Abstract
The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination. Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers' understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.
Highlights
The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhearelated morbidity indicates the need for a better understanding of the determinants of long-term behavior change
Diarrhea remains a major cause of under-5 morbidity in children in the developing world
Those afflicted by severe childhood diarrheal illness may endure lifelong health problems including nutritional deficits, stunted growth, decreased immune function, and impaired cognitive development.[1,2]
Summary
Diarrhea remains a major cause of under-5 morbidity in children in the developing world Those afflicted by severe childhood diarrheal illness may endure lifelong health problems including nutritional deficits, stunted growth, decreased immune function, and impaired cognitive development.[1,2] In light of the financial and political challenges of establishing centralized infrastructure for water delivery and waste removal in resource-poor settings, interim intervention activities increasingly focus on individual and household behavior change for preventing transmission of diarrhea-causing pathogens among children. Numerous randomized controlled trials (RCTs) have demonstrated the efficacy of point-of-use water treatment (POUWT) on water quality and diarrheal disease prevention.[3,4,5,6,7,8] In a systematic review of 11 RCTs, POUWT was shown to reduce the risk of diarrheal illness by 39%,9 and a meta-analysis of 21 studies of chlorination demonstrated a reduced childhood diarrhea risk of 29%.10. Several POUWT methods have exhibited reductions in adherence over time,[11,12,13,14] while studies on chlorination have shown attenuation of the reduced risk of childhood diarrhea when follow-up exceeds even short periods of only 10 weeks.[10]
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