The purpose of this presentation is to shed light on how a new toolkit from the World
Health Organization and UNICEF can help to monitor and evaluate household water
treatment and safe storage projects for greater sustainability.
3. Household water treatment is a possible solution. It can be used to improve the quality of
water consumed in the home. A series of meta‐analyses (Fewtrell et al., 2005; Clasen et al.,
2006;, Waddington et al., 2009) showed that HWTS could reduce the incidence of diarrheal
disease by between 35% and 47%. However, these reviews group together the findings
from a wide variety of studies of varying quality. For example, studies are often too short to
evaluate sustained use or the results were based on self‐reported data. In addition, results
from HWTS programs are often inconsistent, because the implementing methodology often
varies. This can make it difficult to compare program results.
The images along below illustrate six examples of accepted and proven HWTS methods.
Each has its advantages and disadvantages and the choice of which one to use depends on
the local context. Some methods protect against re‐contamination such as through a
chlorine residual or a safe storage mechanism (i.e. solar disinfection in a plastic bottle). The
last image with the red question mark indicates that boiling is not ideal due to a range of
factors: sub‐optimal performance, no protective factor against recontamination risk,
creates smoke in the household, heightens the risk of burn injuries, and environmental
issues.
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4. There are various challenges to sustainability which are often placed into several broad
categories. This list is not intended to be exhaustive (for example, environmental
sustainability is not shown here). Facets of sustainability include financial, operational,
contextual, and behavioral.
Financial sustainability may refer to whether a program or project is self‐funded or has a
long‐term funding support. For example, has the government adopted a policy and
allocated budgetary funding and support for it on an ongoing basis?
Operational sustainability may refer to the existence of functioning supply chains for spare
parts and expertise to set up and maintain systems. An aspect of this may consider
whether there is capacity in the local community to repair broken systems.
Contextual sustainability can refer to the existence of supportive local leaders. It may also
refer to interest and investment from local entrepreneurs and the acceptability of a product
by local users. Some may also refer to contextual sustainability as the ‘enabling
environment’ or the existence of supportive and functional policies and regulations.
Behavioral sustainability refers to lasting changes in behavior over time that lead to the
practice becoming habitual, and even a social norm. This is important because without
correct and consistent use over time, health impact cannot be achieved. The behavioral
aspect of sustainability is the focus of this presentation.
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14. A systematic review of behavior change interventions (Parker Fiebelkorn et al. 2012)
provided limited insight into what behavioral techniques work for HWTS. This was mainly
because the studies failed to report sufficiently on the models used to stimulate behavior
change. Some possible factors that were mentioned include: self‐efficacy, cost of product,
taste, whether currently practicing, believes water is dirty/can make their children sick.
Other studies which reviewed the effectiveness of HWTS were too short to gain insight into
sustained use over time (Hunter, 2009; Arnold & Colford, 2007; Waddington et al. 2009).
Moreover, effectiveness tended to decline with the length of the study (i.e. the longer the
study, the more levels of relevant HWTS outcomes dropped off). However, one study in
Haiti showed sustained use over a period of ten years (Harshfield et al. 2012) but did not
look at the behavioral aspects of this success. An unpublished study (Ritter, 2007) looking
at the Haiti program suggested that highly consistent use was associated with distance to
sales point, promotion via household visits, and perceived social support. Other factors
that may play a role include ongoing training for users and continuous follow‐up (Lantagne
& Clasen, 2009), social support (Russo et al. 2012) and social norms (Wood et al. 2012).
Parker Fiebelkorn and colleagues (2012) suggest that in order to improve our knowledge of
behavior change models that work for HWTS, we need to use more objective outcome
measures (e.g. free chlorine residual in drinking‐water instead of self‐reported treatment)
and longitudinal data that yields insight to behavior change over time. This is consistent
with good M&E practice and is the purpose of the M&E toolkit for HWTS which is shown on
the next slide.
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16. The following are the 20 recommended indicators from the WHO & UNICEF M&E toolkit.
Some of these indicators can be used to monitor sustainability. Which of these would you
use?
First of all, for the purposes of this presentation, we are referring to the behavioral aspect
of sustainability. This means that individuals, households, and communities continue the
desired behavior over time and suggests that monitoring needs to occur with some
frequency and continuity so as to determine whether the behavior is continuing and is
sustained.
The choice of which indicator(s) you use is going to be determined by the questions you
want to answer and the trends you want to assess. Think about the indicator that is most
appropriate for determining the answer to that question, and think about how often you
will need to collect the data. What are you trying to learn?
For example, if I wanted to understand whether my program was having an effect on HWTS
behavior, I would find a target audience which is known to be consuming contaminated
water, measure their water quality at baseline, use a sampling approach to select a
representative and unbiased sample of households, and then follow up with them at 1, 3,
6, and 12 months to measure correct (water quality testing of their stored drinking water),
consistent (frequency of sampling and determining whether they are consuming water
from any other source), and sustained use (accumulated data over time).
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