Household point-of-use (POU) water treatment technologies targeted at vulnerable populations are microbiologically effective and, in small trials, improve health. We do not understand the factors that influence preference for and adoption of these technologies by target end-users. We cycled 400 rural subsistence farm households in western Kenya through three randomly ordered two-month trials of three POU products: dilute hypochlorite solution, porous ceramic filtration, and a combined flocculant-disinfectant powdered mixture to compare relative end-user preferences and usage. Households reported higher usage of both dilute hypochlorite and filters than the flocculant-disinfectant. Averaged among all participating households, Escherichia coli reductions in treated water were generally higher among those that received dilute hypochlorite solution than among those receiving either of the other two products. Among those households that self-reported product usage, the E. coli reductions achieved by dilute hypochlorite and the flocculant-disinfectant are statistically equivalent to one another and higher than the reductions achieved by filters. At the same time, households ranked filters most frequently as their most preferred product.

BackgroundThere is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why.MethodsWe gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water's contamination with E. coli (compared to 200 control households).FindingsHouseholds reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls.ConclusionTraditional arguments for the low adoption of POU products focus on affordability, consumers' lack of information about germs and the dangers of unsafe water, and specific products not meshing with a household's preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users, household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.

Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.

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