1

RESEARCH BRIEF

The objective of this Point-of-Use Product Trial isto contribute to the base of formative researchavailable to develop the national Point-of-Use

(POU) Marketing Strategy and a hygiene improvementstrategy and implementation workplan for POU watertreatment for four selected DACAW (DecentralizedAction for Children and Women) districts in Nepal

These four districts are the focus of the USAID-fundedand UNICEF-supported pilot districts namely PanchtharParsa Kapilvastu and Dang where hygiene activities havecontinued since the mid-nineties This specific formativeresearch component aimed to provide a hands-onconsumer perspective of the general concept of watertreatment and explore consumer perception of usingfour types of water treatment methods over time tocapture perceived benefits and obstacles of use

The trial methods included those proven efficacious in labconditions and currently or soon-to-be-available in Nepalndash boiling SODIS (solar disinfection) colloidal silver (CS)filters and chlorination Twenty mothers in each districtwere asked to try one method supplied to them free ofcost for a period of about one month five mothers ineach district tried one method Trained qualitativeresearchers visited mothers in their home approximately 3and 30 days after the initial visit to assess immediate reac-tions and then reactions and continued practice over time

Each method was evaluated by a group of mothers withsmall children according to particular characteristics bull Taste bull Smell bull Appearance bull Temperature

After trying one method for a minimum of one monthrespondents were shown water treatment options andasked to compare ldquotheirrdquo method with the others usingthe characteristics outlined above A short baselinesurvey essentially an abbreviated version of the largerUNICEF baseline survey was applied in each householdat first visit to assess sociodemographic measurescurrent knowledge perceptions and practice related tohygiene and sanitation

A fifth treatment method the Biosand filter wasconsidered for the product trial but eventually was notincluded for both logistic and security reasons The sizeand weight of the filter made transport difficult andsuspicious to mobilize throughout the districts given theprecarious security situation in Nepal and the possibilityof the components being mistaken for homemadebombs As a solution researchers re-visited householdsfrom a previous filter promotion project and talked with

BRINGING THE CONSUMERTO THE TABLEPERCEPTIONS AND PRACTICE OF HOUSEHOLD WATER TREATMENT METHODS IN NEPAL

bull Acceptability to family members bull Effort convenience maintenance bull Perceived effectiveness bull Perceived value

RESEARCH BRIEF May 2006

This document was prepared for review by the United States Agency for International Development It was prepared by the Hygiene Improvement Project and the Academy for Educational Development

Photo Julia Rosenbaum Academy for Educational Development

2

RESEARCH BRIEF

a small sample of current and past Biosand filter usersand interviewed them about the likes and dislikes of thattreatment method As in the other study householdsBiosand users were shown the other four treatmentmethods and asked to compare Biosand to those othermethods commenting on the various criteria such assmell taste effort and so on

KEY FINDINGSAll mothers participating in the study were quite willingand needed little convincing to try the water treatmentmethod assigned to them This was particularly note-worthy because the general finding is that most house-holds visited do not see their water as unfit for drinkingOther studies have shown that up to 56 percent of tubewell water had fecal contamination (Arsenic Testing Studyin the Terai 2003) and the 2001 DHS survey docu-mented hygiene and storage practices that guaranteedfurther contamination of water at the household levelActual contamination at point of first contact wasassessed and many but not all water samples collectedprior to method use were contaminated

Households were overall successful in using the varioustechniques to treat water On the second visit mostdrinking water tested clean indicating householderssuccess at using the method This was true for allmethods but the CS filter which actually showed a slightincrease in contamination rates It is assumed but notproven that water still testing positive for coliform and e-coli after treatment was from secondary contaminationalthough researchers have no evidence that water wasever effectively treated

Respondents across all districts noted the following charac-teristics of water that was ldquogood and fit to drinkrdquobull Clearbull Free of turbidity visible dirt andor sand and to a

lesser extentbull Free of bugs and insectsbull Absent of (objectionable) smellbull Cool water was also a highly desired attribute though

not necessarily tied to water that was ldquofitrdquo to drink

Virtually no one expressed any sense of ldquomicrobialrdquo orbacterial contamination (not the words per se rather theconcept of matter in the water that might cause illness)when considering the need to treat water Likewise fewattributed diseases in general or diarrhea in particular tounfit water rather most attributed diarrhea to ldquostalerdquofood While some significant number responded thatdrinking clean water could help to avoid diarrhea thiswas not a predominant concept for most participants

The respondents were not able to comment and givetheir opinion on the attributes of drinking water easilyespecially concerning the waterrsquos appearance and textureThe researchers had to probe with specific words andnote respondent opinions after respondents were givendescriptions such as slippery and oily texture

Households were overall successful in

using the various techniques to treat water

On the second visit most drinking water

tested clean indicating householdersrsquo

success at using the method

Photo UNICEFNepal

3

RESEARCH BRIEF

After baseline measure when researchersexplained that the method left with them (and onthe final visit when all methods were explained)would remove bacteria and invisible disease-causing matter in the water participants appearedto grasp this concept of lsquocontaminationrsquo andvalued the benefit of making the water ldquohealthierrdquofor their family They repeated this benefitthroughout the interviews both at second andthird visits

Demonstration prior to assigning the method wasenough to learn to use the assigned methodadequately and for the most part proper use wasmaintained over the one-month study periodMost respondents anticipated on first visit that theywould be able to use the method easily and this opinionpersisted over the month-long trial During the onemonth observation period respondents made few adap-tations or modifications of the treatment methodsdespite the study design which invited problem-solvingand method adjustment to increase desirability and easeof method use This lack of barriers to use perceiveddifficulties or dislikes of methods was actually asurprising finding as researchers had anticipated greaterresistance to incorporating a routine of treating waterThe few modifications made or observed are outlined inthe last section of the summary

Without considering the cost of purchase or use themost popular method across all districts was the CS filterfor its ease of use followed by chlorinating water Theother two methods SODIS and to a lesser extent boilingwere satisfactory to consumers Serious concerns arosehowever about the efficacy of the CS filter based on the level of contaminated water after treatment with the CS

filter Questions remain about the efficacy of the CS filterand it will be important to determine whether problemsare with the filter systems themselves or with secondarycontamination associated with improper filter maintenance

Most common dislikes of the methods included thewarm temperature rendered by boiling SODIS and to amuch lesser degree perceived to be from chlorinationSome respondents found the smell of chlorination to beproblematic although no one discontinued use becauseof the smell Interestingly smell rather than taste of chlo-rination was more commonly mentioned as disagreeableSmell was mentioned to a lesser extent with other methodsOther barriers included the receptacle size or rather thelimited amount of water that could be disinfected at onetime and the time needed to disinfect another ldquobatchrdquoThis was true for all methods except for SODIS wherehouseholds were given an adequate number of bottles todisinfect the householdrsquos water supply The portability ofthe SODIS bottles was a perceived benefit of thistreatment method

1 In Panchthar researchers were unable to return to most homes within 30 days due to the security situation As a result chlorine users had run out oftheir 30-day supply and therefore technically ldquodiscontinuedrdquo use though for no reason other than lack of supply and unavailability of product in thecommercial market

4

RESEARCH BRIEF

While participants had little previous practice storingwater and particularly storing water or ldquoletting it sitrdquoovernight little resistance was encountered in storingSODIS or the CS filter treated water

All respondents said that they had shared their one-month method use experience with their neighbors andwere overall quite positive about the new watertreatment methods introduced to themDiscontinuation of treatment method was almost exclu-sively attributable to method malfunction or running outof supply Method malfunction was observed more in thecases of SODIS (weather conditions) and the CS filter(broken filter candle or candle nut)

While most study participants continued their methoduse over the entire trial period1 anecdotal evidencesuggests that they did not exclusively consume disinfectedwater over the study period rather supplemented thetreated water with their lsquoregularrsquo water Certainly withthe exception of solar disinfected water which is disin-fected in its own portable container no participantscarried treated water to drink outside the home

Researchers noted a lack of a second vessel for treatingand storing water as an obstacle to easy treatment withall methods other than the CS filter Lack of furniture orobjects to lift the CS filter from the ground to access thetap was an initial obstacle that was easily resolved byhouseholders (often with researcher assistance) by raisingthe filter on a platform of bricks or similar material

Other findingsbull Respondents perceived SODIS (solar disinfection) as a

relatively easy water disinfection method but did notparticularly ldquolikerdquo it as it depended on sun andcouldnrsquot be used in all weather conditions Manyreported general lack of availability of bottles thatcould present a barrier to method use The researchteam also reported unavailability of bottles at studylocations Even among the respondents using bottlesfor drinking water was not a common practice Manyrespondents using SODIS were eager to try adifferent water treatment method preferably a

method that could be used throughout the year andnot be dependent on sunshine No respondentexpressed any reservations about drinking water thathad stayed overnight or of the perceived effec-tiveness of ldquosolarrdquo disinfection even on a cloudy day

bull Respondents liked the ease and convenience of theCS filter and their reported commitment tocontinued filter use was high The CS filter was themethod most preferred among all the others across arange of attributes It was also the least preferredwith reference to the filterrsquos affordability During thestudy period however participants found the filtersthemselves to be delicate and a number experiencedproblems with the candles All households thatstopped using the CS filters had done so becausetheir filters no longer functioned Problems includedldquosheddingrdquo clay from chips in the candles colorldquobleedingrdquo into the upper filtration bucket leakingtaps and broken connector screw knob or candleField workers observed inconsistent quality and flowrate of candles Lastly water from three-fourths of allfilters tested positive for contamination All filterswere confirmed functional before being given torespondents so we can assume high rates were dueto either fatal damage occurring somewhere aftertesting or secondary contamination due to someunidentified reason These product issues are ofconcern and must be resolved before this methodcan be widely promoted

bull Most mothers using chlorination accepted the methodwell They reported the method to be easy to useHowever most respondents reported the smell ofthe disinfected water to be not good

Using bottles for drinking water was not

a common practice Many reported

general lack of availability of bottlesmdasha

potential barrier to method use

5

RESEARCH BRIEF

bull Most respondents said they are willing and able to payfor the method at its market price Across the rangeof water attributes chlorination was the second mostpreferred treatment method after the CS filterHowever the respondents were more comfortablewith the price of chlorination to that of the CS filter

bull Most respondents reported boiling to be an easyprocess to disinfect water It was however the leastpreferred water treatment method Boiled water wassaid to be warm and not pleasant to consume partic-ularly during the hot summer months It was found tobe unappealing to family members The respondentsdid not comment on the reduced time required forboiling water in this ldquonewrdquo recommended boilingtechnique which instructed that water was disinfectedat the sight of the first big bubble This is mostprobably attributable to the fact the householdersadhered to the previous recommendation of bringingwater to a hard boil for 3-10 minutes

Among the BioSand filter current and past users the flowrate seemed to be a concern for all and all were wellaware of the filterrsquos benefits but the effort and thepatience needed to collect water was cited as the majorreasons as to why some of them discontinued use

CONSIDERATIONS AND DISCUSSIONIncorporating consumer perception and practice intohousehold water treatment strategies is vital to creatingeffective and sustainable programs

The practice of water treatment is a complex behaviorProducts and supplies must be available householdersmust believe that drinking water may have negativehealth effects and they must be motivated and possessthe skills to practice the treatment consistently andcorrectly

Water treatment practice can be broken into thefollowing sub-behaviorsbull Obtain waterbull Separate drinking (and cooking) waterbull Placestore in a clean vessel

bull Choose a methodobtain that methodbull Treat correctlybull Protect (cover store and use water without

recontaminating)bull Drink this water always at home (at work and

in school)

Households must be able to perform each behaviorconsistently and correctly to realize individual and publichealth impact As highlighted in the research findingseach sub-behavior carries its own set of barriers andchallenges that must be few enough to assure the entireset of behaviors are practiced The Nepal HouseholdWater Treatment Marketing Strategy being informed bythis research must address the following barriers topromote water treatment uptake at scale

AAnnyy ssttrraatteeggyy mmuusstt ffiirrsstt aaddddrreessss ppeerrcceeppttiioonn ooff rriisskk aass ppaarrttooff aa bbeehhaavviioorr cchhaannggee ssttrraatteeggyy Since respondents voicedlittle concern about any microbial or bacterial contami-nation a marketing strategy would have to heightenhousehold awareness that cool clear water can still causediarrhea

TThhee uuppttaakkee ooff hhoouusseehhoolldd wwaatteerr ttrreeaattmmeenntt wwiillll ddeeppeenndduuppoonn mmeetthhooddss mmeeeettiinngg hhoouusseehhoolldd ppeerrcceeppttiioonnss ooff wwaatteerr tthhaatt iiss ccoonnssiiddeerreedd ffiitt ttoo ddrriinnkk Any treatment productmust be able to produce water that people consider fit

Photo Voiles Sans Frontiegraveres Suisse

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

2

RESEARCH BRIEF

a small sample of current and past Biosand filter usersand interviewed them about the likes and dislikes of thattreatment method As in the other study householdsBiosand users were shown the other four treatmentmethods and asked to compare Biosand to those othermethods commenting on the various criteria such assmell taste effort and so on

KEY FINDINGSAll mothers participating in the study were quite willingand needed little convincing to try the water treatmentmethod assigned to them This was particularly note-worthy because the general finding is that most house-holds visited do not see their water as unfit for drinkingOther studies have shown that up to 56 percent of tubewell water had fecal contamination (Arsenic Testing Studyin the Terai 2003) and the 2001 DHS survey docu-mented hygiene and storage practices that guaranteedfurther contamination of water at the household levelActual contamination at point of first contact wasassessed and many but not all water samples collectedprior to method use were contaminated

Households were overall successful in using the varioustechniques to treat water On the second visit mostdrinking water tested clean indicating householderssuccess at using the method This was true for allmethods but the CS filter which actually showed a slightincrease in contamination rates It is assumed but notproven that water still testing positive for coliform and e-coli after treatment was from secondary contaminationalthough researchers have no evidence that water wasever effectively treated

Respondents across all districts noted the following charac-teristics of water that was ldquogood and fit to drinkrdquobull Clearbull Free of turbidity visible dirt andor sand and to a

lesser extentbull Free of bugs and insectsbull Absent of (objectionable) smellbull Cool water was also a highly desired attribute though

not necessarily tied to water that was ldquofitrdquo to drink

Virtually no one expressed any sense of ldquomicrobialrdquo orbacterial contamination (not the words per se rather theconcept of matter in the water that might cause illness)when considering the need to treat water Likewise fewattributed diseases in general or diarrhea in particular tounfit water rather most attributed diarrhea to ldquostalerdquofood While some significant number responded thatdrinking clean water could help to avoid diarrhea thiswas not a predominant concept for most participants

The respondents were not able to comment and givetheir opinion on the attributes of drinking water easilyespecially concerning the waterrsquos appearance and textureThe researchers had to probe with specific words andnote respondent opinions after respondents were givendescriptions such as slippery and oily texture

Households were overall successful in

using the various techniques to treat water

On the second visit most drinking water

tested clean indicating householdersrsquo

success at using the method

Photo UNICEFNepal

3

RESEARCH BRIEF

After baseline measure when researchersexplained that the method left with them (and onthe final visit when all methods were explained)would remove bacteria and invisible disease-causing matter in the water participants appearedto grasp this concept of lsquocontaminationrsquo andvalued the benefit of making the water ldquohealthierrdquofor their family They repeated this benefitthroughout the interviews both at second andthird visits

Demonstration prior to assigning the method wasenough to learn to use the assigned methodadequately and for the most part proper use wasmaintained over the one-month study periodMost respondents anticipated on first visit that theywould be able to use the method easily and this opinionpersisted over the month-long trial During the onemonth observation period respondents made few adap-tations or modifications of the treatment methodsdespite the study design which invited problem-solvingand method adjustment to increase desirability and easeof method use This lack of barriers to use perceiveddifficulties or dislikes of methods was actually asurprising finding as researchers had anticipated greaterresistance to incorporating a routine of treating waterThe few modifications made or observed are outlined inthe last section of the summary

Without considering the cost of purchase or use themost popular method across all districts was the CS filterfor its ease of use followed by chlorinating water Theother two methods SODIS and to a lesser extent boilingwere satisfactory to consumers Serious concerns arosehowever about the efficacy of the CS filter based on the level of contaminated water after treatment with the CS

filter Questions remain about the efficacy of the CS filterand it will be important to determine whether problemsare with the filter systems themselves or with secondarycontamination associated with improper filter maintenance

Most common dislikes of the methods included thewarm temperature rendered by boiling SODIS and to amuch lesser degree perceived to be from chlorinationSome respondents found the smell of chlorination to beproblematic although no one discontinued use becauseof the smell Interestingly smell rather than taste of chlo-rination was more commonly mentioned as disagreeableSmell was mentioned to a lesser extent with other methodsOther barriers included the receptacle size or rather thelimited amount of water that could be disinfected at onetime and the time needed to disinfect another ldquobatchrdquoThis was true for all methods except for SODIS wherehouseholds were given an adequate number of bottles todisinfect the householdrsquos water supply The portability ofthe SODIS bottles was a perceived benefit of thistreatment method

1 In Panchthar researchers were unable to return to most homes within 30 days due to the security situation As a result chlorine users had run out oftheir 30-day supply and therefore technically ldquodiscontinuedrdquo use though for no reason other than lack of supply and unavailability of product in thecommercial market

4

RESEARCH BRIEF

While participants had little previous practice storingwater and particularly storing water or ldquoletting it sitrdquoovernight little resistance was encountered in storingSODIS or the CS filter treated water

All respondents said that they had shared their one-month method use experience with their neighbors andwere overall quite positive about the new watertreatment methods introduced to themDiscontinuation of treatment method was almost exclu-sively attributable to method malfunction or running outof supply Method malfunction was observed more in thecases of SODIS (weather conditions) and the CS filter(broken filter candle or candle nut)

While most study participants continued their methoduse over the entire trial period1 anecdotal evidencesuggests that they did not exclusively consume disinfectedwater over the study period rather supplemented thetreated water with their lsquoregularrsquo water Certainly withthe exception of solar disinfected water which is disin-fected in its own portable container no participantscarried treated water to drink outside the home

Researchers noted a lack of a second vessel for treatingand storing water as an obstacle to easy treatment withall methods other than the CS filter Lack of furniture orobjects to lift the CS filter from the ground to access thetap was an initial obstacle that was easily resolved byhouseholders (often with researcher assistance) by raisingthe filter on a platform of bricks or similar material

Other findingsbull Respondents perceived SODIS (solar disinfection) as a

relatively easy water disinfection method but did notparticularly ldquolikerdquo it as it depended on sun andcouldnrsquot be used in all weather conditions Manyreported general lack of availability of bottles thatcould present a barrier to method use The researchteam also reported unavailability of bottles at studylocations Even among the respondents using bottlesfor drinking water was not a common practice Manyrespondents using SODIS were eager to try adifferent water treatment method preferably a

method that could be used throughout the year andnot be dependent on sunshine No respondentexpressed any reservations about drinking water thathad stayed overnight or of the perceived effec-tiveness of ldquosolarrdquo disinfection even on a cloudy day

bull Respondents liked the ease and convenience of theCS filter and their reported commitment tocontinued filter use was high The CS filter was themethod most preferred among all the others across arange of attributes It was also the least preferredwith reference to the filterrsquos affordability During thestudy period however participants found the filtersthemselves to be delicate and a number experiencedproblems with the candles All households thatstopped using the CS filters had done so becausetheir filters no longer functioned Problems includedldquosheddingrdquo clay from chips in the candles colorldquobleedingrdquo into the upper filtration bucket leakingtaps and broken connector screw knob or candleField workers observed inconsistent quality and flowrate of candles Lastly water from three-fourths of allfilters tested positive for contamination All filterswere confirmed functional before being given torespondents so we can assume high rates were dueto either fatal damage occurring somewhere aftertesting or secondary contamination due to someunidentified reason These product issues are ofconcern and must be resolved before this methodcan be widely promoted

bull Most mothers using chlorination accepted the methodwell They reported the method to be easy to useHowever most respondents reported the smell ofthe disinfected water to be not good

Using bottles for drinking water was not

a common practice Many reported

general lack of availability of bottlesmdasha

potential barrier to method use

5

RESEARCH BRIEF

bull Most respondents said they are willing and able to payfor the method at its market price Across the rangeof water attributes chlorination was the second mostpreferred treatment method after the CS filterHowever the respondents were more comfortablewith the price of chlorination to that of the CS filter

bull Most respondents reported boiling to be an easyprocess to disinfect water It was however the leastpreferred water treatment method Boiled water wassaid to be warm and not pleasant to consume partic-ularly during the hot summer months It was found tobe unappealing to family members The respondentsdid not comment on the reduced time required forboiling water in this ldquonewrdquo recommended boilingtechnique which instructed that water was disinfectedat the sight of the first big bubble This is mostprobably attributable to the fact the householdersadhered to the previous recommendation of bringingwater to a hard boil for 3-10 minutes

Among the BioSand filter current and past users the flowrate seemed to be a concern for all and all were wellaware of the filterrsquos benefits but the effort and thepatience needed to collect water was cited as the majorreasons as to why some of them discontinued use

CONSIDERATIONS AND DISCUSSIONIncorporating consumer perception and practice intohousehold water treatment strategies is vital to creatingeffective and sustainable programs

The practice of water treatment is a complex behaviorProducts and supplies must be available householdersmust believe that drinking water may have negativehealth effects and they must be motivated and possessthe skills to practice the treatment consistently andcorrectly

Water treatment practice can be broken into thefollowing sub-behaviorsbull Obtain waterbull Separate drinking (and cooking) waterbull Placestore in a clean vessel

bull Choose a methodobtain that methodbull Treat correctlybull Protect (cover store and use water without

recontaminating)bull Drink this water always at home (at work and

in school)

Households must be able to perform each behaviorconsistently and correctly to realize individual and publichealth impact As highlighted in the research findingseach sub-behavior carries its own set of barriers andchallenges that must be few enough to assure the entireset of behaviors are practiced The Nepal HouseholdWater Treatment Marketing Strategy being informed bythis research must address the following barriers topromote water treatment uptake at scale

AAnnyy ssttrraatteeggyy mmuusstt ffiirrsstt aaddddrreessss ppeerrcceeppttiioonn ooff rriisskk aass ppaarrttooff aa bbeehhaavviioorr cchhaannggee ssttrraatteeggyy Since respondents voicedlittle concern about any microbial or bacterial contami-nation a marketing strategy would have to heightenhousehold awareness that cool clear water can still causediarrhea

TThhee uuppttaakkee ooff hhoouusseehhoolldd wwaatteerr ttrreeaattmmeenntt wwiillll ddeeppeenndduuppoonn mmeetthhooddss mmeeeettiinngg hhoouusseehhoolldd ppeerrcceeppttiioonnss ooff wwaatteerr tthhaatt iiss ccoonnssiiddeerreedd ffiitt ttoo ddrriinnkk Any treatment productmust be able to produce water that people consider fit

Photo Voiles Sans Frontiegraveres Suisse

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

3

RESEARCH BRIEF

After baseline measure when researchersexplained that the method left with them (and onthe final visit when all methods were explained)would remove bacteria and invisible disease-causing matter in the water participants appearedto grasp this concept of lsquocontaminationrsquo andvalued the benefit of making the water ldquohealthierrdquofor their family They repeated this benefitthroughout the interviews both at second andthird visits

Demonstration prior to assigning the method wasenough to learn to use the assigned methodadequately and for the most part proper use wasmaintained over the one-month study periodMost respondents anticipated on first visit that theywould be able to use the method easily and this opinionpersisted over the month-long trial During the onemonth observation period respondents made few adap-tations or modifications of the treatment methodsdespite the study design which invited problem-solvingand method adjustment to increase desirability and easeof method use This lack of barriers to use perceiveddifficulties or dislikes of methods was actually asurprising finding as researchers had anticipated greaterresistance to incorporating a routine of treating waterThe few modifications made or observed are outlined inthe last section of the summary

Without considering the cost of purchase or use themost popular method across all districts was the CS filterfor its ease of use followed by chlorinating water Theother two methods SODIS and to a lesser extent boilingwere satisfactory to consumers Serious concerns arosehowever about the efficacy of the CS filter based on the level of contaminated water after treatment with the CS

filter Questions remain about the efficacy of the CS filterand it will be important to determine whether problemsare with the filter systems themselves or with secondarycontamination associated with improper filter maintenance

Most common dislikes of the methods included thewarm temperature rendered by boiling SODIS and to amuch lesser degree perceived to be from chlorinationSome respondents found the smell of chlorination to beproblematic although no one discontinued use becauseof the smell Interestingly smell rather than taste of chlo-rination was more commonly mentioned as disagreeableSmell was mentioned to a lesser extent with other methodsOther barriers included the receptacle size or rather thelimited amount of water that could be disinfected at onetime and the time needed to disinfect another ldquobatchrdquoThis was true for all methods except for SODIS wherehouseholds were given an adequate number of bottles todisinfect the householdrsquos water supply The portability ofthe SODIS bottles was a perceived benefit of thistreatment method

1 In Panchthar researchers were unable to return to most homes within 30 days due to the security situation As a result chlorine users had run out oftheir 30-day supply and therefore technically ldquodiscontinuedrdquo use though for no reason other than lack of supply and unavailability of product in thecommercial market

4

RESEARCH BRIEF

While participants had little previous practice storingwater and particularly storing water or ldquoletting it sitrdquoovernight little resistance was encountered in storingSODIS or the CS filter treated water

All respondents said that they had shared their one-month method use experience with their neighbors andwere overall quite positive about the new watertreatment methods introduced to themDiscontinuation of treatment method was almost exclu-sively attributable to method malfunction or running outof supply Method malfunction was observed more in thecases of SODIS (weather conditions) and the CS filter(broken filter candle or candle nut)

While most study participants continued their methoduse over the entire trial period1 anecdotal evidencesuggests that they did not exclusively consume disinfectedwater over the study period rather supplemented thetreated water with their lsquoregularrsquo water Certainly withthe exception of solar disinfected water which is disin-fected in its own portable container no participantscarried treated water to drink outside the home

Researchers noted a lack of a second vessel for treatingand storing water as an obstacle to easy treatment withall methods other than the CS filter Lack of furniture orobjects to lift the CS filter from the ground to access thetap was an initial obstacle that was easily resolved byhouseholders (often with researcher assistance) by raisingthe filter on a platform of bricks or similar material

Other findingsbull Respondents perceived SODIS (solar disinfection) as a

relatively easy water disinfection method but did notparticularly ldquolikerdquo it as it depended on sun andcouldnrsquot be used in all weather conditions Manyreported general lack of availability of bottles thatcould present a barrier to method use The researchteam also reported unavailability of bottles at studylocations Even among the respondents using bottlesfor drinking water was not a common practice Manyrespondents using SODIS were eager to try adifferent water treatment method preferably a

method that could be used throughout the year andnot be dependent on sunshine No respondentexpressed any reservations about drinking water thathad stayed overnight or of the perceived effec-tiveness of ldquosolarrdquo disinfection even on a cloudy day

bull Respondents liked the ease and convenience of theCS filter and their reported commitment tocontinued filter use was high The CS filter was themethod most preferred among all the others across arange of attributes It was also the least preferredwith reference to the filterrsquos affordability During thestudy period however participants found the filtersthemselves to be delicate and a number experiencedproblems with the candles All households thatstopped using the CS filters had done so becausetheir filters no longer functioned Problems includedldquosheddingrdquo clay from chips in the candles colorldquobleedingrdquo into the upper filtration bucket leakingtaps and broken connector screw knob or candleField workers observed inconsistent quality and flowrate of candles Lastly water from three-fourths of allfilters tested positive for contamination All filterswere confirmed functional before being given torespondents so we can assume high rates were dueto either fatal damage occurring somewhere aftertesting or secondary contamination due to someunidentified reason These product issues are ofconcern and must be resolved before this methodcan be widely promoted

bull Most mothers using chlorination accepted the methodwell They reported the method to be easy to useHowever most respondents reported the smell ofthe disinfected water to be not good

Using bottles for drinking water was not

a common practice Many reported

general lack of availability of bottlesmdasha

potential barrier to method use

5

RESEARCH BRIEF

bull Most respondents said they are willing and able to payfor the method at its market price Across the rangeof water attributes chlorination was the second mostpreferred treatment method after the CS filterHowever the respondents were more comfortablewith the price of chlorination to that of the CS filter

bull Most respondents reported boiling to be an easyprocess to disinfect water It was however the leastpreferred water treatment method Boiled water wassaid to be warm and not pleasant to consume partic-ularly during the hot summer months It was found tobe unappealing to family members The respondentsdid not comment on the reduced time required forboiling water in this ldquonewrdquo recommended boilingtechnique which instructed that water was disinfectedat the sight of the first big bubble This is mostprobably attributable to the fact the householdersadhered to the previous recommendation of bringingwater to a hard boil for 3-10 minutes

Among the BioSand filter current and past users the flowrate seemed to be a concern for all and all were wellaware of the filterrsquos benefits but the effort and thepatience needed to collect water was cited as the majorreasons as to why some of them discontinued use

CONSIDERATIONS AND DISCUSSIONIncorporating consumer perception and practice intohousehold water treatment strategies is vital to creatingeffective and sustainable programs

The practice of water treatment is a complex behaviorProducts and supplies must be available householdersmust believe that drinking water may have negativehealth effects and they must be motivated and possessthe skills to practice the treatment consistently andcorrectly

Water treatment practice can be broken into thefollowing sub-behaviorsbull Obtain waterbull Separate drinking (and cooking) waterbull Placestore in a clean vessel

bull Choose a methodobtain that methodbull Treat correctlybull Protect (cover store and use water without

recontaminating)bull Drink this water always at home (at work and

in school)

Households must be able to perform each behaviorconsistently and correctly to realize individual and publichealth impact As highlighted in the research findingseach sub-behavior carries its own set of barriers andchallenges that must be few enough to assure the entireset of behaviors are practiced The Nepal HouseholdWater Treatment Marketing Strategy being informed bythis research must address the following barriers topromote water treatment uptake at scale

AAnnyy ssttrraatteeggyy mmuusstt ffiirrsstt aaddddrreessss ppeerrcceeppttiioonn ooff rriisskk aass ppaarrttooff aa bbeehhaavviioorr cchhaannggee ssttrraatteeggyy Since respondents voicedlittle concern about any microbial or bacterial contami-nation a marketing strategy would have to heightenhousehold awareness that cool clear water can still causediarrhea

TThhee uuppttaakkee ooff hhoouusseehhoolldd wwaatteerr ttrreeaattmmeenntt wwiillll ddeeppeenndduuppoonn mmeetthhooddss mmeeeettiinngg hhoouusseehhoolldd ppeerrcceeppttiioonnss ooff wwaatteerr tthhaatt iiss ccoonnssiiddeerreedd ffiitt ttoo ddrriinnkk Any treatment productmust be able to produce water that people consider fit

Photo Voiles Sans Frontiegraveres Suisse

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

4

RESEARCH BRIEF

While participants had little previous practice storingwater and particularly storing water or ldquoletting it sitrdquoovernight little resistance was encountered in storingSODIS or the CS filter treated water

All respondents said that they had shared their one-month method use experience with their neighbors andwere overall quite positive about the new watertreatment methods introduced to themDiscontinuation of treatment method was almost exclu-sively attributable to method malfunction or running outof supply Method malfunction was observed more in thecases of SODIS (weather conditions) and the CS filter(broken filter candle or candle nut)

While most study participants continued their methoduse over the entire trial period1 anecdotal evidencesuggests that they did not exclusively consume disinfectedwater over the study period rather supplemented thetreated water with their lsquoregularrsquo water Certainly withthe exception of solar disinfected water which is disin-fected in its own portable container no participantscarried treated water to drink outside the home

Researchers noted a lack of a second vessel for treatingand storing water as an obstacle to easy treatment withall methods other than the CS filter Lack of furniture orobjects to lift the CS filter from the ground to access thetap was an initial obstacle that was easily resolved byhouseholders (often with researcher assistance) by raisingthe filter on a platform of bricks or similar material

Other findingsbull Respondents perceived SODIS (solar disinfection) as a

relatively easy water disinfection method but did notparticularly ldquolikerdquo it as it depended on sun andcouldnrsquot be used in all weather conditions Manyreported general lack of availability of bottles thatcould present a barrier to method use The researchteam also reported unavailability of bottles at studylocations Even among the respondents using bottlesfor drinking water was not a common practice Manyrespondents using SODIS were eager to try adifferent water treatment method preferably a

method that could be used throughout the year andnot be dependent on sunshine No respondentexpressed any reservations about drinking water thathad stayed overnight or of the perceived effec-tiveness of ldquosolarrdquo disinfection even on a cloudy day

bull Respondents liked the ease and convenience of theCS filter and their reported commitment tocontinued filter use was high The CS filter was themethod most preferred among all the others across arange of attributes It was also the least preferredwith reference to the filterrsquos affordability During thestudy period however participants found the filtersthemselves to be delicate and a number experiencedproblems with the candles All households thatstopped using the CS filters had done so becausetheir filters no longer functioned Problems includedldquosheddingrdquo clay from chips in the candles colorldquobleedingrdquo into the upper filtration bucket leakingtaps and broken connector screw knob or candleField workers observed inconsistent quality and flowrate of candles Lastly water from three-fourths of allfilters tested positive for contamination All filterswere confirmed functional before being given torespondents so we can assume high rates were dueto either fatal damage occurring somewhere aftertesting or secondary contamination due to someunidentified reason These product issues are ofconcern and must be resolved before this methodcan be widely promoted

bull Most mothers using chlorination accepted the methodwell They reported the method to be easy to useHowever most respondents reported the smell ofthe disinfected water to be not good

Using bottles for drinking water was not

a common practice Many reported

general lack of availability of bottlesmdasha

potential barrier to method use

5

RESEARCH BRIEF

bull Most respondents said they are willing and able to payfor the method at its market price Across the rangeof water attributes chlorination was the second mostpreferred treatment method after the CS filterHowever the respondents were more comfortablewith the price of chlorination to that of the CS filter

bull Most respondents reported boiling to be an easyprocess to disinfect water It was however the leastpreferred water treatment method Boiled water wassaid to be warm and not pleasant to consume partic-ularly during the hot summer months It was found tobe unappealing to family members The respondentsdid not comment on the reduced time required forboiling water in this ldquonewrdquo recommended boilingtechnique which instructed that water was disinfectedat the sight of the first big bubble This is mostprobably attributable to the fact the householdersadhered to the previous recommendation of bringingwater to a hard boil for 3-10 minutes

Among the BioSand filter current and past users the flowrate seemed to be a concern for all and all were wellaware of the filterrsquos benefits but the effort and thepatience needed to collect water was cited as the majorreasons as to why some of them discontinued use

CONSIDERATIONS AND DISCUSSIONIncorporating consumer perception and practice intohousehold water treatment strategies is vital to creatingeffective and sustainable programs

The practice of water treatment is a complex behaviorProducts and supplies must be available householdersmust believe that drinking water may have negativehealth effects and they must be motivated and possessthe skills to practice the treatment consistently andcorrectly

Water treatment practice can be broken into thefollowing sub-behaviorsbull Obtain waterbull Separate drinking (and cooking) waterbull Placestore in a clean vessel

bull Choose a methodobtain that methodbull Treat correctlybull Protect (cover store and use water without

recontaminating)bull Drink this water always at home (at work and

in school)

Households must be able to perform each behaviorconsistently and correctly to realize individual and publichealth impact As highlighted in the research findingseach sub-behavior carries its own set of barriers andchallenges that must be few enough to assure the entireset of behaviors are practiced The Nepal HouseholdWater Treatment Marketing Strategy being informed bythis research must address the following barriers topromote water treatment uptake at scale

AAnnyy ssttrraatteeggyy mmuusstt ffiirrsstt aaddddrreessss ppeerrcceeppttiioonn ooff rriisskk aass ppaarrttooff aa bbeehhaavviioorr cchhaannggee ssttrraatteeggyy Since respondents voicedlittle concern about any microbial or bacterial contami-nation a marketing strategy would have to heightenhousehold awareness that cool clear water can still causediarrhea

TThhee uuppttaakkee ooff hhoouusseehhoolldd wwaatteerr ttrreeaattmmeenntt wwiillll ddeeppeenndduuppoonn mmeetthhooddss mmeeeettiinngg hhoouusseehhoolldd ppeerrcceeppttiioonnss ooff wwaatteerr tthhaatt iiss ccoonnssiiddeerreedd ffiitt ttoo ddrriinnkk Any treatment productmust be able to produce water that people consider fit

Photo Voiles Sans Frontiegraveres Suisse

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

5

RESEARCH BRIEF

bull Most respondents said they are willing and able to payfor the method at its market price Across the rangeof water attributes chlorination was the second mostpreferred treatment method after the CS filterHowever the respondents were more comfortablewith the price of chlorination to that of the CS filter

bull Most respondents reported boiling to be an easyprocess to disinfect water It was however the leastpreferred water treatment method Boiled water wassaid to be warm and not pleasant to consume partic-ularly during the hot summer months It was found tobe unappealing to family members The respondentsdid not comment on the reduced time required forboiling water in this ldquonewrdquo recommended boilingtechnique which instructed that water was disinfectedat the sight of the first big bubble This is mostprobably attributable to the fact the householdersadhered to the previous recommendation of bringingwater to a hard boil for 3-10 minutes

Among the BioSand filter current and past users the flowrate seemed to be a concern for all and all were wellaware of the filterrsquos benefits but the effort and thepatience needed to collect water was cited as the majorreasons as to why some of them discontinued use

CONSIDERATIONS AND DISCUSSIONIncorporating consumer perception and practice intohousehold water treatment strategies is vital to creatingeffective and sustainable programs

The practice of water treatment is a complex behaviorProducts and supplies must be available householdersmust believe that drinking water may have negativehealth effects and they must be motivated and possessthe skills to practice the treatment consistently andcorrectly

Water treatment practice can be broken into thefollowing sub-behaviorsbull Obtain waterbull Separate drinking (and cooking) waterbull Placestore in a clean vessel

bull Choose a methodobtain that methodbull Treat correctlybull Protect (cover store and use water without

recontaminating)bull Drink this water always at home (at work and

in school)

Households must be able to perform each behaviorconsistently and correctly to realize individual and publichealth impact As highlighted in the research findingseach sub-behavior carries its own set of barriers andchallenges that must be few enough to assure the entireset of behaviors are practiced The Nepal HouseholdWater Treatment Marketing Strategy being informed bythis research must address the following barriers topromote water treatment uptake at scale

AAnnyy ssttrraatteeggyy mmuusstt ffiirrsstt aaddddrreessss ppeerrcceeppttiioonn ooff rriisskk aass ppaarrttooff aa bbeehhaavviioorr cchhaannggee ssttrraatteeggyy Since respondents voicedlittle concern about any microbial or bacterial contami-nation a marketing strategy would have to heightenhousehold awareness that cool clear water can still causediarrhea

TThhee uuppttaakkee ooff hhoouusseehhoolldd wwaatteerr ttrreeaattmmeenntt wwiillll ddeeppeenndduuppoonn mmeetthhooddss mmeeeettiinngg hhoouusseehhoolldd ppeerrcceeppttiioonnss ooff wwaatteerr tthhaatt iiss ccoonnssiiddeerreedd ffiitt ttoo ddrriinnkk Any treatment productmust be able to produce water that people consider fit

Photo Voiles Sans Frontiegraveres Suisse

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

6

to drink Findings from this study revealed that anytreated water will have to be clear not turbid and nothave an offensive odor Cool water was also highlyvalued

DDrriinnkkiinngg aanndd ccooookkiinngg wwaatteerr aarree nnoott ccuurrrreennttllyy sseeppaarraatteeddffrroomm ootthheerr hhoouusseehhoolldd wwaatteerr A household watertreatment marketing or promotion strategy will need tofocus on increasing the availability of additional waterstorage containers to convince consumers to separatedrinking and cooking water from other water Increasedaccess to plastic PET bottles may be required soconsumers will use solar disinfection If drinking andcooking water are not separated households would needto treat up to 150 liters of water a day about 10 timesthe amount used for drinking This signifies 10 times thecost and 10 times the effort creating a tremendousbarrier to treating water

The lack of an additional vessel creates a number ofcritical challenges and invites the question of whichrecommendation is appropriate for the marketingstrategy bull treat all water requiring exponential time andor

product to treat water also used for cleaning washingand cooking

bull separate and treat water used just for drinking (andcooking) requiring that drinking water is separatedfrom other waters when currently a separate orspare container for drinking water may not be readilyavailable

bull treat drinking water consumed in the home withseparate containers as above but also have an articulated strategy for drinking treated water outside of the household compound (in the fields at school etc)

HHeellpp eennttiirree hhoouusseehhoolldd ddrriinnkk ttrreeaatteedd wwaatteerr aallll tthhee ttiimmee Itbecame quite clear that while most households wereactively engaging in water treatment when promptedfew treated water all the time This was related to anumber of factors including lack of an extra waterstorage container in the household to treat enough waterfor continuous use and lack of a portable vessel to carrywhen outside the home Also related was a perceivedlack of time to treat enough water for household use(see discussion below on receptacle size)

It is unclear whether householders felt the nneeeedd toconsume disinfected water all the time which relates to alack of perception of poor water quality While childrenand elders were named as benefiting most from goodwater differential consumption by age or gender was notobserved

AAddddrreessssiinngg iissssuueess ooff aacccceessss Because participants hadlittle overall resistance to treating water (though few sawa need for it other than simple cloth filtration to reduceturbidity) household water treatment promotion shouldseek to assure working products that are available andaffordable This meansbull assuring the eeffffiiccaaccyy of all methods (particularly the

CS filter) and bull assuring eeaassyy aacccceessss of product through dispersed

distribution systems and schemes that assure price isnot an insurmountable barrier to use This refers inparticular to the CS filter that for the average Nepalifamily requires a sizable initial outlay of cash Financeand credit schemes have been used successfully toallow for installment payments on filters No methodaside from boiling is currently available in rural Nepal

RESEARCH BRIEF

Photo UNICEFNepal

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

RESEARCH BRIEF

although promoters of both hypochlorite productsassure stepped up distribution in project interventionareas In other settings the cost of chlorination hasbeen carefully studied to so poor and rural peoplecan purchase it The private sector in other countieshas assisted with distributing empty PET bottles inrural areas for solar disinfection

CChhaannggiinngg pprroodduucctt ttoo mmeeeett ccoonnssuummeerr nneeeedd Study partici-pants commented on the slow flow rate of filters and thesmall size of the filter storage unit and the boiling kettleThus to ensure sustained uptake of these treatmentmethods products may need to be redesigned to meetthese consumer needs

Some anticipated barriers most notably a prohibition on drinking water stored overnight were not mentioned by householders as disadvantages of certain watertreatment methods most notably SODIS and possiblythe filters

TThhee iimmppoorrttaannccee ooff aann iinntteerrppeerrssoonnaall ccoommmmuunniiccaattiioonnccoommppoonneenntt Most respondents accurately described toresearchers the steps involved in each method both at 3and 30 days Most reported talking to family and

neighbors about their method This implies that treatment is conceptually easy to grasp and that respon-dents retained detailed explanations even over a one month period One can speculate that the intensive inter-personal component of the research helped to anchorsomewhat detailed instructions in the minds of house-holders and therefore any demand creation andpromotion should include an interpersonal component

CONCLUSIONUnderstanding the consumer or household viewpoint iscritical to the uptake of household water treatment andstorage methods To reduce diarrheal disease from watercontamination and to achieve household and publichealth impact water treatment methods must be effica-cious in inactivating pathogens that cause diarrhea Butthey must also be feasible and affordable to house-holders and practiced consistently and correctlyResearch findings such as these provide critical input todeveloping a water treatment marketing strategy as isbeing done currently in Nepal

Full research findings study instruments and the NepalMarketing Strategy can be found on the HIP websitewwwhipwatsannet

7

Fieldwork and analysis conducted by Solutions Inc under challenging circumstances for the Hygiene Improvement Project(HIP) under contract GHS-I-00-04-00024-00 HIP is led by the Academy for Educational Development partnering withARD Inc the Manoff Group Inc and the International Water and Sanitation Centre (IRC) based in the Netherlands HIPrsquosresource partners are Aga Khan Foundation Hindustan Lever and the International Rescue Committee

For more information please contact Hygiene Improvement ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington DC 20009USAwwwaedorgwwwhipwatsannet

The authorrsquos views expressed in this publication do not necessarily reflect the view of the United States Agency forInternational Development or the United States Government

US Agency for International DevelopmentRonald Reagan Building

Washington DC 20523-1000