• 1.

    Bain R, Cronk R, Wright J, Yang H, Slaymaker T, Bartram J, 2014. Fecal contamination of drinking-water in low- and middle-income countries: a systematic review and meta-analysis. PLoS Med 11: e1001644.

    • Search Google Scholar
    • Export Citation
  • 2.

    Shaheed A, Orgill J, Montgomery MA, Jeuland MA, Brown J, 2014. Why “improved” water sources are not always safe. Bull World Health Organ 92: 283289.

    • Search Google Scholar
    • Export Citation
  • 3.

    Ercumen A, Gruber JS, Colford JM, 2014. Water distribution system deficiencies and gastrointestinal illness: a systematic review and meta-analysis. Environ Health Perspect 122: 651660.

    • Search Google Scholar
    • Export Citation
  • 4.

    Hunter PR, MacDonald AM, Carter RC, 2010. Water supply and health. PLoS Med 7: e1000361.

  • 5.

    Albert J, Luoto J, Levine D, 2010. End-user preferences for and performance of competing POU water treatment technologies among the rural poor of Kenya. Environ Sci Technol 44: 44264432.

    • Search Google Scholar
    • Export Citation
  • 6.

    Clasen T, Roberts I, Rabie T, Schmidt W, Cairncross S, 2015. Interventions to improve water quality for preventing diarrhoea (Review). Cochrane Database Syst Rev 10: CD004794.

    • Search Google Scholar
    • Export Citation
  • 7.

    Lantagne DS, Quick R, Mintz ED, 2006. Household Water Treatment and Safe Storage Options in Developing Countries: A Review of Current Implementation Practices. Washington DC: US Center for Disease Control.

  • 8.

    Sobsey MD, 2002. Managing Water in the Home: Accelerated Health Gains from Improved Water Supply. Geneva, Switzerland: World Health Organization.

  • 9.

    Wolf J., 2014. Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Health 19: 928942.

    • Search Google Scholar
    • Export Citation
  • 10.

    Arnold BF, Colford JM Jr, 2007. Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: a systematic review and meta-analysis. Am J Trop Med Hyg 76: 354364.

    • Search Google Scholar
    • Export Citation
  • 11.

    Arnold B, Arana B, Mäusezahl D, Hubbard A, Colford JM, 2009. Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol 38: 16511661.

    • Search Google Scholar
    • Export Citation
  • 12.

    Mäusezahl D., 2009. Solar drinking water disinfection (SODIS) to reduce childhood diarrhoea in rural Bolivia: a cluster-randomized, controlled trial. PLoS Med 6: e1000125.

    • Search Google Scholar
    • Export Citation
  • 13.

    Parker Fiebelkorn A, Person B, Quick RE, Vindigni SM, Jhung M, Bowen A, Riley PL, 2012. 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. Soc Sci Med 75: 622633.

    • Search Google Scholar
    • Export Citation
  • 14.

    Stauber CE, Printy ER, McCarty FA, Liang KR, Sobsey MD, 2012. Cluster randomized controlled trial of the plastic BioSand Water filter in Cambodia. Environ Sci Technol 46: 722728.

    • Search Google Scholar
    • Export Citation
  • 15.

    Brown J, Clasen T, 2012. High adherence is necessary to realize health gains from water quality interventions. PLoS One 7: e36735.

  • 16.

    Enger KS, Nelson KL, Rose JB, Eisenberg JNS, 2013. The joint effects of efficacy and compliance: a study of household water treatment effectiveness against childhood diarrhea. Water Res 47: 11811190.

    • Search Google Scholar
    • Export Citation
  • 17.

    Hunter PR, Zmirou-Navier D, Hartemann P, 2009. Estimating the impact on health of poor reliability of drinking water interventions in developing countries. Sci Total Environ 407: 26212624.

    • Search Google Scholar
    • Export Citation
  • 18.

    Burt Z, Njee RM, Mbatia Y, Msimbe V, Brown J, Clasen TF, Malebo HM, Ray I, 2017. User preferences and willingness to pay for safe drinking water: experimental evidence from rural Tanzania. Soc Sci Med 173: 6371.

    • Search Google Scholar
    • Export Citation
  • 19.

    Amrose S, Burt Z, Ray I, 2015. Safe drinking water for low-income regions. Annu Rev Environ Resour 40: 203231.

  • 20.

    Figueroa ME, Kincaid DL, 2010. Social, Cultural and Behavioral Correlates of Household Water Treatment and Storage. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health.

  • 21.

    Luoto J, Mahmud M, Albert J, Luby S, Najnin N, Unicomb L, Levine DI, 2012. Learning to dislike safe water products: results from a randomized controlled trial of the effects of direct and peer experience on willingness to pay. Environ Sci Technol 46: 62446251.

    • Search Google Scholar
    • Export Citation
  • 22.

    Mosler H-J, 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431449.

    • Search Google Scholar
    • Export Citation
  • 23.

    Bertrand M, Mullainathan S, Shafir E, 2004. A behavioral-economics view of poverty. Am Econ Rev 94: 419423.

  • 24.

    Gruber JS, Reygadas F, Arnold BF, Ray I, Nelson K, Colford JM, 2013. A stepped wedge, cluster-randomized trial of a household UV-disinfection and safe storage drinking water intervention in rural Baja California Sur, Mexico. Am J Trop Med Hyg 89: 238245.

    • Search Google Scholar
    • Export Citation
  • 25.

    Reygadas F, Gruber JS, Ray I, Nelson KL, 2015. Field efficacy evaluation and post-treatment contamination risk assessment of an ultraviolet disinfection and safe storage system. Water Res 85: 7484.

    • Search Google Scholar
    • Export Citation
  • 26.

    NSF, 2002. NSF International Standard/American National Standard for Drinking Water Treatment Units—Ultraviolet Microbiological Water Treatment Systems. Available at: http://edge.rit.edu/edge/P11413/public/NSF%20Standard%2055. Accessed May 20, 2017.

  • 27.

    WHO, 2011. Evaluating Household Water Treatment Options: Health-Based Targets and Microbiological Performance Specifications. Geneva, Switzerland: World Health Organization. Available at: http://apps.who.int//iris/handle/10665/44693. Accessed November 15, 2014.

  • 28.

    Feise RJ, 2002. Do multiple outcome measures require p-value adjustment? BMC Med Res Methodol 2: 8.

  • 29.

    Yelland LN, Salter AB, Ryan P, 2011. Performance of the modified Poisson regression approach for estimating relative risks from clustered prospective data. Am J Epidemiol 174: 984992.

    • Search Google Scholar
    • Export Citation
  • 30.

    Hussey MA, Hughes JP, 2007. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials 28: 182191.

  • 31.

    Gertler PJ, Martinez S, Premand P, Rawlings LB, Vermeersch CMJ, 2011. Impact Evaluation in Practice. Washington, DC: World Bank. Available at: http://hdl.handle.net/10986/2550.

  • 32.

    Rao V, Woolcock M, 2003. Integrating qualitative and quantitative approaches in program evaluation. Bourguignon F, Pereira da Silva LA, eds. The Impact of Economic Policies on Poverty and Income Distribution: Evaluation Techniques and Tools. Washington, DC: World Bank Publications.

  • 33.

    Rosa G, Clasen T, 2017. Consistency of use and effectiveness of household water treatment among Indian households claiming to treat their water. Am J Trop Med Hyg 97: 259270.

    • Search Google Scholar
    • Export Citation
  • 34.

    Ray I, 2007. Women, water, and development. Annu Rev Environ Resour 32: 421449.

  • 35.

    Colindres RE, Jain S, Bowen A, Mintz E, Domond P, 2007. After the flood: an evaluation of in-home drinking water treatment with combined flocculent-disinfectant following Tropical Storm Jeanne—Gonaives, Haiti, 2004. J Water Health 5: 367374.

    • Search Google Scholar
    • Export Citation
  • 36.

    Freeman MC, Quick RE, Abbott DP, Ogutu P, Rheingans R, 2009. Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya. J Water Health 7: 527534.

    • Search Google Scholar
    • Export Citation
  • 37.

    Luby SP, Mendoza C, Keswick BH, Chiller TM, Hoekstra RM, 2008. Difficulties in bringing point-of-use water treatment to scale in rural Guatemala. Am J Trop Med Hyg 78: 382387.

    • Search Google Scholar
    • Export Citation
  • 38.

    McLennan JD, 2000. To boil or not: drinking water for children in a periurban barrio. Soc Sci Med 51: 12111220.

  • 39.

    Wood S, Foster J, Kols A, 2012. Understanding why women adopt and sustain home water treatment: insights from the Malawi antenatal care program. Soc Sci Med 75: 634642.

    • Search Google Scholar
    • Export Citation
  • 40.

    Juran L, MacDonald MC, 2014. An assessment of boiling as a method of household water treatment in South India. J Water Health 12: 791802.

  • 41.

    Brown J, Hamoudi A, Jeuland M, Turrini G, 2016. Seeing, believing, and behaving: heterogeneous effects of an information intervention on household water treatment. J Environ Econ Manage 86: 141159.

    • Search Google Scholar
    • Export Citation
  • 42.

    Davis J, Pickering AJ, Rogers K, Mamuya S, Boehm AB, 2011. The effects of informational interventions on household water management, hygiene behaviors, stored drinking water quality, and hand contamination in peri-urban Tanzania. Am J Trop Med Hyg 84: 184191.

    • Search Google Scholar
    • Export Citation
  • 43.

    Jalan J, Somanathan E, 2008. The importance of being informed: experimental evidence on demand for environmental quality. J Dev Econ 87: 1428.

    • Search Google Scholar
    • Export Citation

 

 

 

 

Measuring User Compliance and Cost Effectiveness of Safe Drinking Water Programs: A Cluster-Randomized Study of Household Ultraviolet Disinfection in Rural Mexico

View More View Less
  • 1 Fundación Cántaro Azul, Chiapas, Mexico;
  • 2 Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California;
  • 3 Warren Alpert Medical School, Brown University, Providence, Rhode Island;
  • 4 Department of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, California;
  • 5 Energy and Resources Group, University of California, Berkeley, Berkeley, California

Low adoption and compliance levels for household water treatment and safe storage (HWTS) technologies have made it challenging for these systems to achieve measurable health benefits in the developing world. User compliance remains an inconsistently defined and poorly understood feature of HWTS programs. In this article, we develop a comprehensive approach to understanding HWTS compliance. First, our Safe Drinking Water Compliance Framework disaggregates and measures the components of compliance from initial adoption of the HWTS to exclusive consumption of treated water. We apply this framework to an ultraviolet (UV)–based safe water system in a cluster-randomized controlled trial in rural Mexico. Second, we evaluate a no-frills (or “Basic”) variant of the program as well as an improved (or “Enhanced”) variant, to test if subtle changes in the user interface of HWTS programs could improve compliance. Finally, we perform a full-cost analysis of both variants to assess their cost effectiveness (CE) in achieving compliance. We define “compliance” strictly as the habit of consuming safe water. We find that compliance was significantly higher in the groups where the UV program variants were rolled out than in the control groups. The Enhanced variant performed better immediately postintervention than the Basic, but compliance (and thus CE) degraded with time such that no effective difference remained between the two versions of the program.

    • Supplementary Materials

Author Notes

Address correspondence to Fermín Reygadas, Fundación Cántaro Azul, Daniel Sarmiento 19-A, San Cristóbal de Las Casas, Chiapas 29246, Mexico, E-mail: reygadas@gmail.com or Isha Ray, Energy and Resources Group, University of California, Berkeley, Berkeley, 310 Barrows Hall, Berkeley, CA 94720-3050, E-mail: isharay@berkeley.edu.

Authors’ addresses: Fermín Reygadas, Fundación Cántaro Azul, Chiapas, Mexico, E-mail: reygadas@gmail.com. Joshua S. Gruber, Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, E-mail: jsgruber@gmail.com. Lindsay Dreizler, Warren Alpert Medical School, Brown University, Providence, RI, E-mail: lindsay_dreizler@brown.edu. Kara L. Nelson, Department of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, CA, E-mail: karanelson@berkeley.edu. Isha Ray, Energy and Resources Group, University of California, Berkeley, Berkeley, CA, E-mail: isharay@berkeley.edu.

Save