1. Trial of liquid chlorine dispenser models in urban Bangladeshi households Shaila Arman Research Investigator Water and Sanitation Research Group Center for Communicable Diseases icddr,b 1 Water and Health Conference at UNC, Chapel Hill 30 October, 2012

2. Urban Bangladesh:  Municipal water most common source of drinking water  Around 60% sample found contaminated with microorganism  Drinking contaminated water leads to morbidity and mortality among <5 children 2 Background

3. Point of use water treatment technology:  Households that treat their water less frequently report diarrhea (Clasen et al., 2007)  Chlorine is a low cost home-based water treatment technology that can reduce diarrhea (Arnold and Colford, 2007)  Interventions with liquid chlorine were successful in some settings (Blanton et al. 2006; Parker et al., 2006; Quick et al., 2002; Ram et al., 2007; Stockman et al., 2007; Thevos et al., 2000) 3

4.  In some settings interventions with chlorine were not consistently used due to: -peoples satisfaction with quality of currently available drinking water, even if contaminated -practices related to storing and purifying drinking water -available technologies, where promoted, were not culturally acceptable and feasible 4

5. Objectives  To identify the best chlorine dispenser package (with or without study provided storage vessel) for use in a randomized controlled trial  To provide information for developing culturally compelling intervention, based on feedback from trial participants 5

6. Study period  October-December 2010 6 Study site  Low-income community, Dhaka  No previous water intervention Study population  40 low-income household compounds  Total 359 households Eligibility criteria  Shared water source Description of the trial Study team  Implementation team  Assessment team

7. 7 Households compound in urban Dhaka

8. 8

9.  Hardware: 4 types of chlorine dispenser model with the supply of liquid chlorine at no cost  Reason behind testing the different models: -different amounts of water needed per compound and households -different types and sizes of water storage vessels used in households - no common drinking water storage used in the compounds 9

10. Trial models for liquid chlorine dispenser Model 1 : Reservoir (one turn of the valve from dispenser to treat 15 liters)

11. Model 2: Measuring vessel (one turn of the valve to treat 5 liters)

12. Model 3 : Without measuring vessel (one turn of the valve to treat 5 liters) Model 4: Without measuring vessel (one turn of the valve to treat 2.5 liters)

13. Chlorine dispenser modelsTotal households No of compounds 1. Reservoir (15 liter dosing)8610 13 2. Measuring vessel (5 liter dosing) 9410 3. Without measuring vessel (5 liter dosing) 8710 4. Without measuring vessel (2.5 liter dosing) 9210 Total35940 Distribution of compounds and hardware

14. Implementation team  Enroll sample households  Install hardware and demonstrate use  Household visits twice a month: o Deliver messages on health and non-health benefits o Encourage and address barriers related to hardware use 14

15. Assessment team 15  Collect data on 15 th, 45 th and 60 th days  Assess use by checking residual free chlorine in stored drinking water  Qualitative interviews and household observations

16. 16 Self reported use between 15th day and 60th day

17. Comparison between self-reported use and presence of residual chlorine (0.2-2mg/l) 17 After 15 days of useAfter 60 days of use Self- reported use Chlorine found Self- reported use Chlorine found 122/35954/12284/24427/84

18. 18 Perceived benefits of use Benefits common to all models:  Improved clarity of drinking water  Save time and fuel cost compared to boiling  Keeps children safe from diseases

19. 19 Specific benefits of different models:  Reservoir o Measuring and storing treated water was easy o Less work for compound members as caretakers treated water for common use  With measuring vessel o Measuring water was easy  Without measuring vessel o No unique benefit

20. 20 Perceived barriers to use Barriers common to all models:  Smelt like bleaching powder  Temperature of stored treated water  30-minute wait time  Boilers were not interested  Reluctance of males and children to drink chlorinated water

21. 21  Reservoir o Refilling of reservoirs and maintenance o Unavailability of reservoirs for use  With measuring vessel o Unavailability of measuring vessel at certain times  Without measuring vessel o Measuring recommended amount water was difficult Specific barriers to use of different models:

22. Feedback on strategy and messages 22  Weekly visits of promoters were appreciated o helped to resolve problems related to hardware use and encourage use  Communication material was encouraging o information on contamination of supply water and possibility of getting diarrhea were encouraging

23. Household observation 23  Did not maintain correct amount of water for dosing in arm without measuring vessel  Did not cover or shake vessel after adding chlorine  Measuring vessels not always kept with dispenser to measure recommended amount of water

24. 24 Hardware was not used; kept under a bedstead

25.  Chlorine dispenser with water reservoir model had most self reported use rate  Water chlorination was less feasible in absence of standardized water storage vessel  Strong smell of chlorine and stored water temperature was threat to acceptability of water chlorination  Unavailability of reservoirs with stored treated water and measuring vessel led to decreased use Conclusions 25

26. Recommendations for RCT  Marked participants own vessel to measure correct amount of water for dosing o to minimize conflicts between the compound residents regarding the ownership of the vessel and also reduce responsibility to maintain the common hardware for use  Select caretakers of the hardware and motivate the tenants to drink chlorinated water by them also  Use reported benefits to promote sustainable water treatment behavior change interventions among both boilers and non boilers 26

27. Community members Stephen P. Luby (icddr,b) Leanne Unicomb (icddr,b) Fazlul Kader Chowdhury (icddr,b) Md. Al Mamun (icddr,b) Smriti Roy (icddr,b) Subas Chandra Biswas (icddr,b) Rouha Anamika Sarker (icddr,b) Meghan Scott(icddr,b) Elli Leontsini (John Hopkins Bloomberg School of Public Health) Peter Winch (John Hopkins Bloomberg School of Public Health) Bill and Melinda Gates Foundation For correspondence: shailaarman@icddrb.org 27 Acknowledgements