adoption. Our findings highlight the difficulty of implementing behaviour-based household water treatment and handwashing outside of intensive efficacy trials.

Point of use household drinking water filtration: A practical, effective solution for providing sustained access to safe drinking water in the developing world

The lack of safe water creates a tremendous burden of diarrheal disease and other debilitating, life-threatening illnesses for people in the developing world. Point-of-use (POU) water treatment technology has emerged as an approach that empowers people and communities without access to safe water to improve water quality by treating it in the home. Several POU technologies are available, but, except for boiling, none have achieved sustained, large-scale use. Sustained use is essential if household water treatment technology (HWT) is to provide continued protection, but it is difficult to achieve. The most effective, widely promoted and used POU HWTs are critically examined according to specified criteria for performance and sustainability. Ceramic and biosand household water filters are identified as most effective according to the evaluation criteria applied and as having the greatest potential to become widely used and sustainable for improving household water quality to reduce waterborne disease and death.