The purpose of this presentation is to shed light on how a new toolkit from the World Health Organization and UNICEF can help to monitor and evaluate household water treatment and safe storage projects for greater sustainability.

1. The purpose of this presentation is to shed light on how a new toolkit from the World
Health Organization and UNICEF can help to monitor and evaluate household water
treatment and safe storage projects for greater sustainability.
The WASH Sustainability Forum (http://www.sustainablewash.org/2014‐wash‐
sustainability‐forum) aimed to discuss the practical aspects of sustainability, share current
tools for monitoring and evaluating sustainability, and identify challenges for their use. As
part of this, the International Network on Household Water Treatment and Safe Storage
sought to share the WHO & UNICEF toolkit with the participants of the Forum. Many
thanks to the UNICEF team in New York for funding the expenses associated with attending
the Forum, delivering this presentation, and ensuing discussions.
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2. Let’s take a look at the “big picture”. This chart represents what a lot of us are working
towards – increasing access to water for those in need. The chart illustrates progress
toward the Millennium Development Goal on increased access to “improved water”. The
Millennium Development Goals were agreed by nearly 200 countries in the year 2000 as a
set of goals to improve the quality of life for the world’s poorest people and address major
social and environmental issues. On water, the goal was to reduce by 50% the proportion of
the world’s population that did not have access to improved water. In 1990 about 24% of
the world’s population did not have access to improved sources of water (such as protected
springs, or a borehole). The goal was to reduce this to 12% of the world’s population by
2015. In 2012, it was announced that the drinking water target had been “met” five years
early. Although this seems to be good news there are still at least two problems with this
picture.
The first is that although the target has been reached, there are still hundreds of millions of
people (small red circle) using unimproved sources of water who should be treating their
water prior to consuming it because it is not safe to drink. The second problem is that
recent research shows that hundreds of millions more people (large orange circle) who are
using improved sources of water may be consuming contaminated water. For example, a
protected well is considered an improved source, but research shows that fecal
contamination still occurs in about 25 percent of water from improved sources (Bain et al,
2014). Taken together, we can see that although the drinking water target has been “met”,
there is still a huge amount of work to do.
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3. Household water treatment is a possible solution. It can be used to improve the quality of
water consumed in the home. A series of meta‐analyses (Fewtrell et al., 2005; Clasen et al.,
2006;, Waddington et al., 2009) showed that HWTS could reduce the incidence of diarrheal
disease by between 35% and 47%. However, these reviews group together the findings
from a wide variety of studies of varying quality. For example, studies are often too short to
evaluate sustained use or the results were based on self‐reported data. In addition, results
from HWTS programs are often inconsistent, because the implementing methodology often
varies. This can make it difficult to compare program results.
The images along below illustrate six examples of accepted and proven HWTS methods.
Each has its advantages and disadvantages and the choice of which one to use depends on
the local context. Some methods protect against re‐contamination such as through a
chlorine residual or a safe storage mechanism (i.e. solar disinfection in a plastic bottle). The
last image with the red question mark indicates that boiling is not ideal due to a range of
factors: sub‐optimal performance, no protective factor against recontamination risk,
creates smoke in the household, heightens the risk of burn injuries, and environmental
issues.
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4. There are various challenges to sustainability which are often placed into several broad
categories. This list is not intended to be exhaustive (for example, environmental
sustainability is not shown here). Facets of sustainability include financial, operational,
contextual, and behavioral.
Financial sustainability may refer to whether a program or project is self‐funded or has a
long‐term funding support. For example, has the government adopted a policy and
allocated budgetary funding and support for it on an ongoing basis?
Operational sustainability may refer to the existence of functioning supply chains for spare
parts and expertise to set up and maintain systems. An aspect of this may consider
whether there is capacity in the local community to repair broken systems.
Contextual sustainability can refer to the existence of supportive local leaders. It may also
refer to interest and investment from local entrepreneurs and the acceptability of a product
by local users. Some may also refer to contextual sustainability as the ‘enabling
environment’ or the existence of supportive and functional policies and regulations.
Behavioral sustainability refers to lasting changes in behavior over time that lead to the
practice becoming habitual, and even a social norm. This is important because without
correct and consistent use over time, health impact cannot be achieved. The behavioral
aspect of sustainability is the focus of this presentation.
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5. The practice of correct, consistent and sustained treatment and storage of household
drinking‐water involves many various behaviors, starting from collection of water at the
source, transportation to the home, obtaining a method to practice HWTS, using it
correctly, handling the water safely, storing it well, and always drinking treated water. The
elements of this cycle that are circled in red are those that present opportunities for
re/contamination of drinking‐water (Wright et al. 2004).
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6. The key desired behavioral outcomes with HWTS are correct, consistent, and sustained use.
Correct use is making sure that the method or technology is used in the right way and
improves the quality of the water. Consistent use is making sure that every time the user is
consuming water they are consuming treated water. Even from a single exposure to
contaminated water one can sick. Researchers have modeled the effect of HWTS on health
and found that projected health impact drops off substantially if use is inconsistent (Brown
& Clasen, 2012). Finally, sustained use is about long‐term behavior change.
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8. These photos were taken in the peri‐urban town of Kauma near the city of Lilongwe,
Malawi. They illustrate some unhygienic methods for collecting water at two different
points. Although we don’t know whether this water is intended to be used for drinking, the
risks of contamination during the collection process are evident. Moreover, these two
water points are good examples of sources that may not be delivering safe drinking‐water
to begin with (the first photo shows an uncovered well, and the second shows poor
drainage around the water point – both of these can lead to contamination).
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9. In these first three photos across the top we can see how people are transporting their
water in uncovered containers or where their fingers could potentially contaminate the
water. In the second row, we see two examples of a water filter and a storage container
that are not being used properly (the filter is turned away from the storage bucket and the
second is not being used to hold water). Another factor with the transportation of water is
the distance between the people and the source. The more distant a source is, the less
water people are likely to collect, meaning they will have less for other needs such as hand‐
washing.
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11. Consistent use is especially important for people with immune‐compromised systems, such
as people living with HIV. It is important to note that PLHIV are at high risk for diarrhoea‐
related opportunistic infections such as cryptosporidium and giardia, contracted through
the consumption of dirty drinking water. Policy‐makers and implementing stakeholders
should be aware that chlorine‐only HWTS options are not effective at removing protozoan
parasites such as cryptosporidium or giardia as these are chlorine‐resistant (WHO, 2011).
Thus, for programs focused on PLHIV, only HWTS options effective at removing such
pathogens should be used.
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12. Consistent use is also important for young children, in order to interrupt the vicious cycle of
malnutrition and diarrhea. This photo is of a group of children in a school in Nairobi which
provides them with safe drinking‐water from morning until late afternoon. What we do not
know is the quality of the water they are receiving at home, but the school does emphasize
the importance of safe drinking‐water to the children and their parents, and is working to
create a habit of treating drinking‐water among the children.
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14. A systematic review of behavior change interventions (Parker Fiebelkorn et al. 2012)
provided limited insight into what behavioral techniques work for HWTS. This was mainly
because the studies failed to report sufficiently on the models used to stimulate behavior
change. Some possible factors that were mentioned include: self‐efficacy, cost of product,
taste, whether currently practicing, believes water is dirty/can make their children sick.
Other studies which reviewed the effectiveness of HWTS were too short to gain insight into
sustained use over time (Hunter, 2009; Arnold & Colford, 2007; Waddington et al. 2009).
Moreover, effectiveness tended to decline with the length of the study (i.e. the longer the
study, the more levels of relevant HWTS outcomes dropped off). However, one study in
Haiti showed sustained use over a period of ten years (Harshfield et al. 2012) but did not
look at the behavioral aspects of this success. An unpublished study (Ritter, 2007) looking
at the Haiti program suggested that highly consistent use was associated with distance to
sales point, promotion via household visits, and perceived social support. Other factors
that may play a role include ongoing training for users and continuous follow‐up (Lantagne
& Clasen, 2009), social support (Russo et al. 2012) and social norms (Wood et al. 2012).
Parker Fiebelkorn and colleagues (2012) suggest that in order to improve our knowledge of
behavior change models that work for HWTS, we need to use more objective outcome
measures (e.g. free chlorine residual in drinking‐water instead of self‐reported treatment)
and longitudinal data that yields insight to behavior change over time. This is consistent
with good M&E practice and is the purpose of the M&E toolkit for HWTS which is shown on
the next slide.
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15. The new toolkit from WHO & UNICEF was released in 2012 and offers 20 harmonized
indicators for M&E of HWTS. It also offers an overview of how to design and conduct M&E
activities, as well as other resources such as case studies and example surveys. The toolkit
can be downloaded at
http://www.who.int/household_water/resources/toolkit_monitoring_evaluating/en/.
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16. The following are the 20 recommended indicators from the WHO & UNICEF M&E toolkit.
Some of these indicators can be used to monitor sustainability. Which of these would you
use?
First of all, for the purposes of this presentation, we are referring to the behavioral aspect
of sustainability. This means that individuals, households, and communities continue the
desired behavior over time and suggests that monitoring needs to occur with some
frequency and continuity so as to determine whether the behavior is continuing and is
sustained.
The choice of which indicator(s) you use is going to be determined by the questions you
want to answer and the trends you want to assess. Think about the indicator that is most
appropriate for determining the answer to that question, and think about how often you
will need to collect the data. What are you trying to learn?
For example, if I wanted to understand whether my program was having an effect on HWTS
behavior, I would find a target audience which is known to be consuming contaminated
water, measure their water quality at baseline, use a sampling approach to select a
representative and unbiased sample of households, and then follow up with them at 1, 3,
6, and 12 months to measure correct (water quality testing of their stored drinking water),
consistent (frequency of sampling and determining whether they are consuming water
from any other source), and sustained use (accumulated data over time).
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