Perception of drinking water safety and factors influencing acceptance and sustainability of a water quality intervention in rural southern India

Assessing the Influence of Hand-Dug Well Features and Management on Water Quality

Underground water quality can be affected by natural or human-made influences. This study investigates how the management and characteristics of hand-dug wells impact water quality in 3 suburbs of Kumasi, Ghana, using a combination of qualitative and quantitative research methods. Descriptive analysis, including frequency and percentages, depicted the demographic profiles of respondents. Box plot diagrams illustrated the distribution of physicochemical parameters (Total Dissolved Solid [TDS], Electrical Conductivity [EC], Turbidity, Dissolved Oxygen [DO], and Temperature). Factor analysis evaluated dominant factors among these parameters. Cluster analysis (hierarchical clustering) utilized sampling points as variables to establish spatial variations in water physicochemical parameters. Cramer's V correlation test explored relationships between demographic variables and individual perceptions of water management. One-way ANOVA verified significant mean differences among the physicochemical parameters. Logistic regression models assessed the influence of selected well features (e.g., cover and apron) on TDS, pH, Temperature, Turbidity, and DO. The findings revealed that proximity to human settlements affects water quality, and increasing turbidity is associated with unmaintained covers, significantly impacting water quality (P < .05). Over 80% of wells were located within 10 to 30 m of pollution sources, with 65.63% situated in lower ground and 87.5% being unmaintained. Other significant contamination sources included plastic bucket/rope usage (87.50%), defective linings (75%), and apron fissures (59.37%). Presence of E. coli, Total coliform, and Faecal coliform rendered the wells unpotable. Factor analysis attributed 90.85% of time-based and spatial differences to organic particle decomposition factors. However, Cramer's V correlation analysis found establishing association between demographic factor associations with individual perceptions of hand-dug well management difficult. It is encouraged to promote hand-dug well construction and maintenance standards to ensure that wells are properly built and protected from contamination sources.

Determinants of household safe drinking water practices in Kabul, Afghanistan: New insights from behavioural survey data

More than 2 billion people worldwide lack access to safe drinking water. Household water treatment (HWT) is an interim option for reducing the risk of water born disease. Understanding the factors that influence HWT behaviour is crucial for delivering successful interventions aimed at scaling relevant technologies, but the literature tends to emphasise psychological determinants with little consideration of socioeconomic and contextual factors. This article responds to this literature by using the COM-B model to examine the determinants of HWT practices through a comprehensive and context-sensitive behaviour definition. We informed this model through a cross-sectional survey design in which we collected data from 913 households in two peri‑urban neighbourhoods of Kabul, Afghanistan. Our findings from descriptive statistical and regression analysis highlight the importance of not only psychological but also socio-economic and contextual determinants of HWT behaviour: Especially the COM-B dimensions of reflective and automatic motivation, and physical opportunity - which are heavily influenced by local context and economic circumstances - had statistically significant associations with performing HWT. The practical significance of these dimensions was similarly pronounced. For example, an increase in the physical opportunity index by 0.1 units from an average value of 0.7 to 0.8 would be associated with a 7.7 percentage-point higher likelihood of HWT performance. These results suggest that the COM-B model can be utilised to systematically design interventions aimed at promoting HWT practices, while highlighting the need to broaden behavioural analyses of HWT and consider contextual factors to develop interventions that are tailored to the specific needs and obstacles of different communities.

The Association Between Rainfall, Temperature, and Reported Drinking Water Source: A Multi-Country Analysis

Climate change may alter access to safe drinking water, with important implications for health. We assessed the relationship between temperature and rainfall and utilization of basic drinking water (BDW) in The Gambia, Mozambique, Pakistan, and Kenya. The outcomes of interest were (a) whether the reported drinking water source used in the past 2 weeks met the World Health Organization definition of BDW and (b) use of a BDW source that was always available. Temperature and precipitation data were compiled from weather stations and satellite data and summarized to account for long- and short-term weather patterns and lags. We utilized random forests and logistic regression to identify key weather variables that predicted outcomes by site and the association between important weather variables and BDW use. Higher temperatures were associated with decreased BDW use at three of four sites and decreased use of BDW that is always available at all four sites. Increasing rainfall, both in the long- and short-term, was associated with increased BDW use in three sites. We found evidence for interactions between household wealth and weather variables at two sites, suggesting lower wealth populations may be more sensitive to weather-driven changes in water access. Changes in temperature and precipitation can alter safe water use in low-resource settings-investigating drivers for these relationships can inform efforts to build climate resilience.

Acceptability measures of water, sanitation and hygiene interventions in low- and middle-income countries, a systematic review

BACKGROUND

Inadequate access to water, sanitation, and hygiene (WASH) is an environmental risk factor for poor health outcomes globally, particularly for children in low- and middle-income countries (LMIC). Despite technological advancements, many interventions aimed at improving WASH access return less than optimal results on long term impact, efficacy and sustainability. Research focus in the 'WASH sector' has recently expanded from investigating 'which interventions work' to 'how they are best implemented'. The 'acceptability' of an intervention is a key component of implementation that can influence initial uptake and sustained use. Acceptability assessments are increasingly common for health interventions in clinical settings. A broad scale assessment of how acceptability has been measured in the WASH sector, however, has not yet been conducted.

METHODS/PRINCIPAL FINDINGS

We conducted a systematic literature review of intervention studies published between 1990 and 2021 that evaluated the acceptability of WASH interventions in LMIC settings. Using an implementation science approach, focused outcomes included how acceptability was measured and defined, and the timing of acceptability assessment. We conducted quality assessment for all included studies using the Cochrane Risk of Bias tool for randomised studies, and the Newcastle-Ottawa Scale for non-randomised studies. Of the 1238 records; 36 studies were included for the analysis, 22 of which were non-randomized interventions and 16 randomized or cluster-randomized trials. We found that among the 36 studies, four explicitly defined their acceptability measure, and six used a behavioural framework to inform their acceptability study design. There were few acceptability evaluations in schools and healthcare facilities. While all studies reported measuring WASH acceptability, the measures were often not comparable or described.

CONCLUSIONS

As focus in WASH research shifts towards implementation, a consistent approach to including, defining, and measuring acceptability is needed.

Do health risk perceptions motivate water - and health-related behaviour? A systematic literature review

Health-related risk perceptions are important determinants of health behaviours and components of behaviour change theories. What someone thinks or feels will motivate or hinder their intention or hesitancy to implement a certain behaviour. Thus, a perceived potential risk to our health and well-being can influence our health-promoting and/or health-seeking behaviour. We aimed to review and synthesize available peer-reviewed literature to better understand the links between water and health-related risk perceptions and behaviours. We conducted the first systematic review of peer-reviewed literature on risk perceptions and behaviours in the context of water and health, published between 2000 and 2021. A total of 187 publications met the inclusion criteria. We extracted data relating to study characteristics and categorized our results according to the major themes emerging from the literature, namely drinking water, sanitation, hygiene and wasterelated topics, health risk factors, diseases and mental health implications, and preventative measures. Our review shows that the literature has grown over the past twenty years, reporting information from different countries belonging to different income groups around the globe, conducted in various settings and contexts, among different target populations, from various disciplinary angles, using different methods, theories and approaches. Our review provides evidence of health risk perceptions determining behaviour particularly related to drinking water sources and water safety. Evidence on disease prevention, health seeking, variations and changes in perception and behaviour over space, geography, socioeconomic differences and time, and the relevance of cultural context is provided. Our review shows that risk perception studies are vital for WASH governance in terms of policy, raising awareness, education and behaviour change. In order to make risk perception and behaviour studies even more relevant to effective public health planning and health messaging, future research needs to increasingly focus on early culturally sensitive interventions and changes in perceptions and behaviours over time.

Public Knowledge and Perception of Drinking Water Quality and Its Health Implications: An Example from the Makueni County, South-Eastern Kenya

Due to the semi-arid nature of Makueni County in South-Eastern Kenya, there is a high dependence on groundwater resources for domestic use. Reliance on this source of potable water may have health implications for the population, given the presence of several naturally occurring and potentially harmful elements reported from aquifer source rocks, soil, and water in the area. A survey involving questionnaires and focus group discussions (FGDs) was conducted with 115 individuals to determine the local population’s knowledge, attitude, and perceptions of their drinking water quality and its health impacts. The results show that most respondents (67%) preferred piped water because it was pre-treated and not saline. Only 29% of the respondents were very satisfied with the taste of their drinking water, while the rest complained about varying salinity levels, ranging from slightly salty to very salty. This low satisfaction might have influenced the low daily drinking water consumption (1–2 L) by most respondents. Health issues reported by many (43%) respondents in the area include diarrhoea and gastrointestinal upsets, which may be associated with the saline nature of the drinking water. Elevated fluoride (F−) in the local groundwater was reported, and the health effects remain a concern. Although 91% knew someone with dental fluorosis, 53% did not know the deleterious effects of high F− in drinking water. Most respondents (59%) associated the salty nature of the water with dental fluorosis, and as a result, 48% avoided drinking the salty water to prevent the condition. Despite the high prevalence and known psycho-social effects, most people did not perceive dental fluorosis as a severe health threat. The increased health risks associated with high salinity and high F− in drinking water in Makueni County are poorly understood by most residents, regardless of their education, gender, or age. This warrants an immediate public health education programme and detailed epidemiological studies to determine all the health effects associated with naturally occurring, potentially harmful elements in groundwater in the area.

Drinking Water Quality and Public Health in the Kathmandu Valley, Nepal: Coliform Bacteria, Chemical Contaminants, and Health Status of Consumers

Residents of Nepal’s Kathmandu Valley draw drinking water from tube wells, dug wells, and stone spouts, all of which have been reported to have serious water quality issues. In this study, we analyzed drinking water samples from 35 tube wells, dug wells, stone spouts, and municipal tap water for bacterial and chemical contaminants, including total and fecal coliform, aluminum, arsenic, barium, beryllium, boron, cadmium, cobalt, chromium, copper, fluoride, iron, mercury, manganese, molybdenum, nickel, lead, antimony, selenium, thallium, uranium, vanadium, and zinc. We also asked a sampling of households who used these specific water sources to rate the taste of their water, list any waterborne diseases they were aware of, and share basic health information about household members. This survey provided us with information from 146 households and 603 individuals. We found widespread bacterial contamination of water sources, with 94% of sources having detectable total or fecal coliform. Nepal Drinking Water Quality Standards and World Health Organization (WHO) Drinking-Water Guidelines or health-based values were exceeded for aluminum (max = 0.53 mg/L), arsenic (max = 0.071 mg/L), iron (max = 7.22 mg/L), and manganese (max = 3.229 mg/L). The distribution of water sources with high arsenic, iron, and manganese appeared to be associated with floodplain deposits. Mixed effects logistic regression models were used to examine the interactions between social factors and water contaminants and their effects on household members’ health. Consumers of water sources with both high and low concentrations of manganese were less likely to have a positive attitude towards school than those whose water sources had moderate concentrations of manganese. Social factors, especially education, played a large role in predicting individual health outcomes. Household taste ratings of drinking water were not correlated with iron or manganese concentrations, suggesting that WHO’s reliance on aesthetic criteria for these contaminants instead of formal drinking-water guidelines may not be sufficient to protect public health.

The Perception of Water Contamination and Risky Consumption in El Salvador from a Community Clinical Psychology Perspective

This study was carried out as part of the international cooperation project “Agua Futura” for the improvement of water resource management and the promotion of water, sanitation, and hygiene (WASH) behaviors in rural communities of Central America. Given the relevant healthcare problem of water pollution, especially in El Salvador, the aim was to detect some key factors affecting the perception of water contamination and its risky consumption from a community clinical psychological perspective. Ninety rural inhabitants of El Salvador were administered a structured interview exploring their perceptions about water quality and the impact of water consumption on health. Data were analyzed through a computer-aided thematic analysis—complemented by a qualitative analysis—allowing the detection of sense-making processes based on lexical variability. Different themes were identified with regard to the perception of water quality (i.e., mistrust, danger, and safety) and the beliefs about the impact of water consumption on health (i.e., rationalization, denial, awareness, displacement, and isolation of affect). The results showed heterogeneous perspectives about water quality and sanitation. However, the perceived negative impact of water consumption on health was mostly denied or minimized through massive distortions. Overall, the study highlights the role of defensive patterns in facing issues of water contamination, which may prevent the community from adopting healthy behaviors and adequate water management behaviors.

Urban Water Access and Use in the Kivus: Evaluating Behavioural Outcomes Following an Integrated WASH Intervention in Goma and Bukavu, Democratic Republic of Congo

Increasing the availability and reliability of community water sources is a primary pathway through which many water supply interventions aim to achieve health gains in communities with limited access to water. While previous studies in rural settings have shown that greater access to water is associated both with increased overall consumption of water and use of water for hygiene related activities, there is limited evidence from urban environments. Using data collected from 1253 households during the evaluation of a community water supply governance and hygiene promotion intervention in the cities of Goma and Bukavu, Democratic Republic of Congo, we conducted a secondary analysis to determine the impact of these interventions on household water collection and use habits. Using multiple and logistic regression models we compared differences in outcomes of interest between households in quartiers with and without the intervention. Outcomes of interest included litres per capita day (lpcd) of water brought to the household, lpcd used at the household, and lpcd used for hygiene-related activities. Results demonstrated that intervention households were more likely to use community tapstands than households located in comparison quartiers and collected on average 16.3 lpcd of water, compared with 13.5 lpcd among comparison households (adj. coef: 3.2, 95 CI: 0.84 to 5.53, p = 0.008). However, reported usage of water in the household for domestic purposes was lower among intervention households (8.2 lpcd) when compared with comparison households (9.4 lpcd) (adj. coef: -1.11, 95 CI: -2.29 to 0.07), p = 0.066) and there was no difference between study groups in the amount of water allocated to hygiene activities. These results show that in this setting, implementation of a water supply governance and hygiene promotion intervention was associated with a modest increase in the amount of water being bought to the household, but that this did not translate into an increase in either overall per capita consumption of water or the per capita amount of water being allocated to hygiene related activities.

Predicting factors of public awareness and perception about the quality, safety of drinking water, and pollution incidents

Public perception of drinking water quality and safety results from the interaction of multiple factors, including the public engagement, which requires sufficient knowledge and awareness. This issue has yet to be addressed in Algeria. This study investigated the residents' perception and awareness about the drinking water quality, safety, and water pollution events. A survey-based cross-sectional study was conducted amongst citizens living in the province of Biskra. Multinomial regression analysis was used to identify the predicted public perception factors about drinking water-related issues. Regardless of the degree of public trust in the drinking water sources, the main drinking water source reported by the participants was tank water (43.3%) followed by tap water (32%). Water quality standards are a measure of the condition of water relative to the contaminants. Water consumption profiles gave priority attention to taste (48.7%), odour (35%), appearance (34.7%), and colour (32%), reflecting a low level of knowledge about the water quality standards. Most of the residents (55.7%) reported a deficient communication about the preventive measures to protect public health. The higher level of education showed a statistically significant impact in discriminating between those who felt very satisfied and dissatisfied participants with the drinking water quality and those who felt between satisfied and dissatisfied (P = 0.023, P = 0.034, respectively). Additionally, education level had a statistically significant role in differentiating trust levels in drinking water quality between two groups, those belonging to either confident or relatively confident and the group of extremely worried respondents, with P = 0.000 and P = 0.000, respectively. Interviewed respondents with certain education levels showed higher trust in the safety of drinking water when compared to those with lower education levels. Gender had a significant role in differentiating the group of respondents who were relatively confident from those who were extremely worried (P = 0.016). The public knowledge about the standards of water quality, safety, and the pollution-related issues remains relatively low. This study is of interest to policy makers and public health authorities who implement actions for water contamination prevention and public health protection. These findings could have national implications and are also applicable, in general context, particularly in low and middle-income countries.

Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi

Lack of access to safe drinking water on premises remains widespread in low- and middle-income countries. Interventions to improve access to safe water at the point of collection are essential, but water safety at the point of consumption is also an important consideration. This research aimed to 1) improve understanding of household practices in collecting water with respect to seasonality, and 2) to further assess risk associated with post-collection contamination from the point of collection to the point of consumption. A seasonal cohort study, including 115 households, was conducted in Malawi. Along with household surveys and observations, samples of water were tested for microbial water quality at four different stages of water collection: water source, collection container, storage container, cup of drinking water. Using E. coli as an indicator of contamination (cfu/100 ml), the risk of post-collection contamination was assessed. The results indicate that most water sources were free from contamination; contamination was proportionally lower in the dry season when more sources were found to be classified as having a very low risk of contamination. However, the level of risk of contamination was more likely to increase following collection in water sources that were initially free from contamination. Results show that the degradation in water quality from the point of collection to the point of consumption was more important in the rainy season, which is likely to be driven by the effect of seasonality on the household environment. Filling the collection container at the point of collection and storage at the point of consumption were found to be critical stages for an increased risk of E. coli contamination. Understanding household practices in accessing and handling water during both rainy and dry season is necessary to target appropriate interventions to reduce post-collection contamination.

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.

Households with unimproved water sources in Ethiopia: spatial variation and point-of-use treatment based on 2016 Demographic and Health Survey

Background

Improved water sources are not equally available in all geographical regions. Populations dependent on unsafe water sources are recommended to treat their water at point-of-use using adequate methods to reduce associated health problems. In Ethiopia, the spatial distribution of households using unimproved water sources have been incomplete or ignored in most of the studies. Moreover, evidence on the point-of-use water treatment practice of households dependent on such water sources is scarce. Therefore, the current study is intended to analyze the spatial distribution of unimproved water sources by wealth quintiles at country level and point-of-use treatment (POU) practices using nationally representative data.

Method

The data of 2016 Ethiopian Demographic and Health Survey (EDHS) conducted on 16650 households from 643 clusters were used for the analysis. For spatial analysis, the raw and spatially smoothed coverage data was joined to the geographic coordinates based on EDHS cluster identification code. Global spatial autocorrelation was performed to analyze whether the pattern of unimproved water coverage is clustered, dispersed, or random across the study areas. Once a positive global autocorrelation was confirmed, a local spatial autocorrelation analysis was applied to detect local clusters. The POU water treatment is analyzed based on reported use of either boiling, chlorine (bleach), filtration, or solar disinfection (SODIS).

Results

There were 5005 households using unimproved water sources for drinking purposes. Spatial variation of unimproved water coverage was observed with high coverage observed at Amhara, Afar, Southern Nations Nationalities and People and Somalia regions. Disparity in unimproved water coverage between wealth quintiles was also observed. The reported point-of-use water treatment practice among these households is only 6.24%. The odds of POU water treatment among household heads with higher education status is 2.5 times higher (95% CI = 1.43-4.36) compared to those who did not attend education.

Conclusion

An apparent clustering trend with high unimproved water coverage was observed between regions and among wealth quintiles hence indicates priority areas for future resource allocation and the need for regional and national policies to address the issue. Promoting households to treat water prior to drinking is essential to reduce health problems.

A randomized, double-blind water taste test to evaluate the equivalence of taste between tap water and filtered water in the Taipei metropolis

High water quality and sufficient water availability are the main concerns of water users. Promoting the efficient use of tap water can contribute to sustainable drinking water management and progress towards Sustainable Development Goals. In many metropolises, water suppliers treat municipal water with appropriate treatment processes and well-maintained distribution infrastructure. Under this circumstance, it is acceptable that municipal water can be a source of drinking water. The presence of residual chlorine in tap water, connected to municipal water supply, inactivates pathogenic microorganisms and prevents recontamination. However, adding chlorine to tap water may affect the organoleptic properties of drinking water. On the other hand, the use of point-of-use (POU) water dispensers, which provides an additional treatment step on tap water, is not energy-efficient. A randomized, double-blind water taste test was conducted in the Taipei metropolis to assess whether tap water from public drinking fountains and filtered water from POU water dispensers have similar organoleptic properties. An odds ratio (OR) and the area under the receiver operating characteristic curve (AUC) were used to measure the participants' ability to distinguish between the two water varieties. A five-region hypothesis test was conducted to test the OR, and a 95% bootstrap confidence interval of the AUC was calculated. The results of the study showed that the 95% five-region confidence interval of OR equal to (0.5, 1.49), and the 95% bootstrap confidence interval of AUC equal to (0.42, 0.56). These results implied that people in the Taipei metropolis could not distinguish between tap water and filtered water. It is recommended that more drinking fountains be installed and maintained fully functional and clean to achieve excellence in tap water access.

Barriers and Enabling Factors Associated with the Implementation of Household Solar Water Disinfection: A Qualitative Study in Northwest Ethiopia

Household water treatment including solar disinfection (SODIS) is recognized worldwide as an important intervention for prevention and control of diarrheal and other waterborne diseases. However, in Ethiopia's countryside, SODIS is not being practiced. Therefore, the objective of this qualitative study conducted in villages of Dabat district in northwest Ethiopia was to explore barriers to and enabling factors for consistent and wider implementation of SODIS. This phenomenological study design included four focus group discussions with 25 parents of children younger than 5 years and interviews with four key informants to elicit their experiences and opinions. ATLAS.ti 8.0 software (GmbH, Berlin, Germany) was used for data organization, and the content was analyzed thematically. Enabling factors were categorized into four themes, such as supportive values for SODIS (positive attitude, advantage of SODIS, and cultural acceptance of SODIS), consistent use of SODIS (community's interest, health education, availability of bright sunlight, and simplicity of the method), participation of family and community in daily implementation of the SODIS process (controlling theft of bottles and recognizing the importance of SODIS technology), and willingness to pay for new polyethylene terephthalate (PET) bottles. On the other hand, barriers were grouped into three themes such as sociocultural (poor knowledge, hesitation to leave SODIS bottles unguarded outdoor, less attention, and unplanned social events), environmental (cloud, shadow over SODIS bottles, turbidity and leeches in source water, and geographical settings), and behavioral (mishandling of SODIS bottles and drinking water). The analysis of the data revealed that all the participants had positive attitude toward the implementation of SODIS, and it was culturally accepted. They identified the barriers to and enabling factors for the implementation of SODIS. Promoting enabling factors and mitigating barriers are substantially important for consistent implementation of SODIS as a long-term interventional measure widely in rural Ethiopia for the achievement of the goal of safe drinking water for all.

Evaluation of an Emergency Bulk Chlorination Project Targeting Drinking Water Vendors in Cholera-Affected Wards of Dar es Salaam and Morogoro, Tanzania

In August 2015, an outbreak of cholera was reported in Tanzania. In cholera-affected areas of urban Dar es Salaam and Morogoro, many households obtained drinking water from vendors, who sold water from tanks ranging in volume from 1,000 to 20,000 L. Water supplied by vendors was not adequately chlorinated. The Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children and the U.N. Children’s Fund, Tanzania, collaborated to enroll and train vendors to treat their water with 8.68-g sodium dichloroisocyanurate tablets (Medentech, Ireland). The Centers for Disease Control and Prevention (CDC) provided monitoring and evaluation support. Vendors were provided a 3-month supply of chlorine tablets. A baseline assessment and routine monitoring were conducted by ward environmental health officers. Approximately 3 months after chlorine tablet distribution, an evaluation of the program was conducted. The evaluation included a full enumeration of all vendors, an in-depth survey with half of the vendors enumerated, and focus group discussions. In total, 797 (88.9%) vendors were included in the full enumeration and 392 in the in-depth survey. Free residual chlorine (FRC) was detected in 12.0% of tanks at baseline and 69.6% of tanks during the evaluation; however, only 17.4% of these tanks had FRC ≥ 0.5 mg/L. The results suggest high acceptability and use of the chlorine tablets by water vendors. However, given variation in the water source used and longer storage times, dosing could be increased in future programming. Bulk chlorination using chlorine tablets offers an efficient community-level approach to treating water closer to the point of use.

Barriers and Enablers to Intervention Uptake and Health Reporting in a Water Intervention Trial in Rural India: A Qualitative Explanatory Study

Consumption of unsafe drinking water contributes to the global disease burden, necessitating identification and implementation of effective, acceptable, and sustainable water interventions in resource-limited settings. In a quantitative stepped-wedge cluster randomized trial of a community-based water intervention in rural India, we identified low rates of intervention uptake and reported diarrhea. To better understand and explain these findings, we performed a qualitative study examining barriers and enablers to intervention uptake and health reporting using the COM-B model, where capabilities, opportunities, and motivators interact to generate behavior. We conducted 20 focus groups and one semi-structured interview with participants and four focus groups with data collectors. Multifactorial barriers to intervention uptake included distorted perceptions of water-related health effects, implementation issues that reduced treated water availability; convenience of, and preference for, alternative drinking water sources; delivery of water to plastic storage tanks (perceived as affecting water quality and taste); and resistance to change. Enablers included knowledge of water-related health risks, proximity to tanks, and social opportunity. Barriers to health reporting included variability in interpretation of illness, suspicion regarding the consequences of reporting disease, weariness with repeated questions, and perceived inaction on health data already provided; low survey implementation fidelity was also important. Enablers included surveyor initiatives to encourage reporting and a sense of social responsibility. This qualitative explanatory study allowed better understanding of our quantitative results. It also identified obstacles and facilitators to implementing and evaluating community water interventions, providing insight on how to achieve better intervention uptake and health reporting in future studies.

Measuring Human Water Needs

Water connects the environment, culture, and biology, yet only recently has it emerged as a major focus for research in human biology. To facilitate such research, we describe methods to measure biological, environmental, and perceptual indicators of human water needs. This toolkit provides an overview of methods for assessing different dimensions of human water need, both well‐established and newly‐developed. These include: (a) markers of hydration (eg, urine specific gravity, doubly labeled water) important for measuring the impacts of water need on human biological functioning; (b) methods for measuring water quality (eg, digital colorimeter, membrane filtration) essential for understanding the health risks associated with exposure to microbiological, organic, metal, inorganic nonmental, and other contaminants; and (c) assessments of household water insecurity status that track aspects of unmet water needs (eg, inadequate water service, unaffordability, and experiences of water insecurity) that are directly relevant to human health and biology. Together, these methods can advance new research about the role of water in human biology and health, including the ways that insufficient, unsafe, or insecure water produces negative biological and health outcomes.

Water Source Preferences and Water Quality Perceptions among Women in the Eastern Region, Ghana: A Grounded Theory Study

Residents in the Eastern Region, Ghana with access to improved water sources (e.g., boreholes and covered wells) often choose to collect water from unimproved sources (e.g., rivers and uncovered wells). To assess why, we conducted two field studies to coincide with Ghana’s rainy and dry seasons. During the rainy season, we conducted semi-structured in-depth interviews among a convenience sample of 26 women in four rural communities (including one woman in the dry season). We asked each participant about their attitudes and perceptions of water sources. During the dry season, we observed four women for ≤4 days each to provide context for water collection and water source choice. We used a grounded theory approach considering the multiple household water sources and uses approach to identify three themes informing water source choice: collection of and access to water, water quality perception, and the dynamic interaction of these. Women selected water sources based on multiple factors, including season, accessibility, religious/spiritual messaging, community messaging (e.g., health risks), and ease-of-use (e.g., physical burden). Gender and power dynamics created structural barriers that affected the use of unimproved water sources. A larger role for women in water management and supply decision-making could advance population health goals.

Variations in sensitivity to chlorine in Ecuador and US consumers: implications for community water systems

Successful implementation of chlorination for disinfecting community water systems in developing countries faces obstacles, with rejection of chlorinous flavor as a significant factor. Determining consumers' abilities to accurately detect chlorine in treated water is important to identifying acceptable chlorination levels that are also effective for water disinfection. Chlorine detection sensitivity was tested in untrained Ecuadorian consumers with limited prior experience with chlorinated water and US consumers with extensive prior experience with chlorinated water. Water samples with free chlorine concentrations up to 3.0 mg/L were presented for flavor testing. Ecuadorian consumers showed higher sensitivity, being able to detect chlorination at 2.0 and 3.0 mg/L, while US consumers did not reliably detect chlorine presence for any concentration levels. Additionally, Ecuadorian consumers' rejection of water samples depended on chlorination, showing a statistically significant increase in rejections of samples with chlorine concentrations above 1.0 mg/L. On the other hand, although US consumers rejected more samples overall, their tendency to reject did not vary as a function of chlorination levels. This study demonstrated that limited experience with chlorination is a critical factor for accurate chlorine flavor detection in drinking water.

New insights into antibiotic resistome in drinking water and management perspectives: A metagenomic based study of small-sized microbes

The proliferation of antibiotic resistance genes (ARGs) in drinking water and their potential horizontal transfer to pathogenic microbes may cause failure of antibiotics. However, antimicrobial resistome monitoring in drinking water is not currently routine. The bacterial hosts of ARGs, especially small-sized microbes in drinking water, may not be effectively removed by membrane filtration disinfection and thus pose threats to human health. In the present study, using metagenomic based approach, we investigated antibiotic resistome of small-sized microbes (0.2-0.45 μm) in 20 household drinking water samples from 12 cities in Mainland China, Hong Kong and Singapore. A total of 265 ARG subtypes belonging to 17 ARG types were detected at abundances ranging from 4.0 × 10^-2 to 1.0 × 10⁰ copies/cell. Multidrug, bacitracin and aminoglycoside resistance genes are dominant, and 43 ARG subtypes were specifically carried by small-size microbes. Metagenomic assembly strategy revealed fragments of three opportunistic pathogen, i.e. Pseudomonas alcaligenes, Pseudomonas aeruginosa and Mycobacterium gordonae, carried mexW, aph(3')-I and aac(2')-I, respectively. Drinking water samples were classified into three groups based on the presence of ARG, pathogen and ARG-carrying pathogen. These new insights into the antibiotic resistome of small microbes in drinking water over a broad scale indicate the need for more comprehensive ARGs monitoring and surveillance of drinking water supplies. These findings, together with the perspectives and strategies proposed in this study, could support initiatives to improve drinking water safety.

Appropriate household water treatment methods in Ethiopia: household use and associated factors based on 2005, 2011, and 2016 EDHS data

BACKGROUND

Diarrheal disease attributable to water and sanitation can be prevented using point-of-use water treatment. In Ethiopia, a small number of households treat water at point-of-use with appropriate methods. However, evidence on factors associated with household use of these treatment methods is scarce. Therefore, this study is intended to explore the household use of appropriate point-of-use water treatment and associated factors in Ethiopia.

METHODS

The data of 2005, 2011, and 2016 Ethiopian demographic and health surveys were used for analysis. Households reportedly treating water with bleach, boiling, filtration, and solar disinfection in each survey are considered as treating with appropriate treatment methods. Household water treatment with these treatment methods and factors associated was assessed using bivariate and multivariable regression. In addition, a region level difference in the treatment use was assessed by using multilevel modeling.

RESULTS

The number of households that reported treating water with appropriate water treatment methods was 3.0%, 8.2%, and 6.5% respectively in 2005, 2011, and 2016. Household heads with higher education had 5.99 (95% CI = 3.48, 10.33), 3.61 (95% CI = 2.56, 5.07), and 3.43 (95% CI = 2.19, 6.37) times higher odds of using the treatment methods respectively in 2005, 2011, and 2016 compared to household heads who had no education. There was a significantly high number of households that used appropriate water treatment methods in 2011 (AOR = 2.78, 95% CI = 2.16, 3.57) and 2016 (AOR = 2.18, 95% CI = 1.64, 3.89) compared to 2005 data. In pooled data analysis, the reported use of the treatment methods is associated with household head education, residency, drinking water sources, and owning radio and television. From a multilevel modeling, within-region variation is higher than between-region variations in the use of treatment methods in each survey.

CONCLUSIONS

Below 10% of households reportedly treating water at point-of-use in each survey attributable to different factors. Designing intervention strategies for wide-scale use of treatment methods at the country level is fundamental.

Farmers’ Perception of Water Quality and Risks in the Mashavera River Basin, Georgia: Analyzing the Vulnerability of the Social-Ecological System through Community Perceptions

Competing natural resources usage that leads to dramatic land use changes can threaten the balance of a social-ecological system. When this is the case, communities are directly exposed to the negative consequences of those land use changes. The Mashavera River Basin is considered one of the hotspots of environmental pollution in Georgia. This is of importance for public health because the food production from this basin meets a substantial proportion of the country’s food demand. The farmers’ perception of the water quality and their perceived risks to the economy, health, and lifestyle reflect the status of the environmental and social conditions. The inclusion of farmers’ risk perceptions is an important stage of water quality governance that could enable active civic participation. The approach of this research study was the convergence model in the triangular design of the mixed method approach. As part of the social data, the research study was conducted with a survey of 177 households, for which agriculture was either a main or partial source of income. A few focus group discussions were also conducted. A binary logistic regression analysis was employed as the main method for the analysis. The results from the pollution load index (PLI) were used as the supportive data to verify some geospatial hypotheses. We found that aesthetic attributes (i.e., color changes observed in the river) and the source of the water contamination (i.e., mining sites) were the main predictor variables for a perceived risk to water quality, health, and livelihoods. The people who work in agriculture as the main income source had more concern about their ability to sell their agricultural products as a result of water contamination in the river, compared with people for whom agriculture is a secondary source of income or for self-consumption. Age, amount of land, years of agricultural experience, and the source of water supply for agriculture did not have a significant effect on any of the risk perception or water quality perception models. The results indicate that the health risk is perceived more strongly in areas with more heavily contaminated water compared to less polluted areas. We propose that conducting a public risk perception assessment is an ideal means to detect people’s concerns regarding water quality governance for future risk analysis in Georgia. Another recommendation of this study is an integrated model of risk assessment that combines the results from a public risk perception assessment and a technical assessment. The benefits of such an integrated assessment include finding new hazard-sensitive areas for further analysis, the possibility to cross-check data for verification, communal communication of hazardous conditions by utilizing local knowledge, and the direct participation of the community in monitoring risks.

Effectiveness of Membrane Filtration to Improve Drinking Water: A Quasi-Experimental Study from Rural Southern India

Since point-of-use methods of water filtration have shown limited acceptance in Vellore, southern India, this study evaluated the effectiveness of decentralized membrane filtration 1) with safe storage, 2) without safe storage, versus 3) no intervention, consisting of central chlorination as per government guidelines, in improving the microbiological quality of drinking water and preventing childhood diarrhea. Periodic testing of water sources, pre-/postfiltration samples, and household water, and a biweekly follow up of children less than 2 years of age was done for 1 year. The membrane filters achieved a log reduction of 0.86 (0.69–1.06), 1.14 (0.99–1.30), and 0.79 (0.67–0.94) for total coliforms, fecal coliforms, and Escherichia coli, respectively, in field conditions. A 24% (incidence rate ratio, IRR [95% confidence interval, CI] = 0.76 [0.51–1.13]; P = 0.178) reduction in diarrheal incidence in the intervention village with safe storage and a 14% (IRR [95% CI] = 1.14 [0.75–1.77]; P = 0.530) increase in incidence for the intervention village without safe storage versus no intervention village was observed, although not statistically significant. Microbiologically, the membrane filters decreased fecal contamination; however, provision of decentralized membrane-filtered water with or without safe storage was not protective against childhood diarrhea.

Piped water consumption in Ghana: A case study of temporal and spatial patterns of clean water demand relative to alternative water sources in rural small towns

Continuous access to adequate quantities of safe water is essential for human health and socioeconomic development. Piped water systems (PWSs) are an increasingly common type of water supply in rural African small towns. We assessed temporal and spatial patterns in water consumption from public standpipes of four PWSs in Ghana in order to assess clean water demand relative to other available water sources. Low water consumption was evident in all study towns, which manifested temporally and spatially. Temporal variability in water consumption that is negatively correlated with rainfall is an indicator of rainwater preference when it is available. Furthermore, our findings show that standpipes in close proximity to alternative water sources such as streams and hand-dug wells suffer further reductions in water consumption. Qualitative data suggest that consumer demand in the study towns appears to be driven more by water quantity, accessibility, and perceived aesthetic water quality, as compared to microbiological water quality or price. In settings with chronic under-utilization of improved water sources, increasing water demand through household connections, improving water quality with respect to taste and appropriateness for laundry, and educating residents about health benefits of using piped water should be prioritized. Continued consumer demand and sufficient revenue generation are important attributes of a water service that ensure its function over time. Our findings suggest that analyzing water consumption of existing metered PWSs in combination with qualitative approaches may enable more efficient planning of community-based water supplies and support sustainable development.

A mixed-methods approach to understanding water use and water infrastructure in a schistosomiasis-endemic community: case study of Asamama, Ghana

Background

Surface water contaminated with human waste may transmit urogenital schistosomiasis (UGS). Water-related activities that allow skin exposure place people at risk, but public health practitioners know little about why some communities with access to improved water infrastructure have substantial surface water contact with infectious water bodies. Community-based mixed-methods research can provide critical information about water use and water infrastructure improvements.

Methods

Our mixed-methods study assessed the context of water use in a rural community endemic for schistosomiasis.

Results

Eighty-seven (35.2 %) households reported using river water but not borehole water; 26 (10.5 %) reported using borehole water but not river water; and 133 (53.8 %) households reported using both water sources. All households are within 1 km of borehole wells, but tested water quality was poor in most wells. Schistosomiasis is perceived by study households (89.3 %) to be a widespread problem in the community, but perceived schistosomiasis risk fails to deter households from river water usage. Hematuria prevalence among schoolchildren does not differ by household water use preference. Focus group data provides context for water preferences. Demand for improvements to water infrastructure was a persistent theme; however, roles and responsibilities with respect to addressing community water and health concerns are ill-defined.

Conclusions

Collectively, our study illustrates how complex attitudes towards water resources can affect which methods will be appropriate to address schistosomiasis.