Themes / Topics Drinking Water
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Water Utilities & Intermittent Drinking Water Supply in China

Led by our colleague, Dr. Hongxing Li at the China CDC, this project focused on the management and use of drinking water supply in areas where utilities provide piped drinking water, but for a variety of reasons it is not provided continuously (i.e., piped connections are not supplied with treated drinking water 24 hours a day, 7 days a week). This situation – that of intermittent water supply (IWS) – is relatively widespread in many low- and middle-income countries, as well as in parts of China. This research project, conducted in two Chinese provinces (Shandong and Hubei), assessed and compared management and consumer adaptation strategies, as well as drinking water quality, storage practices, and behaviors and beliefs associated with IWS, with comparison to similar communities living under conditions of continuous water supply (CWS). Water samples (from taps and rooftop storage units) and survey data were collected from 400 households across four villages (2 IWS, 2 CWS) in the two provinces. One of the main reasons the utilities in these regions provided water intermittently was to reduce the electricity costs associated with water supply pumps. Indicators of microbiological contamination were higher in samples from the IWS villages compared with the CWS villages, and we observed higher rates of bottled water use in the IWS villages compared with the CWS villages. As a result of this work, we were able to offer evidence-based recommendations utilities could adopt to reduce water-and-health related risks associated with IWS or transition to CWS.

Bottled Water Safety & Use in Low- & Middle-Income Countries

In the course of our work studying drinking water access, contamination, and treatment in rural areas, we have observed relatively high rates of bottled water use. The reasons for increasing bottled water use in rural areas of low- and middle-income countries are varied, but available data indicates that some of the primary reasons are related to perceptions that bottled water is convenient and safer than available drinking water sources. Results from some of our research studies suggest, however, that bottled water may not always be safe. To better understand increasing use of and reliance on bottled water in LMICs we studied available market data which shows that more than half of the top-ten bottled water consuming countries globally are LMICs, and that bottled water use in LMICs is growing rapidly. With respect to global environmental health this trend is problematic in a number of respects, and, we argue, this increasing reliance on bottled water will likely hamper efforts to provide safe and affordable drinking water for all – one of the key objectives of the UN Sustainable Development Goals. As part of this work, we wish to better understand the nature and extent of bottled water contamination; however, there is relatively little publicly available data on bottled water quality, in LMICs or in high-income countries. To complement one of the only systematic review studies examining bottled water use and safety in LMICs, we conducted a comprehensive systematic review and meta-analysis of publicly available research studies on bottled water quality and associated health outcomes in China. After reviewing 7,000+ Chinese-language records, we extracted and analyzed data from 200+ eligible articles; we published our findings from this research in early 2022.

Boiled or Bottled: Regional and Seasonal Exposures to Drinking Water Contamination and Household Air Pollution in Rural China

Abstract/Summary: We assessed the regional and seasonal prevalence of HWT practices (including bottled water use) in low-income rural areas in two Chinese provinces, evaluated the microbiological safety of drinking water and associated health outcomes, and estimated the air pollution burden associated with the use of solid fuels for boiling. Methods: We conducted cross-sectional surveys and collected drinking water samples from 1,033 rural households in Guangxi and Henan provinces. Temperature sensors affixed to pots and electric kettles were used to corroborate self-reported boiling frequencies and durations, which were used to model household air pollution (HAP) in terms of estimated particulate matter 2.5μm in aerodynamic diameter (PM2.5) concentrations. Results: Based on summer data collection in both provinces, after controlling for covariates, boiling with electric kettles was associated with the largest log reduction in thermotolerant coliforms (TTCs) (0.66log10 TTC most probable number/100mL), followed by boiling with pots (0.58), and bottled water use (0.39); all were statistically significant (p<0.001). Boiling with electric kettles was associated with a reduced risk of TTC contamination [risk ratio (RR)=0.25p<0.001] and reported diarrhea (RR=0.80p=0.672). TTCs were detected in 51% (n=136) of bottled water samples. For households boiling with biomass, modeled PM2.5 concentrations averaged 79μg/m3 (standard deviation=21). Discussion: Our findings suggest that where boiling is already common and electricity access is widespread, the promotion of electricity-based boiling may represent a pragmatic stop-gap means of expanding safe water access until centralized, or decentralized, treated drinking water is available; displacing biomass use for water boiling could also reduce HAP concentrations and exposures. Our results also highlight the risks of increasing bottled water use in rural areas, and its potential to displace other sources of safe drinking water, which could in turn hamper efforts in China and other LMICs toward universal and affordable safe water access.

InnoWat: IFAD & rural water investments

IFAD is currently engaged in over 230 loan operations in 85 countries. About two thirds of that portfolio is related to community-based natural resource management. Poor rural people and their institutions are at the core of this approach. Water is critical to these men and women pastoralists, fishers, farmers, young and old, part- or full-time, urban or rural, indigenous, tribal or otherwise often marginalized people. Itis the key entry point for improving their livelihoods. Water-related interventions are often linked to the building up or restoring of the asset base – and involve many facets and uses. This holistic view is part of the characterization of IFAD’s approach to water interventions in this fact sheet: rather than considering water solely as an input factor in the production chain, we have preferred to follow water throughout rural people’s livelihoods. This approach, combined with a qualitative analysis of the ongoing 2007/08 loan portfolio, yielded a few surprising insights (table 1).Almost half of all projects (45-50 per cent) involve aspects of water resource management at catchment or watershed levels, and hence beyond the immediate household or community level of use.

Developing a Thematic Indicator for Rural Poverty Assessment (MPAT)

The Multidimensional Poverty Assessment Project was a collaborative, international initiative to develop, test, and pilot a new tool for local-level rural poverty assessment. The work was supported by IFAD and guided by a Sounding Board of experts from IFAD, other United Nations agencies, international and regional organizations, and universities around the world, with the majority of its members coming from the Asia region where we developed and tested the tool in China and India. Surveys (household and village level) were developed and tested in an iterative and participatory fashion, as was the indicator structure used to aggregate sub-components and components. The resulting Multidimensional Poverty Assessment Tool (MPAT) provides an assessment, an overview, of ten dimensions central to rural livelihoods, highlighting where additional support or interventions are likely to be most needed. The tool was designed to be universal enough to be relevant to most rural contexts around the world, yet specific enough to provide project managers and others a detailed overview of key dimensions relevant to rural poverty reduction efforts. MPAT was independently evaluated by the European Commission Joint Research Center and a working-paper version of MPAT User’s Guide was released in 2009 as well as the 2009 MPAT Book, which provides a detailed description of why and how the tool was developed. MPAT’s theoretical foundations are described in a 2010 article in Development and Practice.

Electric Kettle Promotion Program in Rural China (RCT)

Results from our previous research in rural China suggests that increasing the use of electric kettles for boiling (i.e., treating) drinking water in low-income areas of rural China could help expand access to safer drinking water, reduce household air pollution, and improve environmental and health outcomes in rural Chinese households currently boiling drinking water with solid-fuels (or not treating their water, or drinking contaminated bottled water). Our study was designed (and pre-registered on Chinese Clinical Trials Register & to evaluate the impact of a pilot Rural Electric Kettle Promotion Program offered to low-income households in rural Anhui Province, China. Specifically, we used a parallel arm cohort cluster-randomized controlled (RCT) trial design with a 1:1 ratio to randomize 30 villages (i.e., clusters) to treatment or control using stratified randomization by geography and by cluster proportions of reported electric kettle use at baseline (900 households total).

[Notes: We pre-specified and pre-registered our statistical analysis plan, but data cleaning and analysis were significantly delayed due to the COVID19 pandemic; we anticipate publishing primary findings starting in 2024]

Water & poverty in rural China: Developing an instrument to assess the multiple dimensions of water & poverty

Abstract/Summary: This paper describes the theoretical foundations and development of a multidimensional, water-focused, thematic indicator of rural poverty: The Water, Economy, Investment and Learning Assessment Indicator (WEILAI). The WEILAI approach was specifically designed for application in rural China, to support poverty alleviation project planning, monitoring and evaluation, as well as targeting and prioritization. WEILAI builds primarily on the basic needs framework of poverty alleviation, and on the methodological structure of the Water Poverty Index, to provide a proxy measure of an area’s poverty by assessing eight key poverty sectors, with a strong focus on the components of water-poverty. The WEILAI approach was piloted and implemented in 534 households in China’s mountainous southwest. This paper describes the indicator construction, weighting schemes, methodology, field sites, and statistical validation of the results. In addition, we discuss the results, feedback from in-country project staff, and the likely utility of the tool for project planning, monitoring and evaluation support. The paper concludes with a discussion of WEILAI’s overall utility and ongoing development.

Microbiological evaluation of household drinking water treatment in rural China shows benefits of electric kettles: A cross-sectional study

Abstract: Background – In rural China ~607 million people drink boiled water, yet little is known about prevailing household water treatment (HWT) methods or their effectiveness. Boiling, the most common HWT method globally, is microbiologically effective, but household air pollution (HAP) from burning solid fuels causes cardiovascular and respiratory disease, and black carbon emissions exacerbate climate change. Boiled water is also easily re-contaminated. Our study was designed to identify the HWT methods used in rural China and to evaluate their effectiveness. Methods – We used a geographically stratified cross-sectional design in rural Guangxi Province to collect survey data from 450 households in the summer of 2013. Household drinking water samples were collected and assayed for Thermotolerant Coliforms (TTC), and physicochemical analyses were conducted for village drinking water sources. In the winter of 2013–2104, we surveyed 120 additional households and used remote sensors to corroborate selfreported boiling data. Findings – Our HWT prevalence estimates were: 27.1% boiling with electric kettles, 20.3% boiling with pots, 34.4% purchasing bottled water, and 18.2% drinking untreated water (for these analyses we treated bottled water as a HWT method). Households using electric kettles had the lowest concentrations of TTC (73% lower than households drinking untreated water). Multilevel mixed-effects regression analyses showed that electric kettles were associated with the largest Log10TTC reduction (-0.60, p<0.001), followed by bottled water (-0.45, p<0.001) and pots (-0.44, p<0.01). Compared to households drinking untreated water, electric kettle users also had the lowest risk of having TTC detected in their drinking water (risk ratio, RR = 0.49, 0.34–0.70, p<0.001), followed by bottled water users (RR = 0.70, 0.53–0.93, p<0.05) and households boiling with pots (RR = 0.74, 0.54–1.02, p = 0.06). Conclusion: As far as we are aware, this is the first HWT-focused study in China, and the first to quantify the comparative advantage of boiling with electric kettles over pots. Our results suggest that electric kettles could be used to rapidly expand safe drinking water access and reduce HAP exposure in rural China.

Predictors of drinking water boiling & bottled water consumption in rural China: A hierarchical modeling approach

Abstract/Summary: Approximately two billion people drink unsafe water. Boiling is the most commonly used household water treatment (HWT) method globally and in China. HWT can make water safer, but sustained adoption is rare and bottled water consumption is growing. To successfully promote HWT, an understanding of associated socioeconomic factors is critical. We collected survey data and water samples from 450 rural households in Guangxi Province, China. Covariates were grouped into blocks to hierarchically construct modified Poisson models and estimate risk ratios (RR) associated with boiling methods, bottled water, and untreated water. Female-headed households were most likely to boil (RR = 1.36, p < 0.01), and among boilers those using electric kettles rather than pots had higher income proxies (e.g., per capita TV ownership RR = 1.42, p < 0.01). Higher-income households with younger, literate, and male heads were more likely to purchase (frequently contaminated) bottled water, or use electric kettles if they boiled. Our findings show that boiling is not an undifferentiated practice, but one with different methods of varying effectiveness, environmental impact, and adoption across socioeconomic strata. Our results can inform programs to promote safer and more efficient boiling using electric kettles, and suggest that if rural China’s economy continues to grow then bottled water use will increase.

Effects of boiling drinking water on diarrhea & pathogen-specific infections in low- & middle-income countries: A systematic review & meta-analysis

Abstract/Summary: Globally, approximately 2 billion people lack microbiologically safe drinking water. Boiling is the most prevalent household water treatment method, yet evidence of its health impact is limited. To conduct this systematic review, we searched four online databases with no limitations on language or publication date. Studies were eligible if health outcomes were measured for participants who reported consuming boiled and untreated water. We used reported and calculated odds ratios (ORs) and random-effects meta-analysis to estimate pathogen-specific and pooled effects by organism group and nonspecific diarrhea. Heterogeneity and publication bias were assessed using I2, meta-regression, and funnel plots; study quality was also assessed. Of the 1,998 records identified, 27 met inclusion criteria and reported extractable data. We found evidence of a significant protective effect of boiling for Vibrio cholerae infections (OR = 0.31, 95% confidence interval [CI] = 0.13–0.79, N = 4 studies), Blastocystis (OR = 0.35, 95% CI = 0.17–0.69, N = 3), protozoal infections overall (pooled OR = 0.61, 95% CI = 0.43–0.86, N = 11), viral infections overall (pooled OR = 0.83, 95% CI =0.7–0.98, N = 4), and nonspecific diarrheal outcomes (OR = 0.58, 95% CI = 0.45–0.77, N = 7). We found no evidence of a protective effect for helminthic infections. Although our study was limited by the use of self-reported boiling and non-experimental designs, the evidence suggests that boiling provides measurable health benefits for pathogens whose transmission routes are primarily water based. Consequently, we believe a randomized controlled trial of boiling adherence and health outcomes is needed.