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Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi
Abstract
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.
... The results show that there were higher levels of faecal water contamination in the dry season compared to the rainy season. These findings contrast with studies by Moyo (2013), Wright et al. (2013), Kostyla, Bain et al. (2015) and Cassivi et al. (2021) which reported higher contamination in the wet season but echo those by Chidavaenzi et al. (1997), Palamuleni (2002), Kulabako et al. (2007) and Tukur and Amadi (2014) which found higher contamination in the dry season. Godfrey et al. (2006) linked higher dry season contamination to pressure on fewer available water sources. ...
... Godfrey et al. (2006) linked higher dry season contamination to pressure on fewer available water sources. In terms of sanitation, the dry season posed more problems in terms of getting access to water to flush toilets and wash hands (Akelo & Nzengya, 2021, Cassivi et al., 2021. The finding of higher contamination in the urban sites tallies with the views of researchers such as Barrett et al. (2000), , Nyenje et al. (2010) Foppen andKansiime (2009), Akelo and Nzengya (2021), Strauch et al. (2021) and Marks, Clair-Caliot et al. (2020) who noted that high urban pollution loads reflect the greater settlement density, number of people using the facilities and sometimes underlying geological conditions. ...
... Seasonally, the rainy season was more contaminated with nitrate than the dry season. This tallies with reports by Barrett et al. (2000), Sorensen et al. (2015a, b) and Cassivi et al. (2021) which show that higher contamination occurs after rainfall events. This is believed to be accelerated by rapid recharge of shallow groundwater which is reflected in shallow well contamination. ...
Many people switch sources of drinking water and sanitation between seasons, yet such shifts are not reflected in the reporting of access to improved water and sanitation services by the Joint Monitoring Programme (JMP). Drawing on quantitative and qualitative data collected from urban and rural sites in dry and rainy seasons in Benue state, Nigeria, this study highlights the importance of seasonal variations in water access and quality. Water testing showed that water sources had higher levels of contamination with coliforms, nitrate and chloride in the dry season than the wet season. The contamination of water from these pollutants is above WHO standards and believed to come mainly from pit latrines. Semi-structured interviews revealed that many people who use improved water and sanitation facilities in the rainy season sometimes switch to poorer quality unimproved sources in the dry season. Travel times for collecting water as well as waiting times also significantly increased in the dry season. It is recommended that this important seasonality element is factored into JMP data collection and reporting.
... 8,10−12 Post collection contamination that may occur from the point of collection to the point of use is an additional concern which relates to access to water. 13,14 Further, source accessibility, e.g., distance and collection time, as well as affordability are key factors 15−18 that may further impact the quantity of water collected by households, over different seasons and time scales. 19 Households are not necessarily systematically collecting water from the nearest source, 20 which suggests that households make trade-offs between a variety of known and unknown factors. ...
... Detailed information on household selection and study design, including survey questionnaires, is available in previous publications. 13,32 Free and informed consent was granted from all households that were recruited under a voluntary participation process. This study was approved by the National Committee on Research in the Social Sciences and Humanities (NCRSH) in Malawi (P.10/18/326) and the Human Research Ethics Board at the University of Victoria (18−1129). ...
... Levels of risk, as used by JMP, were used to classify results as follows: very low risk (<1 cfu/100 mL), low risk (1−10 cfu/100 mL), moderate risk (11−100 cfu/100 mL), and high risk (>100 cfu/ 100 mL). 33 For detailed information regarding water quality testing, see ref 13. Local enumerators received training for data collection and water quality testing. ...
... The UN's Sustainable Development Goal (SDG) 6.1 was set to "achieve universal and equitable access to safe and affordable drinking water for all"; 5 in order to sustainably address this goal, safe drinking water should be viewed as a "source to sip" framework 6 (Fig. 1). Water should be collected from an improved source 7 that is accessible, sustainable, and of adequate quality; 8 transported using a clean fetching container; 9,10 treated consistently and correctly over a sustained period [11][12][13][14][15] using a device that has been adequately operated; [16][17][18][19][20][21] stored using a clean vessel after treatment 9,10,22 , and consumed using a clean cup 9,23,24 . Taken together, these important components comprise household water treatment and safe storage (HWTS), which can be employed to provide protection against diarrheal illness 25 , potentially resulting in substantial positive health impacts 26 . ...
... The UN's Sustainable Development Goal (SDG) 6.1 was set to "achieve universal and equitable access to safe and affordable drinking water for all"; 5 in order to sustainably address this goal, safe drinking water should be viewed as a "source to sip" framework 6 (Fig. 1). Water should be collected from an improved source 7 that is accessible, sustainable, and of adequate quality; 8 transported using a clean fetching container; 9,10 treated consistently and correctly over a sustained period [11][12][13][14][15] using a device that has been adequately operated; [16][17][18][19][20][21] stored using a clean vessel after treatment 9,10,22 , and consumed using a clean cup 9,23,24 . Taken together, these important components comprise household water treatment and safe storage (HWTS), which can be employed to provide protection against diarrheal illness 25 , potentially resulting in substantial positive health impacts 26 . ...
In this Perspective, we present evidence that indicates a discrepancy between laboratory and field performance of point of use water treatment (POUWT) techniques, identified via a narrative review process to investigate the origin of the LRV comparison estimates reported by the WHO. We considered only peer-reviewed articles that reported laboratory and field log reduction values (LRVs) for the same POU technology. We will present a summary of explanations that have been offered by the literature regarding such discrepancies; the potential implications of the “laboratory versus field” data discrepancy; and potential risks posed by conflating the two. Finally, in view of this discussion, we propose a strategy to help mitigate the research gap and explore the potential to improve current health risk assessments and ultimately, recommendations by public health entities and manufacturers of POUWT products.
... These numbers likely underestimate the challenge, because water access indicators often do not adequately consider the multiple layers of water insecurity. For example, not all improved sources yield water of acceptable quality, and water that may be clean at the source can get contaminated through transportation, storage, and handling at the household (Boateng et al., 2013;Smiley, 2017;Cassivi et al., 2021). Global statistics on water supply often focus on international, national, and regional patterns of water insecurity, obscuring the impact of water insecurity and associated health effects on a finer scale Price et al., 2021). ...
... Many of our findings align with the literature on urban water insecurity, showing high household expenditures on water, intermittent water supply, and a heavy time burden of multiple trips and long waiting times (e.g., Adams, 2018;Sarkar, 2020;Cassivi et al., 2021;Stoler et al., 2020). Our finding that some areas coped with water insecurity by instituting one-bucket-at-a-time rules at the water point is consistent with the emerging literature on water sharing (Wutich et al., 2018;Bukachi et al., 2021). ...
Water insecurity is a critical public-health challenge in Africa's urban informal settlements, where most of the population often lacks access to household taps. In these settings, water fetching is disproportionately performed by women. While water fetching is physically laborious and exposes women to multiple risks, the water-insecurity literature has predominantly focused on household experiences, ignoring women's water-collection journeys. This paper uses the water journey as a window into embodied dimensions of water insecurity. Combining theoretical insights from embodiment, embodied political ecology of health, and time geographies, we use video-recorded walking interviews to analyze women's everyday water journeys in Ntopwa, an urban informal settlement in Blantyre, Malawi, from initial decision making through exposure to water-fetching risks and household practices regarding use and storage. We identify three principal sources of environmental risk— terrain, built environment, and human behavior—that present challenges for water collectors. Using the walking interview as a heuristic, we show how the seemingly simple practice of water fetching is compounded by complex decision making, constant spatiotemporal trade-offs, and exposure to diverse risks, all of which have embodied health consequences. Based on our findings, we conclude that interventions seeking to improve household water insecurity must consider the embodied effects of water-fetching journeys. This study also provides methodological insights into using walking interviews and videos for water and health research.
... Availability of water resources including surface water and groundwater of acceptable quality is a crucial dimension of water security. For example, in areas with limited access to water services, the availability of free-flowing untreated surface water and shallow groundwater can alleviate water scarcity for millions of people (Martínez-Santos, 2017;Cassivi et al., 2021). To assess water availability, estimates of total annual renewable water resources per capita comprising both renewable surface water and groundwater resources available in each country in each calendar year are used. ...
... This is very important given the role of girls and women as key agents in obtaining water for their families and communities. Better education for girls and women can lead to more awareness on the sources of household drinking water contamination and how to prevent it (Cassivi et al., 2021), as well as enhance the knowledge and willingness of women and girls to participate in water governance processes , thereby supporting policies aimed at ensuring sustainable water resource management (Okumah et al., 2020). This study provides empirical evidence on the link between gender and education and water security which has so far been lacking in contemporary research on water security as recently highlighted (Shah, 2021). ...
The objectives of this study are two fold: first, to develop a composite water security metric to assess water security at a national scale, and second, to explore the determinants of water security at the same scale in three developing regions – Africa, Asia-Pacific and Latin America and the Caribbean (LAC). The water security index (WSI) was developed using three biophysical (water availability, climate risk and ecosystem vitality) and two socioeconomic (water accessibility and integrated water resources management) variables. Five independent variables (governance, gross domestic product (GDP) per capita, percentage of urban population, official development assistance for water and sanitation services (ODA-WSS) and female primary school completion rate) were used to explore the determinants of water security. Results show that >90% of countries in Africa and the Asia-Pacific regions are water-insecure, whereas most countries in LAC are water-secure except Haiti, Guatemala and Nicaragua. Statistical analyses show that GDP per capita, female primary school completion rate and governance are the key determinants of water security. This study provides empirical evidence on the link between female primary school completion rate and water security. Results further show a strong correlation between water security and ODA-WSS in the region with a higher ODA-WSS per capita than in regions with a low ODA-WSS per capita. This suggests that increasing ODA-WSS per capita may enhance water security in developing regions.
... Cultural and behavioural factors also contribute to water quality issues. In some communities, traditional methods of water collection and storage can heighten the risk of contamination, while poor hygiene practices, such as open defecation, further compromise water quality (Cassivi et al., 2021). Addressing these complex challenges necessitates coordinated efforts that include infrastructure development, stricter regulations enforcement, public education, and international collaboration to ensure universal access to safe drinking water. ...
This study evaluated the quality of sachet and bottled water sold in Ilorin, Nigeria. Water samples were procured from selling points, and their physicochemical and bacteriological quality was assessed using standard methods. The results showed that the respective physicochemical parameters for sachet and bottle waters: temperature (26.6 °C and 23.9 °C), electrical conductivity (142.0 µs/cm and 111.0 µs/cm), total dissolved solids (68.5 mg/L and 58.0 mg/L), pH (7.5 and 7.3), and salinity (0.05 and BDL) of both sachet and bottled water samples respectively were within the permissible range recommended by the World Health Organization (WHO). Bacteriological analysis revealed that total heterotrophic bacterial counts (52.5*Z ± 4.7 and 35.0Z ± 0.9) for sachet and bottled water samples were within WHO limits; however, total coliform counts (51.50*Z ± 2.6 and 33.5Z ± 1.5) exceeded the acceptable range of 0 CFU/mL. Seven bacterial isolates identified were Pseudomonas aeruginosa, Klebsiella spp., Proteus spp., Enterobacter spp., Salmonella spp., Shigella spp. and Bacillus subtilis. The number of bacterial isolates in bottled water was higher, with Klebsiella spp. being the most prevalent. The findings suggest varying degrees of microbiological contamination, indicating that some packaged water samples are not of the highest quality. These results highlight the need for stricter monitoring and quality control measures to ensure the safety of packaged water.
... The uneven percentage of people (rural and urban) who receive clean water services from the Regional Public Drinking Water Company is one of the reasons rural communities use much groundwater as a source of drinking, which is carried out on a self-sufficient basis. Unfortunately, the government's weak supervision of the quality of groundwater used by households causes the quality of groundwater consumed prone to microbial contamination [25][26][27]. More than 90 per cent of groundwater samples in Indonesia exceeded the threshold, with 70 per cent coming from toilet tank leaks and waste discharged into waterways [3]. ...
... For instance, Adams and Vásquez [114] indicated that households in Accra City, Ghana, were more sensitive to water quality as part of their general well-being. Using urban household survey data, Cassivi et al. [115] analyzed water accessibility in Malawi descriptively. They established that degraded water quality from the point of collection and consumption poses significant health risks. ...
... The direct and indirect release of domestic sewage into waterbodies, open excretion, farm run-offs in the midst of wet period having synthetic manures and insect killers, and liquid waste from agricultural production are the main causes of water pollution in rural areas (Hafizur et al., 2017). Due to the lack of common supply systems in these areas, the inhabitants are bound to collect water from deteriorated sources and use it to fulfill their domestic (including drinking) needs (Cassivi et al., 2021;Daud et al., 2017). ...
... A study conducted in Malawi in 2019 investigated E. coli contamination in water in four different stages of water collection: at the water source, at the collection container, at the storage container, and at the cup of drinking water. That study found that the level of contamination would increase in every stage, but the critical steps were filling the collection container and during water storage (Cassivi et al. 2021). Most MICS with the water quality module investigate water storage via only one question that classifies households on whether water is collected directly from the source or from a covered or uncovered container. ...
The world is not on track to achieve universal access to safely managed water by 2030, and access is substantially lower in rural areas. This Sustainable Development Goal target and many other global indicators rely on the classification of improved water sources for monitoring access. We aimed to investigate contamination in drinking water sources, comparing improved and unimproved sources in urban and rural settings. We used data from Multiple Indicator Cluster Surveys, which tested samples from the household water source and a glass of water for Escherichia coli contamination across 38 countries. Contamination was widespread and alarmingly high in almost all countries, settings, and water sources, with substantial inequalities between and within countries. Water contamination was found in 51.7% of households at the source and 70.8% in the glass of water. Some improved sources (e.g., protected wells and rainwater) were as likely to be contaminated as unimproved sources. Some sources, like piped water, were considerably more likely to be contaminated in rural than urban areas, while no difference was observed for others. Monitoring water contamination along with further investigation in water collection, storage, and source classification is essential and must be expanded to achieve universal access to safely managed water.
... 34 Further, post-supply contamination of drinking water has been observed in many settings, suggesting that contamination would increase with storage time, particularly when source water has low contamination. 17,35,36 Although the assumption of randomly distributed variation in water quality likely does not hold, previous work to explain variability in stored water quality has had limited success, with predictors explaining <10% of the variation in water quality using ordinary least-squares regression techniques. 25 Therefore, this approach is useful to give some perspective on how low sampling frequency may miss intermittent consumption of non-compliant quality water. ...
... Households also reported less acceptability of the duration it took filter water by the end of the follow-up. The declining trends in the intermediate outcomes could be the result of seasonality effects on water handling practices in follow-up visits, unsustainable behavior-change, or filter breakage over time 21,22 . In our study population, we observed that the proportion of households using unimproved water sources for their primary drinking water source nearly doubled in the dry season (i.e., endline) in both the intervention and control groups. ...
Unsafe drinking water remains a major cause of mortality and morbidity. While Rwanda’s Community-Based Environmental Health Promotion Programme (CBEHPP) promotes boiling and safe storage, previous research found these efforts to be ineffective in reducing fecal contamination of drinking water. We conducted a cluster randomized control led trial to determine if adding a household water filter with safe storage to the CBEHPP would improve drinking water quality and reduce child diarrhea. We enrolled 1,199 households with a pregnant person or child under 5 across 60 randomly selected villages in Rwamagana district. CBEHPP implementers distributed and promoted water purifiers to a random half of villages. We conducted two unannounced follow-up visits over 13–16 months after the intervention delivery. The intervention reduced the proportions of households with detectable E. coli in drinking water samples (primary outcome) by 20% (PR 0.80, 95% CI 0.74–0.87, p < 0.001) and with moderate and higher fecal contamination (≥10 CFU/100 mL) by 35% (PR 0.65, 95% CI 0.57–0.74, p < 0.001). The proportion of children under 5 experiencing diarrhea in the last week was reduced by 49% (aPR 0.51, 95%CI 0.35–0.73, p < 0.001). Our findings identify an effective intervention for improving water quality and child health that can be added to the CBEHPP.
... The latrine to water ., 2019), showed a strong association between the level of water contamination by coliform bacteria and the density of latrines located adjacent to water sources. In many cases, access to water points that are far from households can generate practices that expose people to risks by using dirty containers or unclean hands that can contaminate the water, at the time of supply (collection), or during transport through canals or plastic pipes and this is well represented in A Seasonal Cohort Study in Malawi of Household Practices in Accessing Drinking Water and Post-Collection Contamination (Cassivi et al., 2021). In reality, the majority of households do not have any collection system for water, domestic waste, or wastewater. ...
The aim of this study is to assess the quality of water for drinking in the rural area of the city of Al-Hoceima, in order to measure the health risks to which people who use it for their needs are exposed. A cross-sectional, descriptive, and analytical study was carried out on 60 households selected randomly. Well and spring water samples(8 wells and 8 springs) were collected in November and December 2019 and analyzed according to the standard methods of water analysis. The survey indicated that water consumed by 80.00% of households does not receive any prior treatment. With the lack of a collective excreta and wastewater management system in the municipality, 99.00% of households have latrines, 50.00% of which are installed within 15meters of the water source. The bacteriological analyses indicate that all the sampled points are contaminated by fecal contamination germs. This poor quality may be due to various anthropogenic activities, and the presence of non-standardized septic tanks.Therefore, protecting and improving water sources must be accompanied by adequate measures of disinfection of these waters before their use.
... Some previous studies include a household drinking water quality assessment in Kisii town, Kenya [11], and a seasonal cohort study on household practices and postcollection contamination of water in Malawi [12]. Furthermore, a sanitary survey was carried out to detect E. coli contamination in water samples from different reservoirs in the rural areas in northern Jordan [13]. ...
... 4 Two portable field kit designs were used in this study ( Figure 1): a standard field kit (SFK; Millipore, USA, see Supplemental Table S1) currently in use by MICS surveys, 4 and a new low-cost field kit (LCFK; glass base from VWR, USA, filter support designed by UNICEF, and not commercially available) that has been trialed during non-MICS surveys in Afghanistan 2 and water quality field research in Malawi. 7,8 An upcoming publication will describe the LCFK in detail, including CAD files to enable others to mass produce this single component. ...
To monitor safely managed drinking water services, an increasing number of countries have integrated water quality testing for Escherichia coli into nationally-representative household surveys such as the Multiple Indicator Cluster Surveys (MICS). However, plastic waste generated during such water quality testing programs, mostly through the use of pre-sterilized disposable materials, is non-negligible. The objective of this study was to evaluate several re-use protocols for disposable filter funnels used by the MICS water quality test kits. Decontamination and re-use protocols were assessed in centralized laboratory and decentralized field settings and neither yielded positive results. Re-use of 100 mL sterile funnels decontaminated with an alcohol wipe resulted in a higher incidence of false positive results (i.e., positive contamination when processing sterile water), both in the laboratory and field; therefore, a higher proportion of positives tests can be expected if these components are re-used. Further improvements to the decontamination technique and training are needed before material re-use can be reliably adopted. Autoclaving the funnels for re-use is feasible, provided that there is capacity to re-package and distribute funnels in a sterile manner.
Diarrhoeal disease remains a leading cause of mortality in children under five in low- and middle-income countries (LMICs) (1). Universal access to safe drinking water, as called for under Sustainable Development Goal 6, is often motivated by perceived health benefits with a historical focus on achieving diarrhoeal disease reductions (2). Here, we show through structural causal modelling that household use of safely managed drinking water services (SMDWS) significantly reduces risks of diarrhoea in children under five compared to the use of drinking water services not fulfilling all of the SMDWS criteria (Relative risk (RR)= 0.90, 95% CI= 0.83-0.98) and services classified as less than basic (RR=0.87, 95% CI=0.78-0.97) across 24 LMICs. Secondary analyses point towards contributions of drinking water availability and fecal contamination at the point of use to risks of child diarrhoea. Specifically, risk reductions of between 4-6% were observed with every 1-log10 decrease in E. coli contamination in stored drinking water. Our findings reaffirm the importance of SMDWS in protecting against diarrhoeal disease, while suggesting that achieving universal access will provide only modest additional reductions in child diarrhoea in LMICs. Further reductions will require
Safe drinking water access is a human right, but data on safely managed drinking water services (SMDWS) is lacking for more than half of the global population. We estimate SMDWS use in 135 low- and middle-income countries (LMICs) at subnational levels with a geospatial modeling approach, combining existing household survey data with available global geospatial datasets. We estimate that only one in three people used SMDWS in LMICs in 2020 and identified fecal contamination as the primary limiting factor affecting almost half of the population of LMICs. Our results are relevant for raising awareness about the challenges and limitations of current global monitoring approaches and demonstrating how globally available geospatial data can be leveraged to fill data gaps and identify priority areas in LMICs.
Women in fisheries-based families face formidable challenges from the impacts of climate change, similar to other vulnerable groups. Responding to these challenges necessitates adaptation. This study presents a systematic literature review (SLR) focusing on the adaptation of women in fisheries-based families to climate change impacts. The review was inspired by several considerations, including the imperative to understand the necessity to reduce bias and enhance transparency comprehensively. Furthermore, it recognises the significance of conducting a more systematic examination of the available literature about women and climate change. Guided by the ROSES review protocol, the review employed a systematic searching strategy and a rigorous quality appraisal process to ensure the quality of selected articles. Thematic analysis, conducted by the primary author with the assistance of two co-authors, was employed to analyse the extracted data. The study identified six main themes and 15 sub-themes. The analysis revealed that women, as primary caretakers of families, support their husbands in fisheries activities while engaging in fisheries and non-fisheries industries to increase household income. Financial literacy is crucial to safeguard women against fraud and other scams despite broader access to credit programmes. The review concluded that women’s daily interactions with natural resources render them attuned to environmental changes. Based on the thematic analysis, women also played a pivotal role in ensuring adequate water supply for their families. In some areas, they must walk for some distance to obtain water for their daily usage and consumption. Furthermore, women foster more robust social ties with the surrounding community, stimulating cooperation in various activities. Despite their influential roles in adaptation, women are marginalised in the decision-making process regarding climate change adaptation. In certain areas, constraints such as the caste system, religious norms, and cultural restrictions impeded women’s access to food, water, land, education, and related government programmes. This review is critical for policymakers and future scholars as it provides the formulation of the best adaptation strategies tailored to women’s specific needs, interests, and abilities in fisheries-based families. Based on multiple studies, this study enhances empirical evidence in this field, providing more options for future research and offering diverse contexts and perspectives on how women in fisheries-based families adapt to the impacts of climate change.
In settings where humans and animals closely coexist, the introduction of faecal material into unprotected water sources significantly increases the risk of contracting diarrhoeal and zoonotic waterborne diseases. The data were gathered from a survey conducted through interviews at randomly sampled villages; additionally, water samples were collected in randomly selected households and their associated feeder catchments. Molecular techniques were used, specifically qPCR, to run host-specific Bacteroides microbial source tracking (MST) assays for human, cattle, pig, chicken and dog faecal contamination. Unexpectedly, the qPCR assays revealed dogs to be the most prevalent (40.65%) depositor of faecal matter in unprotected surface water, followed by humans (40.63%); this finding was contradictory to survey findings indicating cattle as the leading source. At the household level, dogs (16.67%) and chickens (15.28%) played prominent roles, as was expected. Reflecting on some of the basic daily practices in households, nearly 89.00% of the population was found to store water due to erratic supply, in contrast to 93.23% using an improved water source. Additionally, a significant association was found between water, sanitation and hygiene (WASH) variables and the occurrence of MST markers after performing a bivariate linear regression. However, the inconsistency between the MST results and household surveys suggests pervasive sanitation issues, even in households without domesticated animals.
Water quality monitoring at the point of consumption by consumers can improve the understanding of the microbial risk of drinking water. In this study, drinking water samples were collected by citizen science participants according to their normal drinking sources and behaviors. Among six different sample types, tap water received the most attention per sampling frequency (39%) and weighted importance score, followed by drinking fountain (38%) and personal container (21%). Enumeration of Escherichia coli and the total coliform as indicator organisms showed consistent and good quality in water samples from tap water and drinking fountains but significantly higher detection frequencies (90 and 90%, respectively) and median concentrations (14 and 252 CFU/100 mL, respectively) in water samples from personal containers. Microbial community analysis based on 16S rRNA gene amplicon sequencing showed that the microbial communities in water samples from personal containers were less diverse than microbial communities in the other water types, the latter of which showed high similarity in the microbial composition and α and β diversity. Several genera that include species of opportunistic pathogens were detected across samples from drinking water sources, while higher total relative abundances of these genera were detected in water samples from personal containers than others.
Household water insecurity (HWI) can have far‐reaching consequences for human health and well‐being, yet little is known about how environmental seasonality contributes to HWI variation. Using a systematic literature review, we examined the following questions: (1) How does environmental seasonality affect HWI? and (2) How do the effects vary over time? We also highlighted strategic areas for future research. We conducted the search using Scopus, Web of Science, PubMed, ProQuest, and EBSCO Academic Search Complete, with an end search date of February 3, 2021; only English‐language studies were included. Articles were included in the review if analysis studied seasonal temperature, precipitation, or freshwater variation and individual or household experiences with household water adequacy, water reliability, water affordability, or water safety. Bias was evaluated via hand assessment, and articles of poor quality were excluded. Studies that focused on extreme weather events or water insecurity at community or watershed levels were omitted. We identified 67 articles, the majority of which were cross‐sectional ( n = 46, 68.7%). Among longitudinal studies ( n = 21, 31.3%), only one used a quantitative HWI scale, while the rest relied on proxies ( n = 20, 95.2%). Our review also revealed literature gaps related to unequal coverage of freshwater ecosystem habitat types and forms of environmental seasonality. There is a need for more attention to extreme climate events, such as a prolonged multiyear drought. With changing climate expected to exacerbate weather patterns with serious implications, especially for vulnerable populations, understanding seasonality in HWI is important for crafting sustainable engineering and policy responses to water insecurity.
This article is categorized under: Water and Life > Nature of Freshwater Ecosystems
Science of Water > Water and Environmental Change
Engineering Water > Sustainable Engineering of Water
Access to safe drinking water is a key determinant of public health and is considered a basic human right essential to avert waterborne diseases. Understanding the association between household drinking water handling practices and the bacteriological quality of water at the point of use is critical since water quality may deteriorate between source and point of use. This study aimed at determining this association in Murewa district in Zimbabwe. Interviews were conducted with 381 household heads and hygiene practices were observed at selected households. Logistic regression analysis was used to examine the association between household drinking water handling practices and independent variables. The variables that were significantly associated with safe water at the point of use were tertiary education (p = 0.006), monthly income (p = 0.005), cleanliness of water collection containers (p = 0.011) and the method of drawing water from containers (p = 0.001). There is a need to intensify health and hygiene education, emphasising the importance of hygienic water handling practices, cleaning of collection containers and hygienic drawing of water from storage containers. The integration of income-generating activities into WASH projects should be strengthened to enable the acquisition of water collection and storage containers that can safeguard the quality of water between collection and consumption. HIGHLIGHTS
The microbial quality of drinking water deteriorated between source and point of use.;
Participants with higher education were 3.79 times more likely to maintain safe water quality between water source and point of use.;
The method of withdrawing drinking water from storage containers and cleanliness of water collection containers were significant predictors of water quality at the point of use.;
Worldwide, about one out of two people depend on groundwater resources to satisfy their drinking water needs. While groundwater typically is of higher quality than surface water, pollution and geologic conditions may require treating groundwater to meet safe water quality criteria. Herein, a critical overview is presented of water treatment technologies for rural and underserved communities in emerging economies that depend on groundwater. Given that small to medium sized rural communities in emerging economies often lack the financial resources to support technologically complex and expensive centralized public water treatment systems, the focus is on proven technologies that are sustainable and acceptable by the rural population. After an overview of the underlying treatment mechanisms and the principal groundwater contaminants targeted by the traditional, advanced, and experimental water treatment technologies, we identify the groundwater quality parameters that may impact or interfere with the technology performance. We also introduce enabling environmental factors that might govern the implementation of water treatment technologies in the target communities and a brief discussion of safe storage of water after treatment to underline the importance of protecting the water from re-contamination. Our overview is further supported by tabulated summaries of the principal (dis)advantages of each technology covered herein, including cost considerations and social acceptance. Overall, our review suggests that underserved rural communities have sustainable and affordable options for cases where the quality of local groundwater resources requires treatment.
The study assessed changes in water quality between the water source and the tap of locally produced low cost ceramic water filters used by a community living in hygienically critical conditions in a remote mountainous area in Western Nepal. Data was collected from 42 rural households during two visits. The effectiveness of filter handling on its performance was assessed through microbiological analysis, structured household interviews and structured observations. Water quality decreased significantly when source water was filled into transport containers, while the use of the filters improved drinking water quality for about 40% of the households. Highly inadequate filter cleaning practices involving the use of contaminated raw water, hands (geo mean = 110 E. coli CFU/100 mL) and cleaning tools (geo mean = 80 E. coli CFU/100 mL) stained hygienic parts of the filter. The use of boiling water to disinfect the filters was significantly correlated with improved filter performance and should be further promoted. However, even disinfected filters achieved a very low average LRV for E. coli of 0.4 in the field and performed worse than during laboratory tests (LRV for E. coli of 1.5–2). Comprehensive training on adequate filter handling, as well as better filter products, are required to improve the impact of filter use.
Urban‐rural inequalities in water access constitute one of the major obstacles to achieving universal water coverage. In Sub‐Saharan Africa, these inequalities have persisted for decades. The Sustainable Development Goals (SDGs) seek to achieve universal access to safely managed water, which requires that an improved source be located on premises, available when needed, and free from contamination. This paper draws on empirical evidence from household surveys in peri‐urban and rural Malawi to examine urban‐rural differences in access to safely managed water. The paper highlights issues with the SDGs’ definition and monitoring indicators and outlines lessons for improving water access given existing inequalities between urban and rural areas. It concludes by arguing that a one‐size‐fits‐all approach to governance, monitoring, and planning cannot eliminate inequalities in water access, especially between urban and rural areas.
Background
The Sustainable Development Goals (SDGs) require household survey programmes such as the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) to enhance data collection to cover new indicators. This study aims to evaluated methods for assessing water quality, water availability, emptying of sanitation facilities, menstrual hygiene management and the acceptability of water quality testing in households which are key to monitoring SDG targets 6.1 and 6.2 on drinking Water, Sanitation and Hygiene (WASH) and emerging issues.
Methods
As part of a MICS field test, we interviewed 429 households and 267 women age 15–49 in Stann Creek, Belize in a split-sample experiment. In a concurrent qualitative component, we conducted focus groups with interviewers and cognitive interviews with respondents during and immediately following questionnaire administration in the field to explore their question comprehension and response processes.
Findings
About 88% of respondents agreed to water quality testing but also desired test results, given the potential implications for their own health. Escherichia coli was present in 36% of drinking water collected at the source, and in 47% of samples consumed in the household. Both questions on water availability necessitated probing by interviewers. About one quarter of households reported emptying of pit latrines and septic tanks, though one-quarter could not provide an answer to the question. Asking questions on menstrual hygiene was acceptable to respondents, but required some clarification and probing.
Conclusions
In the context of Belize, this study confirmed the feasibility of collecting information on the availability and quality of drinking water, emptying of sanitation facilities and menstrual hygiene in a multi-purpose household survey, indicating specific areas to improve question formulation and field protocols. Improvements have been incorporated into the latest round of MICS surveys which will be a major source of national data for monitoring of SDG targets for drinking water, sanitation and hygiene and emerging issues for WASH sector programming.
Household water treatment with chlorine can improve microbiological quality and reduce diarrhea. Chlorination is typically assessed using free chlorine residual (FCR), with a lower acceptable limit of 0.2 mg/L, however, accurate measurement of FCR is challenging with turbid water. To compare potential measures of adherence to treatment and water quality, we chlorinated recently-collected water in rural Kenyan households and measured total chlorine residual (TCR), FCR, oxidation reduction potential (ORP), and E. coli concentration over 72 h in clay and plastic containers. Results showed that 1) ORP served as a useful proxy for chlorination in plastic containers up to 24 h; 2) most stored water samples disinfected by chlorination remained significantly less contaminated than source water for up to 72 h, even in the absence of FCR; 3) TCR may be a useful proxy indicator of microbiologic water quality because it confirms previous chlorination and is associated with a lower risk of E. coli contamination compared to untreated source water; and 4) chlorination is more effective in plastic than clay containers presumably because of lower chlorine demand in plastic.
To prevent diseases associated with inadequate sanitation and poor hygiene, people needing latrines and behavioural interventions must be identified. We compared two indicators that could be used to identify those people. Indicator 1 of household latrine coverage was a simple Yes/No response to the question “Does your household have a latrine?” Indicator 2 was more comprehensive, combining questions about defecation behaviour with observations of latrine conditions. Using a standardized procedure and questionnaire, trained research assistants collected data from 6,599 residents of 16 rural villages in Indonesia. Indicator 1 identified 30.3% as not having a household latrine, while Indicator 2 identified 56.0% as using unimproved sanitation. Indicator 2 thus identified an additional 1,710 people who were missed by Indicator 1. Those 1,710 people were of lower socioeconomic status (p < 0.001), and a smaller percentage practiced appropriate hand-washing (p < 0.02). These results show how a good indicator of need for sanitation and hygiene interventions can combine evidences of both access and use, from self-reports and objective observation. Such an indicator can inform decisions about sanitation-related interventions and about scaling deworming programmes up or down. Further, a comprehensive and locally relevant indicator allows improved targeting to those most in need of a hygiene-behaviour intervention.
Background:
It is estimated that more than two-thirds of the population in sub-Saharan Africa (SSA) must leave their home to collect water, putting them at risk for a variety of negative health outcomes. There is little research, however, quantifying who is most affected by long water collection times.
Objectives:
This study aims to a) describe gender differences in water collection labor among both adults and children (< 15 years of age) in the households (HHs) that report spending more than 30 minutes collecting water, disaggregated by urban and rural residence; and b) estimate the absolute number of adults and children affected by water collection times greater than 30 minutes in 24 SSA countries.
Methods:
We analyzed data from the Demographic Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) (2005-2012) to describe water collection labor in 24 SSA countries.
Results:
Among households spending more than 30 minutes collecting water, adult females were the primary collectors of water across all 24 countries, ranging from 46% in Liberia (17,412 HHs) to 90% in Cote d'Ivoire (224,808 HHs). Across all countries, female children were more likely to be responsible for water collection than male children (62% vs. 38%, respectively). Six countries had more than 100,000 households (HHs) where children were reported to be responsible for water collection (greater than 30 minutes): Burundi (181,702 HHs), Cameroon (154,453 HHs), Ethiopia (1,321,424 HHs), Mozambique (129,544 HHs), Niger (171,305 HHs), and Nigeria (1,045,647 HHs).
Conclusion:
In the 24 SSA countries studied, an estimated 3.36 million children and 13.54 million adult females were responsible for water collection in households with collection times greater than 30 minutes. We suggest that accessibility to water, water collection by children, and gender ratios for water collection, especially when collection times are great, should be considered as key indicators for measuring progress in the water, sanitation and hygiene sector.
The study examined relationships among meteorological parameters, water quality and diarrheal
disease counts in two urban and three rural sites in Tamil Nadu, India. Disease surveillance was
conducted between August 2010 and March 2012; concurrently water samples from street-level taps
in piped distribution systems and from household storage containers were tested for pH, nitrate,
total dissolved solids, and total and fecal coliforms. Methodological advances in data collection
(concurrent prospective disease surveillance and environmental monitoring) and analysis (preserving
temporality within the data through time series analysis) were used to quantify independent effects
of meteorological conditions and water quality on diarrheal risk. The utility of a local calendar in
communicating seasonality is also presented. Piped distribution systems in the study area showed
high seasonal fluctuations in water quality. Higher ambient temperature decreased and higher rainfall
increased diarrheal risk with temperature being the predominant factor in urban and rainfall in rural
sites. Associations with microbial contamination were inconsistent; however, disease risk in the
urban sites increased with higher median household total coliform concentrations. Understanding
seasonal patterns in health outcomes and their temporal links to environmental exposures may lead
to improvements in prospective environmental and disease surveillance tailored to addressing public
health problems.
Acceptance and long-term sustainability of water quality interventions are pivotal to realizing continued health benefits. However, there is limited research attempting to understand the factors that influence compliance to or adoption of such interventions.
Eight focus group discussions with parents of young children - including compliant and not compliant households participating in an intervention study, and three key-informant interviews with village headmen were conducted between April and May 2014 to understand perceptions on the effects of unsafe water on health, household drinking water treatment practices, and the factors influencing acceptance and sustainability of an ongoing water quality intervention in a rural population of southern India.
The ability to recognize health benefits from the intervention, ease of access to water distribution centers and the willingness to pay for intervention maintenance were factors facilitating acceptance and sustainability of the water quality intervention. On the other hand, faulty perceptions on water treatment, lack of knowledge about health hazards associated with drinking unsafe water, false sense of protection from locally available water, resistance to change in taste or odor of water and a lack of support from male members of the household were important factors impeding acceptance and long term use of the intervention.
This study highlights the need to effectively involve communities at important stages of implementation for long term success of water quality interventions. Timely research on the factors influencing uptake of water quality interventions prior to implementation will ensure greater acceptance and sustainability of such interventions in low income settings.
International monitoring of drinking water and sanitation shapes awareness of countries' needs and informs policy, implementation and research efforts to extend and improve services. The Millennium Development Goals established global targets for drinking water and sanitation access; progress towards these targets, facilitated by international monitoring, has contributed to reducing the global disease burden and increasing quality of life. The experiences of the MDG period generated important lessons about the strengths and limitations of current approaches to defining and monitoring access to drinking water and sanitation. The methods by which the Joint Monitoring Programme (JMP) of WHO and UNICEF tracks access and progress are based on analysis of data from household surveys and linear regression modelling of these results over time. These methods provide nationally representative and internationally comparable insights into the drinking water and sanitation facilities used by populations worldwide, but also have substantial limitations: current methods do not address water quality, equity of access, or extra-household services. Improved statistical methods are needed to better model temporal trends. This article describes and critically reviews JMP methods in detail for the first time. It also explores the impact of, and future directions for, international monitoring of drinking water and sanitation.
BACKGROUND: Access to safe drinking-water is a fundamental requirement for good health and is also a human right. Global access to safe drinking-water is monitored by WHO and UNICEF using as an indicator "use of an improved source," which does not account for water quality measurements. Our objectives were to determine whether water from "improved" sources is less likely to contain fecal contamination than "unimproved" sources and to assess the extent to which contamination varies by source type and setting. METHODS AND FINDINGS: Studies in Chinese, English, French, Portuguese, and Spanish were identified from online databases, including PubMed and Web of Science, and grey literature. Studies in low- and middle-income countries published between 1990 and August 2013 that assessed drinking-water for the presence of Escherichia coli or thermotolerant coliforms (TTC) were included provided they associated results with a particular source type. In total 319 studies were included, reporting on 96,737 water samples. The odds of contamination within a given study were considerably lower for "improved" sources than "unimproved" sources (odds ratio [OR] = 0.15 [0.10-0.21], I2 = 80.3% [72.9-85.6]). However over a quarter of samples from improved sources contained fecal contamination in 38% of 191 studies. Water sources in low-income countries (OR = 2.37 [1.52-3.71]; p
Objective
To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.Methods
For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year 2012, and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years (DALYs) by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.ResultsIn 2012, 502 000 diarrhoea deaths were estimated to be caused by inadequate drinking water and 280 000 deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to 297 000 deaths. In total, 842 000 million diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1.5% of the total disease burden and 58% of diarrhoeal diseases. In children under 5 years old, 361 000 deaths could be prevented, representing 5.5% of deaths in that age group.Conclusions
This estimate confirms the importance of improving water and sanitation in low- and middle-income settings for the prevention of diarrhoeal disease burden. It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene.
Drinking water quality was investigated in seven rural villages surrounding Mount Kasigau in southeastern Kenya, where water is piped from unprotected dammed streams and springs in the Kasigau cloud forest down to taps, kiosks, and tanks in the villages. Analyses were conducted for nutrients, trace metals, and pathogen indicators in water from community taps, water stored in homes, and collection points along the pipelines up to catchment dams on the mountain. Water was relatively free from nutrient and trace-metal contamination; however, all samples were contaminated with total coliforms and nearly all were contaminated with Escherichia coli. There was no discernable pattern in the extent of contamination from the catchment dams to the villages. In each of three villages chosen for further study, six residents were selected for a more in-depth investigation. Water quality was generally worse in water stored in those homes compared to water collected at the village taps. The quality of drinking water in homes where treatment was applied was no better than in homes with no water treatment. The Kasigau villages, as many other areas in the developing world, need inexpensive and effective water treatment, as well as an assessment of the effectiveness of sanitary and hygienic practices.
Resource-limited communities throughout the developing world face significant environmental health problems related to the myriad of coliform sources within those communities. This study comprehensively investigated contamination sources and the biological and chemical mechanisms sustaining them in two adjacent communities in rural Limpopo, South Africa. An 8-month study was conducted of household (n = 14) and source water quality, measurements of biofilm layers on the inside of household water storage containers and water transfer devices, and also hand-based coliforms and hand-washing effectiveness. A 7-day water container incubation experiment was also performed to determine the biological and chemical changes that occur in a household water storage container independent of human interference. Results indicate that household drinking water frequently becomes contaminated after collection but before consumption (197 versus 1,046 colony-forming units/100 mL; n = 266; p < 0.001). The most important contamination sources include biofilm layers on the inside of storage containers (1.85 ± 1.59 colony-forming units/cm(2); n = 44), hands (5,097 ± 2,125 colony-forming units/hand; n = 48), and coliform regrowth resulting from high assimilable organic carbon (AOC) levels during storage. A maximum specific growth rate, μ max, of 0.072 ± 0.003 h(-1) was determined for total coliform bacteria on AOC, and a high correlation between AOC concentrations and the growth potential of total coliform bacteria was observed. These results support the implementation of point-of-use water treatment and other interventions aimed at maintaining the safe water chain and preventing biological regrowth.
Microbial drinking-water quality testing plays an essential role in measures to protect public health. However, such testing remains a significant challenge where resources are limited. With a wide variety of tests available, researchers and practitioners have expressed difficulties in selecting the most appropriate test(s) for a particular budget, application and setting. To assist the selection process we identified the characteristics associated with low and medium resource settings and we specified the basic information that is needed for different forms of water quality monitoring. We then searched for available faecal indicator bacteria tests and collated this information. In total 44 tests have been identified, 18 of which yield a presence/absence result and 26 of which provide enumeration of bacterial concentration. The suitability of each test is assessed for use in the three settings. The cost per test was found to vary from 5.00 for a presence/absence test and from 7.50 for a quantitative format, though it is likely to be only a small component of the overall costs of testing. This article presents the first comprehensive catalogue of the characteristics of available and emerging low-cost tests for faecal indicator bacteria. It will be of value to organizations responsible for monitoring national water quality, water service providers, researchers and policy makers in selecting water quality tests appropriate for a given setting and application.
As the first article in a four-part PLoS Medicine series on water and sanitation, Jamie Bartram and Sandy Cairncross argue that the massive burden of ill health associated with poor hygiene, sanitation, and water supply demands more attention from health professionals and policymakers.
Lack of access to safe water remains a significant risk factor for poor health in developing countries. There has been little research into the health effects of frequently carrying containers of water. The aims of this study were to better understand how domestic water carrying is performed, identify potential health risk factors and gain insight into the possible health effects of the task.
Mixed methods of data collection from six were used to explore water carrying performed by people in six rural villages of Limpopo Province, South Africa. Data was collected through semi-structured interviews and through observation and measurement. Linear regression modelling were used to identify significant correlations between potential risk factors and rating of perceived exertion (RPE) or self reported pain. Independent t-tests were used to compare the mean values of potential risk factors and RPE between sub-groups reporting pain and those not reporting pain.
Water carrying was mainly performed by women or children carrying containers on their head (mean container weight 19.5 kg) over a mean distance of 337 m. The prevalence of spinal (neck or back) pain was 69% and back pain was 38%. Of participants who carried water by head loading, the distance walked by those who reported spinal pain was significantly less than those who did not (173 m 95%CI 2-343; p = 0.048). For head loaders reporting head or neck pain compared to those who did not, the differences in weight of water carried (4.6 kg 95%CI -9.7-0.5; p = 0.069) and RPE (2.5 95%CI -5.1-0.1; p = 0.051) were borderline statistically significant. For head loaders, RPE was significantly correlated with container weight (r = 0.52; p = 0.011) and incline (r = 0.459; p = 0.018)
Typical water carrying methods impose physical loading with potential to produce musculoskeletal disorders and related disability. This exploratory study is limited by a small sample size and future research should aim to better understand the type and strength of association between water carrying and health, particularly musculoskeletal disorders. However, these preliminary findings suggest that efforts should be directed toward eliminating the need for water carrying, or where it must continue, identifying and reducing risk factors for musculoskeletal disorders and physical injury.
In-house contamination of drinking-water is a persistent problem in developing countries. This study aimed at identifying critical points of contamination and determining the extent of recontamination after water treatment. In total, 81 households were visited, and 347 water samples from their current sources of water, transport vessels, treated water, and drinking vessels were analyzed. The quality of water was assessed using Escherichia coli as an indicator for faecal contamination. The concentration of E. coli increased significantly from the water source [median=0 colony-forming unit (CFU)/100 mL, interquartile range (IQR: 0-13)] to the drinking cup (median=8 CFU/100 mL; IQR: 0-550; n=81, z=-3.7, p<0.001). About two-thirds (34/52) of drinking vessels were contaminated with E. coli. Although boiling and solar disinfection of water (SODIS) improved the quality of drinking-water (median=0 CFU/100 mL; IQR: 0-0.05), recontamination at the point-of-consumption significantly reduced the quality of water in the cups (median=8, IQR: 0-500; n=45, z=-2.4, p=0.015). Home-based interventions in disinfection of water may not guarantee health benefits without complementary hygiene education due to the risk of posttreatment contamination.
Paired water samples were collected and analysed for thermotolerant coliforms (TTC) from 20 sources (17 developed or rehabilitated by Oxfam and 3 others) and from the stored household water supplies of 100 households (5 from each source) in 13 towns and villages in the Kailahun District of Sierra Leone. In addition, the female head of the 85 households drawing water from Oxfam improved sources was interviewed and information recorded on demographics, hygiene instruction and practices, sanitation facilities and water collection and storage practices. At the non-improved sources, the arithmetic mean TTC load was 407/100 ml at the point of distribution, rising to a mean count of 882/100 ml at the household level. Water from the improved sources met WHO guidelines, with no faecal contamination. At the household level, however, even this safe water was subject to frequent and extensive faecal contamination; 92.9% of stored household samples contained some level of TTC, 76.5% contained more than the 10 TTC per 100 ml threshold set by the Sphere Project for emergency conditions. The arithmetic mean TTC count for all samples from the sampled households was 244 TTC per 100 ml (geometric mean was 77). These results are consistent with other studies that demonstrate substantial levels of faecal contamination of even safe water during collection, storage and access in the home. They point to the need to extend drinking water quality beyond the point of distribution to the point of consumption. The options for such extended protection, including improved collection and storage methods and household-based water treatment, are discussed.
Diarrhoea and water-borne diseases are leading causes of mortality in developing countries. To understand the socio-cultural factors impacting on water safety, we documented knowledge, attitudes and practices of water handling and usage, sanitation and defecation in rural Tamilnadu, India, using questionnaires and focus group discussions, in a village divided into an upper caste Main village and a lower caste Harijan colony. Our survey showed that all households stored drinking water in wide-mouthed containers. The quantity of water supplied was less in the Harijan colony, than in the Main village (P<0.001). Residents did not associate unsafe water with diarrhoea, attributing it to 'heat', spicy food, ingesting hair, mud or mosquitoes. Among 97 households interviewed, 30 (30.9%) had toilets but only 25 (83.3%) used them. Seventy-two (74.2%) of respondents defecated in fields, and there was no stigma associated with this traditional practice. Hand washing with soap after defecation and before meals was common only in children under 15 years (86.4%). After adjusting for other factors, perception of quantity of water received (P<0.001), stated causation of diarrhoea (P=0.02) and low socio-economic status (P<0.001) were significantly different between the Main village and the Harijan colony. Traditional practices may pose a significant challenge to programmes aimed at toilet usage and better sanitation.
Billions of people globally gained access to improved drinking water sources and sanitation in the last decades, following effort towards achieving the Millennium Development Goals. Global progress remains a general indicator as it is unclear if access is equitable across groups of the population. Agenda 2030 calling for `leaving no one behind', there is a need to focus on the variations of access in different groups of the population, especially in the context of low- and middle-income countries including Malawi. We analyzed data from Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) to describe emerging trends on progress and inequalities in water supply and sanitation services over a 25-year period (1992–2017), as well as to identify the most vulnerable populations in Malawi. Data were disaggregated with geographic and socio-economic characteristics including regions, urban and rural areas, wealth and education level. Analysis of available data revealed progress in access to water and sanitation among all groups of the population. The largest progress was generally observed in the groups that were further behind at the baseline year, which likely reflects good targeting in interventions/improvements to reduce the gap in the population. Overall, results demonstrated that some segments of the population – foremost poorest Southern rural populations – still have limited access to water and are forced to practise open defecation. Finally, we suggest including standardized indicators that address safely managed drinking water and sanitation services in future surveys and studies to increase the accuracy of national estimates.
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, 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 the data supporting this relationship is 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 Southern Malawi to enhance understanding of the measures 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.
There remains a pressing need for systematic water quality monitoring strategies to assess drinking water safety and to track progress towards the Sustainable Development Goals (SDG). This study incorporated water quality testing into an existing national socioeconomic survey in Yogyakarta province, Indonesia; the first such study in Indonesia in terms of SDG tracking. Multivariate regression analysis assessed the association between faecal and nitrate contamination and drinking water sources household drinking water adjusted for wealth, education level, type of water sources and type of sanitation facilities. The survey observed widespread faecal contamination in both sources for drinking water (89.2%, 95%CI: 86.9-91.5%; n=720) and household drinking water (67.1%, 95%CI: 64.1-70.1%; n=917) as measured by Escherichia coli. This was despite widespread improved drinking water source coverage (85.3%) and commonly self-reported boiling practices (82.2%). E.coli concentration levels in household drinking water were associated with wealth, education levels of a household head, and type of water source (i.e. vender water or local sources). Following the proposed SDG definition for Target 6.1 (water) and 6.2 (sanitation), the estimated proportion of households with access to safely managed drinking water and sanitation was 8.5% and 45.5%, respectively in the study areas, indicating substantial difference from improved drinking water (82.2%) and improved sanitation coverage (70.9%) as per the MDGs targets. The greatest contamination and risk factors were found in the poorest households indicating the urgent need for targeted and effective interventions here. There is suggested evidence that sub-surface leaching from on-site sanitation adversely impacts on drinking water sources, which underscores the need for further technical assistance in promoting latrine construction. Urgent action is still needed to strengthen systematic monitoring efforts towards tracking SDG Goal 6.
We compared dry and rainy season water sources and their quality in the urban region of Port Harcourt, Nigeria. Representative sampling indicated that municipal water supplies represent < 1% of the water sources. Residents rely on privately constructed and maintained boreholes that are supplemented by commercially packaged bottled and sachet drinking water. Contamination by thermotolerant coliforms increased from 21% of drinking water sources in the dry season to 42% of drinking water sources in the rainy season (N = 356 and N = 397). The most significant increase was in sachet water, which showed the lowest frequencies of contamination in the dry season compared with other sources (15%, N = 186) but the highest frequencies during the rainy season (59%, N = 76). Only half as many respondents reported drinking sachet water in the rainy season as in the dry season. Respondents primarily used flush or pour-flush toilets connected to septic tanks (85%, N = 399). The remainder relied on pit latrines and hanging (pier) latrines that drained into surface waters. We found significant associations between fecal contamination in boreholes and the nearby presence of hanging latrines. Sanitary surveys of boreholes showed that more than half were well constructed, and we did not identify associations between structural or site deficiencies and microbial water quality. The deterioration of drinking water quality during the rainy season is a serious public health risk for both untreated groundwater and commercially packaged water, highlighting a need to address gaps in monitoring and quality control.
Purpose
Water is a basic human right that is still not ensured for many people worldwide. Essential for human health and development, water security is an increasingly important area for social welfare research. At the household level, a common water security proxy is access to an improved source of drinking water such as piped water, a public tap, or a protected well. In urban areas of developing countries, however, recent research has identified important household disparities that regional and national statistics on improved access can mask. To extend these analyses, this study examines seasonal differences in household water security—an emerging priority area due to urbanization, population growth, and environmental change trends.
Methods
Data are from randomly sampled household surveys (N = 396) in Baguio City, the Philippines, on water quantity, quality, and accessibility in dry versus rainy seasons. Bivariate and principal component analyses were performed.
Results
Water quantity and accessibility are lower in the dry than rainy season for several measures, typically with a wide range among households. Water quality is rated somewhat higher in the dry than rainy season. Principal component analysis yields a multidimensional measure of dry season hardship and no comparable rainy season measure.
Conclusions
Important heterogeneities of seasonal water security exist among households in this study. More rigorous documentation of local inequities is needed, incorporating seasonal aspects of water security that are appropriate for local contexts.
Household water treatment with sodium hypochlorite has been shown to reduce self-reported diarrheal disease in developing countries. Reported hypochlorite use, time since treatment, total chlorine residual (TCR), and E. coli concentration results from 589 household surveys in rural Kenya were analyzed to quantify the effect of exceeding recommended 24 hour post-treatment water storage time in ceramic pots. Exceeding storage time recommendations impacted treatment efficacy, as 87% of reported treaters with TCR >= 0.2 mg/L storing their water <= 24 hours met World Health Organization (WHO) E. coli guideline values, compared to 77% of reported treaters with TCR >= 0.2 mg/L storing water >24 hours (p = 0.024) and 7% of reported non-treaters. Implementing organizations face the trade-off between promoting treating water every 24 hours and accepting slightly compromised efficacy.
Many water providers in urban developing country contexts have to supply the water intermittently due to the disparity between rapidly growing demand and investment in supply infrastructure. This can lead to water quality risks such as ingress of polluted groundwater and unsafe household storage. This study has investigated the common risks and possible alternative solutions down the supply chain in the Nagpur municipal piped network through quantitative and qualitative data collection. The water quality testing indicated a significant reduction in water quality between tap and point-of-use. Interviews and a sanitary survey indicated storage design, inappropriate extraction practice and children's access as the most frequent household storage risks. The people with socio-economically lower status were found to be in greatest need of interventions. The study leads to the following recommendations: there is a need for the evolution of a Water Safety Plan to enable supportive structures for good risk assessment which includes all stakeholders from source to point-of-use; community awareness of water quality risks needs to be raised; low cost 'improved' water storage at household level should be promoted; and the levels of residual chlorine should be investigated and adjustments made to assure potable water at point-of-use.
The objective of this study was to investigate the quality of on-plot piped water and rainwater at the point of consumption in an area with rapidly expanding coverage of 'improved' water sources.
Cross-sectional study of 914 peri-urban households in Kandal Province, Cambodia, between July-August 2011. We collected data from all households on water management, drinking water quality and factors potentially related to post-collection water contamination. Drinking water samples were taken directly from a subsample of household taps (n = 143), stored tap water (n = 124), other stored water (n = 92) and treated stored water (n = 79) for basic water quality analysis for Escherichia coli and other parameters.
Household drinking water management was complex, with different sources used at any given time and across seasons. Rainwater was the most commonly used drinking water source. Households mixed different water sources in storage containers, including 'improved' with 'unimproved' sources. Piped water from taps deteriorated during storage (P < 0.0005), from 520 cfu/100 ml (coefficient of variation, CV: 5.7) E. coli to 1100 cfu/100 ml (CV: 3.4). Stored non-piped water (primarily rainwater) had a mean E. coli count of 1500 cfu/100 ml (CV: 4.1), not significantly different from stored piped water (P = 0.20). Microbial contamination of stored water was significantly associated with observed storage and handling practices, including dipping hands or receptacles in water (P < 0.005), and having an uncovered storage container (P = 0.052).
The microbial quality of 'improved' water sources in our study area was not maintained at the point of consumption, possibly due to a combination of mixing water sources at the household level, unsafe storage and handling practices, and inadequately treated piped-to-plot water. These results have implications for refining international targets for safe drinking water access as well as the assumptions underlying global burden of disease estimates, which posit that 'improved' sources pose minimal risks of diarrhoeal diseases.
This study has investigated the common risks associated with the water quality changes from the source to the consumer households and the associated disease burden in the piped water supplies. Samples from the source to the household storage from Nagpur City were collected and analysed for heavy metals, nutrient and microbial parameters. Sanitary risks were identified at the households during the socio-economic and sanitary survey. The water quality deterioration was the most at household storage around 30.3 % indicating that measures need to be taken to safeguard the water quality at the consumer level. Then, 31.2 % of the samples collected from public standposts and handpumps were positive for faecal contamination which implies that it is the weaker sections of the society who suffer the consequences of drinking unsafe water the most. On the basis of the laboratory results, risk analysis by surveying the WTPs, point-of-use behaviour at households and sanitary status at different socio-economic strata, the Water Safety Plan for Nagpur City was structured. The aim was to ensure that safe and improved water is reached to the individual household.
Access to household water connections remains low in sub-Saharan Africa, representing a public health concern. Previous studies have shown water stored in the home to be more contaminated than water at the source; however, the mechanisms of post-supply contamination remain unclear. Using water quality measurements and structured observations of households in Bagamoyo, Tanzania, this study elucidates the causal mechanisms of the microbial contamination of drinking water after collection from a communal water source. The study identifies statistically significant loadings of fecal indicator bacteria (FIB) occurring immediately after filling the storage container at the source and after extraction of the water from the container in the home. Statistically significant loadings of FIB also occur with various water extraction methods, including decanting from the container and use of a cup or ladle. Additionally, pathogenic genes of Escherichia coli were detected in stored drinking water but not in the source from which it was collected, highlighting the potential health risks of post-supply contamination. The results of the study confirm that storage containers and extraction utensils introduce microbial contamination into stored drinking water, and suggest that further research is needed to identify methods of water extraction that prevent microbial contamination of drinking water.
Using the experience of pilot projects promoted by the World Health Organization, assesses the institutional requirements for conserving capital investments in the rural water supply sector. In particular, the book examines the human and technical resources required for monitoring, maintaining and improving the safety of rural water supply services. Intended as a practical guide to improving the quality of service from small water supplies, it describes the essential minimum of reliable methods for monitoring water quality and discusses new cost-effective approaches to sanitary inspection of community water supplies. The pilot projects were in Indonesia, Peru and Zambia. Chapters examine: infrastructure in the three areas; surveillance planning; sanitary inspections; bacteriological and physico-chemical analysis; evaluation of surveillance results; remedial action; and the WHO strategy for technical cooperation. -after Publisher
Plastic containers in the range of 5-20 L are widely used - especially in rural African settings - to collect, transport and store water for domestic use, including drinking, bathing and hygiene. The pathogen content of the waters in these containers has not been adequately characterized as yet. This paper presents the primary findings of a synoptic survey of drinking water quality samples from these containers and involved collection of bacterial indicator and pathogenicity gene data. In total, 571 samples of a variety of waters were taken in rural communities in South Africa and the Escherichia coli numbers measured. Of the E. coli positive samples, 46% (n = 148) were screened for the presence of E. coli pathogen gene markers. Though synoptic, the survey provided many insights into the issues that drove the study. Container use markedly degraded water quality as judged by indicator counts, even where improved water supply services were in place. Household container use also appeared to promote regrowth or contamination of containers with pathogenic E. coli strains. Polymerase chain reaction (PCR) analysis also showed that the diversity of potential pathogenic E. coli carrying virulence genes was great. All seven genes screened for (Ial, Stx1, Stx2, EaeA, Eagg, ST, LT) were found in the waters, alone or as mixtures (number of different combinations = 31) including those characteristic of the more dangerous invasive and haemorrhagic E. coli strains. Given the central role of containers in the management of water supply to rural communities, it is clear the microbiology of these waters requires much further characterization.
This study investigated whether a water-handling hygiene education programme could improve the health-related microbiological quality of container water stored and used in households in a dense urban settlement in the Free State Province. Previous studies in the area indicated that stored container water became contaminated during the process of fetching from communal standpipes and then storing and handling the water at home, which exposed the study population to a potential risk of microbiological infection. A water-hygiene education programme was implemented together with a health-related microbiological water quality assessment programme. Members of selected households participated in a series of domestic water-handling hygiene education training sessions over a period of eight months and the quality of their stored water monitored for improvement in tandem over the same period. The results were compared to those of similar tests done during previous studies in the same area. Turbidity, heterotrophic bacteria numbers and total coliform bacteria were used as indicators of general microbial water quality while E. coli bacteria were used to indicate faecal pollution. While the results generally reflected significant improvements for all the indicators from the previous studies, a potential risk of infection was still indicated for consumers. Based on education programme attendance profile, the study sample was divided into frequent, intermittent and never groups. No significant changes were found in water quality between the three groups, even though the frequent group attended most of the training sessions. This implies that the programme did not have a particular influence on any one group. Container-stored water was still being contaminated in the domestic environment despite the water-handling hygiene education programme. An improved hygiene-education programme appears to be needed to change deep-rooted inherent behaviours such as hand-washing prior to water handling as well as proper protection of container-stored water from environmental contamination.
A unitary environmental classification of water-and excreta-related communicable diseases is presented, which comprises seven categories: Feco-oral waterborne and water-washed diseases; non-feco-oral water-washed (skin and eye) diseases; geohelminthiases; taeniases; water-based diseases (bacterial and fungal, as well as helminthic); insect-vector diseases; and rodent-vector diseases. The global burden of some of these diseases in 1990 is reviewed. Water-and excreta-related diseases were responsible for 2,700,000 deaths in that year (5.3% of all deaths) and for the loss of 93,200,000 disability-adjusted life years (6.8% of all DALYs). Almost all these deaths and loss of DALYs occurred in developing countries (99.9 and 99.8%, respectively).
Summary Improving domestic hygiene practices is potentially one of the most effective means of reducing the global burden of diarrhoeal diseases in children. However, encouraging behaviour change is a complex and uncertain business. If hygiene promotion is to succeed, it needs to identify and target only those few hygiene practices which are the major source of risk in any setting. Using biological reasoning, we hypothesize that any behaviours which prevent stools from getting into the domestic arena, the child's main habitat, are likely to have a greater impact on health than those practices which prevent pathogens in the environment from being ingested. Hence safe stool disposal, a primary barrier to transmission, may be more important than hand-washing before eating, which constitutes a secondary barrier, for example. We review the epidemiological evidence for the effect of primary and secondary barrier behaviours and suggest that it supports this conclusion. In the absence of local evidence to the contrary, hygiene promotion programmes should give priority to the safe disposal of faecal material and the adequate washing of hands after contact with adult and child stools.
Microbiological safety of water is commonly measured using indicator organisms, but the spatiotemporal variability of these indicators can make interpretation of data difficult. Here, we systematically explore the variability in Escherichia coil concentrations in surface source and household drinking water in a rural Ecuadorian village over one year. We observed more variability in water quality on an hourly basis (up to 2.4 log difference) than on a daily (2.2 log difference) or weekly basis (up to 1.8 log difference). E. coli counts were higher in the wet season than in the dry season for source (0.42 log difference, p < 0.0001) and household (0.11 log difference, p = 0.077) samples. In the wet season, a 1 cm increase in weekly rainfall was associated with a 3% decrease (p = 0.006) in E. coli counts in source samples and a 6% decrease (p = 0.012) in household samples. Each additional person in the river when source samples were collected was associated with a 4% increase (p = 0.026) in E. coil counts in the wet season. Factors affecting household water quality included rainfall, water source, and covering the container. The variability can be understood as a combination of environmental (e.g., seasonal and soil processes) and other drivers (e.g., human river use, water practices, and sanitation), each working at different time scales.
Socio-economic status is an important determinant of health and survival in rural Africa and necessitates a practical and valid instrument to implement in health studies. Our objective was to investigate the validity of the rapid appraisal method to assess socio-economic status and its ability to identify individuals at risk. Among 1573 households in rural northern Ghana, we calculated the Demographic Health Survey (DHS) wealth index and conducted two rapid appraisal methods: self-reported wealth and interviewer-reported wealth. In addition we followed the 25,184 participants from these households for survival with a mean follow-up of 3.9 years, during which 885 participants died. The DHS wealth index was moderately correlated to self-reported wealth (Spearman's rho 0.59, P<0.001) and interviewer-reported wealth (Spearman's rho 0.75, P<0.001). Mortality risks were significantly higher for people with lower than average self-reported wealth [hazard ratio (HR) 1.30 (95% CI 1.11-1.51)] and lower interviewer-reported wealth [HR 1.40 (95% CI 1.21-1.62)]. Mortality risks were lower for people with higher self-reported wealth [HR 0.81 (95% CI 0.32-2.03)] and higher interviewer-reported wealth [HR 0.84 (95% CI 0.58-1.21)]. Similar discriminative mortality risks were assessed when using tertiles of the DHS wealth index (Ptrend<0.001).
The bacteriological quality of drinking water sources and of stored household water was examined in a rural area of Malawi, before and after improvement of the method of water supply. Among the traditional water sources, water quality was better in springs than in wells and rivers. During the rainy season, there was a considerable deterioration of water quality, which was most pronounced in wells. The improved water supply system consisted of piped, untreated surface water from an uninhabited mountain area. This water contained a mean value of 54 faecal coliforms per 100 ml which can be regarded as acceptable in this setting. During collection of drinking water and during household storage, there was considerable contamination, which mirrored the unhygienic environment. Contamination was worse during the rainy season than during the dry season. Technical interventions aimed at improving water supply in rural areas of developing countries will probably not become effective unless combined with comprehensive health education programmes for the population concerned.
The present study covered two rural communities of South Africa: Ncera and Ntselamanzi villages. Raw water from Ncera river is used by the community of Ncera village for drinking, while the community of Ntselamanzi receives their drinking water from Alice purification system. Treated water is supplied to the community by a public standpipe system. In rural communities of South Africa, many households use polyethylene (PE) and galvanized steel (GS) containers for the storage of their drinking water. To investigate the regrowth and survival of indicator microorganisms on the surface of household containers during the storage of drinking water, PE and GS slides were suspended in the appropriate household containers for a period of 48 h. This period of 48 h was chosen as the study period because results from the questionnaire indicated that the largest percentage (62%) of households store their water for that length of time. The experiment was performed to test drinking water as it is collected and stored by rural communities. No disinfection of household containers or slides was done during the study period. Attached coliphages (F-RNA (FP) and somatic phage (SP), coliform bacteria (total coliform (TC), presumptive Escherichia coli (EC), Salmonella (Sal) and Clostridium perfringens (CP) were measured during the study period. With the exception of CP, attached indicator microorganisms consisted of TC, presumptive E. coli and Salmonella, somatic and F-RNA coliphages, although the yield (average count) for the last four groups (EC: < 1-3 cfu cm(-2), Sal: < 1-15 cfu cm(-2), FP: < 1-7 pfu cm(-2), SP: < 1-7pfu cm(-2)) was lower than that of TC (3-183 cfu cm(-2)). However, the lowest yield of indicator microorganisms was noted for presumptive E. coli. Whereas the occurrence and survival of TC was noted on the surface of household containers during the entire period of the experimental study, other indicator microorganisms occurred from time to time. The regrowth of indicator microorganisms occurred 48 h after the exposure of slides to both types of test waters. This length of time mostly resulted in the regrowth of TC (with an increase in bacterial counts) while the persistence of other indicator organism groups on the surface of the slides was apparent. A comparison between PE and GS containers showed that more TC (average count) regrew on PE than on GS containers (for river water, PE: from 36 to 55 cfu cm(-2), GS: from 25 to 26 cfu cm(-2); for standpipe water, PE: from 147 to 183 cfu cm(-2), GS from 3 to 4 cfu cm(-2)). This study revealed that both types of household containers supported the growth and survival of indicator microorganisms due to the bad quality of the intake water before storage. The storage of drinking water for 48 h mainly resulted in the regrowth of TC. Nevertheless, the persistence of other indicator microorganisms was observed on the surface of household containers.
To assess the extent and causes of microbiological contamination of household drinking water between source and point-of-use in developing countries.
A systematic meta-analysis of 57 studies measuring bacteria counts for source water and stored water in the home to assess how contamination varied between settings.
The bacteriological quality of drinking water significantly declines after collection in many settings. The extent of contamination after water collection varies considerably between settings, but is proportionately greater where faecal and total coliform counts in source water are low.
Policies that aim to improve water quality through source improvements may be compromised by post-collection contamination. Safer household water storage and treatment is recommended to prevent this, together with point-of-use water quality monitoring.
Studies in Southern Africa have shown that even when microbiologically safe water is supplied to developing communities at communal standpipes, contamination by high numbers of pathogenic microorganisms may occur during the processes of fetching water from the supply source and storage during use at home, rendering such waters unsafe for human consumption. This study investigated the occurrence of biofilm in PVC storage containers as one possible reason for this deterioration, using heterotrophic bacteria and total coliform counts as well as turbidity as indicators. A second objective was to determine whether biofilm in water-storage containers could contribute to hazardous microbiological contamination indicated by Escherichia coli and Clostridium perfringens. Results indicated that increased microbiological contamination is associated with biofilm. The biofilm harbours heterotrophic bacteria, total coliforms and C. perfringens. E. coli could not be associated directly with the levels of biofilm in containers but rather appears to be introduced intermittently from the ambient domestic environment. When dislodged with the biofilm, these bacteria contributed substantially to the deterioration of the microbiological quality of supplied water stored in plastic containers.
The deterioration of drinking water quality following its collection from a community well or standpipe and during storage in the home has been well documented. However, there is a view that post-supply contamination is of little public health consequence. This paper explores the potential health risk from consuming re-contaminated drinking water. A conceptual framework of principal factors that determine the pathogen load in household drinking water is proposed. Using this framework a series of hypotheses are developed in relation to the risk of disease transmission from re-contaminated drinking water and examined in the light of current literature and detailed field observation in rural Honduran communities. It is shown that considerable evidence of disease transmission from re-contaminated drinking water exists. In particular the type of storage container and hand contact with stored drinking water has been associated with increased incidence of diarrhoeal disease. There is also circumstantial evidence linking such factors as the sanitary conditions in the domestic environment, cultural norms and poverty with the pathogen load of household stored drinking water and hence the risk of disease transmission. In conclusion it is found that re-contaminated drinking water represents a significant health risk especially to infants, and also to those with secondary immunodeficiency.
The importance of domestic water quality management in the context of faecal-oral disease transmission
- A F Trevett
- R C Carter
- S F Tyrrel
- D Van Bodegom
- L May
- M Kuningas
- R Kaptijn
- F Thomése
- H J Meij
- J Amankwa
- R G J Westendorp
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UNICEF 2019 MICS 6 TOOLS.
van Bodegom, D., May, L., Kuningas, M., Kaptijn, R., Thomése, F., Meij, H.J.,
Amankwa, J., Westendorp, R.G.J., 2009. Socio-economic status by rapid appraisal
is highly correlated with mortality risks in rural Africa. Trans. R. Soc. Trop. Med.
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WHO 2020 New sanitary inspection packages for drinking-water.