Abstract
Objectives. We qualitatively assessed beliefs, attitudes, and behaviors related to diarrhea and water filtration in rural Kenya.
Methods. A public health campaign was conducted in rural western Kenya to give community members a comprehensive prevention package of goods and services, including a personal water filter or a household water filter (or both). Two months after the campaign, we conducted qualitative interviews with 34 campaign attendees to assess their beliefs, attitudes, and behaviors related to diarrhea and use of the filtration devices.
Results. Participants held generally correct perceptions of diarrhea causation. Participants provided positive reports of their experiences with using filters and of their success with obtaining clean water, reducing disease, and reducing consumption of resources otherwise needed to produce clean water. Several participants offered technical suggestions for device improvements, and most participants were still using the devices at the time of the assessment.
Conclusions. Novel water filtration devices distributed as part of a comprehensive public health campaign rapidly proved acceptable to community members and were consistent with community practices and beliefs.
People in much of the world lack sufficient household and personal access to safe drinking water, especially in sub-Saharan Africa.1 Goal 7 of the Millennium Development Goals (MDGs) of the United Nations calls for the proportion of people without sustainable access to safe drinking water and basic sanitation to be cut in half by 2015.2 This goal is of particular relevance to public health because of the associations among water quality, sanitation, and diarrhea, which is one of the leading causes of death globally, especially among children.3–7
Diarrhea incidence is directly related to consumption of contaminated water,6,8 and improvements in access to water lead to improvements in health status.9 The population of sub-Saharan Africa is sorely lacking in access to clean water, with only 58% of the population having access.2 Sub-Saharan Africa also lags in sanitation improvements; by 2006, only 31% of the population had access to improved sanitation (defined as facilities that ensure hygienic separation of human excreta from human contact),10 a proportion that was only halfway to the MDG.
Several factors contribute to the lack of water sanitation in developing countries. First, large-scale water treatment is expensive and requires infrastructure capabilities that are often absent in low-resource settings.11 Second, household-level interventions promoting water sanitation have obtained mixed results12 and are often cumbersome to implement and sustain.13,14 Third, it is difficult to motivate people to change their behaviors related to water access and consumption.8
Over the past decade, several household-level and personal-level interventions and strategies have been developed to promote family access to safe water.9,15–18 Among these are 2 point-of-use water filtration devices with demonstrated effectiveness and usability: the LifeStraw personal water filter, a portable device, and LifeStraw Family, a larger filter that can serve an entire household.19–21 Access to safe water at the individual and household levels is particularly important for people with HIV/AIDS, who often require more clean water for consumption or hygiene.22 Point-of-use water filtration has been demonstrated to be feasible in low-resource regions in Africa.23,24 Accordingly, these 2 point-of-use water filter devices were recently distributed in a rural Kenyan community as part of an integrated bundle of commodities and services aimed at rapidly improving the region's capacity to meet water- and health-related MDGs. After the devices were distributed, we conducted a qualitative assessment that examined community members’ attitudes toward diarrhea and their experiences with the distributed devices.
METHODS
The water filters were distributed as part of an Integrated Prevention Campaign that took place over 1 week in Lurambi Division of Kakamega District, Western Province, Kenya, in September 2008. Diarrhea prevalence in this region of Kenya is significant, with nearly 1 in 5 children younger than 5 years experiencing diarrhea within the previous 2 weeks.25 Diarrhea is also a consistently significant symptom among preschool children in the area.26 Nearly 47 000 people participated in the Integrated Prevention Campaign; those who did received an integrated bundle of services and commodities aimed at rapidly expanding protection from key diseases targeted by the MDGs.27 These services and commodities included a water filter, voluntary counseling and testing for HIV, condoms, long-lasting insecticide-treated nets, cotrimoxazole prophylaxis for those with HIV, and health education and advice.
The 2 filters distributed were the LifeStraw and the LifeStraw Family. LifeStraw is a portable device worn around the neck or carried by hand that functions as a straw when inserted into a container of water, providing immediate filtration of contaminants. The LifeStraw Family filter is a larger-capacity device, intended for mounting on a wall or ceiling, that filters water in larger batches and enables storage of filtered water. The personal device was distributed mainly to men, who often work or travel away from home in this region of Kenya. The family device was distributed to women, who are the primary providers of food and water in most households in the region.
The Vestergaard Frandsen company (the manufacturer of the 2 water-filter devices) developed the campaign, adapting past campaign approaches. A team of local, national, and global public- and private-sector partners, including the Kenya Ministry of Health and the Kenya Medical Research Institute, implemented the campaign. As campaign participants left the product distribution point, they were told that we would be conducting in-depth qualitative interviews with participants to evaluate their understanding of diarrhea and its causes and to assess their experiences with the filters. If campaign participants consented to participate in the study, they were registered for inclusion, and their contact information was taken.
We conducted the qualitative interviews 2 months after the campaign. At the start of the interview, we informed participants of the study's purpose, reassured them of confidentiality, and obtained their written consent to be interviewed. Local interviewers conducted the interviews, which lasted an average of almost 1.5 hours. The interviews were audiotaped, transcribed, and translated from Kiswahili (82% of the interviews) or local languages (9%) into English (the remainder of the interviews were in English and needed no translation).
Two experienced social scientists coded the text sections and analyzed them using NVivo 8 (QSR International, Cambridge, MA). We developed code lists both from study objectives and from the data. We then selected specific codes related to the topics of interest and text-examined them for recurring themes and to find illustrative quotes to elaborate on specific findings from the analysis.28
RESULTS
We conducted a total of 34 interviews. Approximately half of the participants were female, with an average age of 38 years. Most participants were farmers with some secondary school education.
Perceptions of Causes of Diarrhea
When asked what they thought the causes of diarrhea were, most participants responded by discussing several interrelated concepts involving water, food, hygiene, and environment (Table 1).
TABLE 1.
Perceived Causes of Diarrhea and Precampaign Actions Taken to Prevent Diarrhea for Participants (n = 34): Integrated Prevention Campaign, Kenya, 2008
| No. (%) | |
| Perceived causes of diarrhea | |
| Dirty or bad water | 27 (79) |
| Dirty or bad food | 23 (68) |
| Dirt (general) | 8 (24) |
| Not washing hands | 7 (21) |
| No toilet | 6 (18) |
| Flies | 4 (12) |
| Specific foods | 4 (12) |
| Dirty utensils | 3 (9) |
| Germs | 3 (9) |
| Other diseases | 3 (9) |
| Precampaign actions taken to prevent diarrhea | |
| Boiled water | 15 (44) |
| Did nothing | 8 (24) |
| Kept environment clean | 5 (15) |
| Treated water | 5 (15) |
| Personal cleanliness | 4 (12) |
| Covered food and water | 4 (12) |
| Cleaned toilet | 3 (9) |
| Washed hands | 3 (9) |
Food and water.
Participants most frequently said that factors involving consumption of water and food were the most common causes of diarrhea. Overall, as shown in Table 1, most participants said that “dirty,” “bad,” or otherwise contaminated water caused diarrhea. After contaminated water, dirty or spoiled food was the next most frequently named cause of diarrhea:
If you eat dirty food [or] you don't wash your hands when you want to eat, you must diarrhea [participants used the word for “diarrhea” as both a verb and a noun].
Causes of diarrhea are mostly taking unclean food, or food that is not well-cooked, and dirty water.
Food can lead to diarrhea when it is not covered, because you do not know what something from outside will bring to it. Such food can bring disease. If you buy food that food was dirty and cook it, that food can bring disease.
I know that dirt brings diarrhea. This occurs when utensils are not clean and yet someone uses them to eat. Also when one eats without having washed hands. You can also diarrhea when you eat dirty food. Some people diarrhea when they eat food brought from the night before.
Participants also sometimes implicated the consumption of raw or poorly cooked foods as a cause of diarrhea. Several participants also cited consumption of certain foods, such as guava and sweet potatoes, as a cause of diarrhea:
When I eat maize and beans, the stomach starts grumbling; then I start to diarrhea.
Something I can eat and diarrhea is sweet potatoes. If I eat food, and in particular sweet potatoes, I diarrhea very much. Again, if I mix beef and chicken soup, I diarrhea. For kales, I have to eat them when they are still fresh. If I use what is not fresh, I diarrhea. And if I mix with beef and chicken soup, I suffer.
Hygiene.
Secondary to food- and water-related factors, participants noted that hygiene-related factors also caused diarrhea. For example, several participants mentioned that not washing hands (particularly among children) or not having a proper toilet can lead to diarrhea:
[W]hen a homestead lacks a toilet and people help themselves anywhere, the flies that move around the dirt will carry germs, and people get diarrhea.
[I]f you don't cut your nails it can contribute, because you can go somewhere or you scratch yourself and you touch things and then you swallow or the children drink dirty water. This causes diarrhea.
[I]f children are dirty and they eat food when they have not washed their hands, maybe they have gone for a long call and they have not washed their hands; if they eat like that it will cause diarrhea.
[I]f you use a dirty toilet, you must be infected with diarrhea.
In addition to dirty hands and toilet facilities, several participants also said flies and germs could cause diarrhea:
It comes when someone has gone to the open bush to answer nature's call. Germs from such an area can get carried by wind. If someone breathes them in, diarrhea is caused.
I know that diarrhea is caused by drinking dirty water. I also know that diarrhea can be by eating dirty food [or] unclean environments in which there are feces everywhere from which flies come to settle on food.
I know diarrhea is brought by flies. If they settle on food I eat, so that causes diarrhea. Also if the latrine is dirty, the dirty flies cause diarrhea.
Traditional and biomedical causes of diarrhea.
Few participants mentioned a cause of diarrhea unrelated to food and water consumption or hygiene. Only 1 participant, for instance, named a more traditional cause of diarrhea:
The moon is on, and that she is growing milk teeth, and that some people have put her bad things on the stomach.
Biomedically speaking, 1 participant noted that AIDS caused diarrhea, and 2 other participants said that malaria caused diarrhea:
It is also brought about by the AIDS virus.
I think malaria can cause diarrhea. If you are not well treated, malaria can get into the stomach and cause diarrhea.
Sometimes you might find that you are developing malaria and that malaria can cause diarrhea.
Past Diarrhea Prevention Efforts
We asked participants whether they had ever taken any actions to prevent diarrhea before the Integrated Prevention Campaign was conducted. One quarter of the participants indicated they had never taken any special measures to prevent diarrhea before:
At times boiling is hard, and I can't lie to you, I don't boil. So we just take the water, believing it's clean. We never used to boil. In that pump, we don't put chlorine, but there's a time when we remove all the pipes and clean it and then we put it back together and continue using the water.
The most commonly reported previous actions relating to household prevention of diarrhea concerned the handling of food and water. Participants indicated that they had boiled their household's water to prevent diarrhea, which some also mentioned as a cumbersome process, or that they had let the water settle:
[What] I did to avoid diarrhea is boiling water, but it reaches a point, because we live in a local area, we decide to stop; but we are still compliant and we continue boiling. If we get sick, we seek the treatment from the doctor, though we have not had problems of diarrhea so much.
I and my family fetched water from the river and stored it in pots. The water was then left to settle over time before drinking it.
Now we used to fetch water, then leave it to settle. Then we decant it into another clean container; then we use it for drink.
Participants also mentioned treating their water chemically to prevent diarrhea, and several mentioned covering food and water to keep out flies and dirt. Three participants mentioned washing their food before cooking and consuming it, and 1 participant mentioned filtering her family's water through a cloth.
Participants noted that keeping their environment (house and surroundings) clean helped prevent diarrheal diseases, and 3 participants mentioned specifically using clean toilet facilities:
We used to keep the environment clean; we have a clean toilet. We also use clean water, and we have been boiling water for the children. Even if you go to the hospital they tell you to boil water for them.
Several participants mentioned maintaining personal cleanliness and the importance of washing their hands to prevent diarrhea:
We were using clean utensils, wearing shoes when going to the latrine, and washing hands. To eat food, it is a must that you wash it before you eat.
I used to make sure that when I am around, children don't play in dirt, so I check their fingernails and hands to make sure they are clean. Most of the dirt stays in the fingernails and then goes to the food.
If you go out, you wash your hands with soap there, because you might get anything, like germs have entered into your nails; and if you wash your hands, if you get into the house and touch utensils, you will not have spread the germs of diarrhea anywhere.
Attitudes and Practices Related to Water Filtering
Water filters were well received by respondents and were generally used to create clean water:
When I got it [household water filter], I was so happy and started filtering the water immediately.
Yes, it has a very big benefit, because, according to what I was told, this filter prevents me from drinking dirty water. So even if I get water that I trust to be good water, this filter helps remove all the bacteria, and I get clean water. It therefore has a big benefit.
Yes, the use of the LifeStraw is of great benefit to me because it's portable, and you can go with it anywhere, like in the market, at the funerals, anywhere. It's portable, it's good, I love it.
Table 2 presents the filter procurement experiences of campaign attendees participating in this evaluation. Overall, 85% of participants received either the personal water filter or the household water filter; 24 participants received a personal filter, and 12 participants received a household filter. As shown in Table 3, 24 out of the 29 participants (83%) who received filters were still using their filters 2 months after the campaign. Participants described several filter usage scenarios:
I even used it at night and put it back in the cupboard because dirt gets inside if I leave it up; there is a lot of dirt here… . I use it in the evening. I put in water and it filters; then I put the clean water into a pot; then it chills. It stays for two days. Then I filter water again [participant was a household filter user].
When I go on a trip and I get to a place where the water doesn't belong to me, I walk with it [the personal water filter]. If I want to drink water they give me, then I use the filter to pull the water and drink the water. It has two sides with covers, so I remove the covers, I put it in water, and I pull the water to drink. I use it at home when I am late to do the filtering of water for the whole family [personal filter user].
Yes, I usually take water, then I pour it, and the red one removes the dirty water, then the clear one removes clean water for drinking… . I use it like this time [morning]; then I put the water in a pot for use later. The one for my husband, he walks with it during daytime [both personal and household filter user].
I was given a personal water filter. I place it in a glass of water before I start drinking the water. It is helping me because I am a farmer and sometimes I rent a farm far away. I use that water filter to drink even water from a river if I am far from home. I drink this water without any fear. My family members do not use my personal water filter. My wife was given a family water filter. Hers is big, while mine is small. For the family water filter, my wife knows how it operates. If my water filter is far, my wife gives me water she has filtered [both personal and household filter user].
I have the water filter I was given. I can even show it to you. I go to the farm to plant my vegetables; I go with my personal water filter. When my wife brings me water at the farm, I use the water filter. It is clean water from it. I believe in it… . It is good water. These people really helped us [both personal and household filter user].
TABLE 2.
Types of Water Filter Received for Participants (n = 34): Integrated Prevention Campaign, Kenya, 2008
| Types of Filter Received | No. (%) |
| None | 5 (15) |
| Personal filter only | 17 (50) |
| Household filter only | 5 (15) |
| Both filters | 7 (21) |
| Received at least personal filter | 24 (71) |
| Received at least household filter | 12 (35) |
| Received any kind of filter | 29 (85) |
TABLE 3.
Water Filter Usage Characteristics for Participants (n = 34): Integrated Prevention Campaign, Kenya, 2008
| Filter Usage Characteristics | No. (%) |
| Received a filter (either personal or household) | 29 (85) |
| Was still using filter at assessmenta | 24 (83) |
| No longer using personal filterb | 4 (17) |
| No longer using household filterc | 1 (8) |
| Named an advantage of filter usea | 27 (93) |
| Named a disadvantage of filter usea | 7 (24) |
| Advantages of filter usea | |
| Now have access to clean water | 19 (66) |
| No diarrhea/stomach problems now | 12 (41) |
| Convenient | 4 (14) |
| Saves money or other resources | 4 (14) |
| Disadvantages of filter usea | |
| Slow water flow | 5 (17) |
| Sometimes breaks/needs fixing | 2 (7) |
Among those receiving filters (n = 29).
Among those receiving personal filters (n = 24).
Among those receiving household filters (n = 12).
The 5 participants who were no longer using the filters they were given cited a variety of reasons for discontinuing usage, including perceived inconvenience, operational difficulties, or difficulties adapting to filter use:
I used it until it reached a time when it stopped working. I used it for 1 month only. My child was playing with it, and it got spoiled. I used to put it in a tin of water; then I pull through [demonstrates how to pull water through the straw]. I used to use it so much during supper because I don't take water so much during the day [personal filter user].
I used it the first days that I got it, but what is difficult about it is that the pulling of the water is quite difficult. Someone may be very thirsty, and the time you take to pull the water before you take is too long [laughs]. So we were wondering what kind of filters you brought us that are out to finish our strength. I left it completely. I used to get water in a cup or plastic container; then I open it and start pulling the water directly into my stomach. I used to use it when I was thirsty. I used it for two days [personal filter user].
No. It's not working. It just gives us bad water. The water filter gives dirty water. It's not working [household filter user].
I don't use it so much now because I take water from my father's house where I eat from, and water is filtered using the family filter. I have kept my filter in my father's house. If I need to go somewhere, I carry it along because it is a personal filter [personal filter user].
Participants most commonly noted that the filters allowed them to have access to clean water, and 12 respondents (35%) indicated that they or their families no longer experienced stomach problems or diarrhea:
I don't have enough firewood to keep boiling water, and it gets a certain smell when it stays in the pot for three to four days. It also prevents one from taking dirty water. We do not have water from pumps, and we have been depending on boiled water.
There are good benefits. First of all, if you drink that water, you feel the water is heavy refreshing, like the water has been treated with medicine. Then when it comes out, and comparing to the one you thought was clean, this is cleaner… . So it has helped me.
I have noted some benefits because when using the water filter, I enjoy because I know I am drinking clean water.
I personally used to drink water, and I used to suffer in my stomach. But from the time I was given the water filter I do not experience stomach problems any more. Because I used to boil water or put in Watergard in order to drink. Since that time I am used to this water filter.
Children no longer diarrhea as a result of dirty water. One happily drinks such water because it is clean.
Water from that filter looks much cleaner than what you get from the river. Before I used to get stomachache always, but since I started using the water which has been filtered I don't have any more stomachache. So I don't know if it's another disease that was cropping up from the water or what. Now I can see a difference. Then this child was diarrhea. The way we were drinking water without filtering, he was diarrhea. Now that I am giving him water that is filtered, he has stopped diarrhea.
Several participants also indicated that the filters enabled them or their families to save money because they no longer needed to use fuel for boiling, pay medical expenses associated with diarrheal illnesses, or bear other costs:
I have noted some benefits from the water filter. We no longer have diarrhea as we used to. Previously I was forced to buy water for my child, who is at college. As a result of the health campaign, I no longer buy water.
The benefit is that I don't have to buy Watergard after I was given the water filter. I don't have stomach pains
Yes, the water you get is clean. Also, it has reduced the cumbersome nature of boiling water to purify, and it has reduced the cost of using fuel to boil the water.
The most commonly noted disadvantage of using the filters included difficulties in sucking water through the personal filter, or, less commonly, broken parts. One participant noted that the filter was complicated, and another complained of stomach problems with filter use when first using it:
It is not bad, but you need to have time to filter the water. You have to not be in a hurry because it filters little by little. You just need time to do it. For the personal one, when you pull water you have to use a little more strength [both personal and household filter user].
There is a chemical that has been put inside. The first time you drink the water, you feel like it is sour. It does not taste like the normal water I take, so I thought maybe it is the chemical used in the filter that is bringing that taste; the water that is drawn from the river is different in taste from the water in the container drawn by the filter. The taste is always on the first gulp taken any time I drink the water up to now [personal filter user].
There is some difficulty in using the personal water filter. However, overall it gives me clean water. The difficulty has to do with sucking in water. The family filter sometimes fails to function. The red knob that pushes pressure up usually fails. That is why I said earlier that we need an expert who can repair in case it fails so that we can get clean water. However, it is functioning [both personal and household filter user].
The only disadvantage is when you are sucking water, you get so tired in the jaws [personal filter user].
None, apart from carrying it everywhere you go [personal filter user].
Typically, however, participants were appreciative of the water filters, and most did not list a disadvantage of any kind:
I have never seen any disadvantage, but I have always seen the advantage [personal filter user].
I do not experience any difficulty when using my personal water filter. I find it quite okay [personal filter user].
I have tried to inquire from my wife, and she tells me that she has not encountered any difficulty. I have also not seen any disadvantage of using the water filter [both personal and household filter user].
There is no disadvantage I have seen [personal filter user].
There is nothing bad about it [both personal and household filter user].
Finally, participants were thankful for the water filters, and they encouraged expansion of the program and continued distribution of filters:
Yes, it is of very big benefit. In fact, I would encourage that more of these filters be given to other people in the country, not only in this area here. There are other people who move from place to place and do not always have clean permanent water to drink. At least this could help the government in controlling and treating diarrhea cases and things like cholera. It would really help.
I am grateful to our government because they took pity on us, because they saw that our needs were addressed and we now have water filters.
I do not have any disadvantage of using the water filter. I feel that the government is helping us.
DISCUSSION
Access to clean water is critical to global health improvement, especially in sub-Saharan Africa. Large-scale interventions require an infrastructure that is not commonly found in low-resource regions, perhaps necessitating a more personal, household solution for the provision of clean water while physical infrastructure grows. Point-of-use water filtration devices for households and individuals provide an opportunity to access clean water for consumption in low-resource settings. Such devices have demonstrated their effectiveness in reducing pathogen load and diarrhea incidence.15–19,21,29,30 In fact, filtration may offer the most effective household water treatment.15
The qualitative interviews we conducted with people who participated in the Integrated Prevention Campaign showed that attendees found the filtration devices included with the campaign's services and commodities to be acceptable and useful. The assessments also showed that common community notions concerning diarrhea causation and its correlates were quite accurate and were thus consistent with the type of intervention these novel devices offer, as other research in Kenya has found.31 The essential accuracy of the community's conceptions of diarrhea should enhance the probability that households and individuals will implement technologies to prevent the disease.
That said, this study is limited in scope because of its small sample size and its qualitative methodology, which was intended more to identify narratives of personal experience with filters and beliefs around water and diarrhea than to quantify relationships. This assessment occurred in 2008; since then, usage patterns may have shifted. Further surveys of sufficient power to identify sustained usage and variation in patterning are necessary to provide the full breadth of water-related information from the region.
Assessment participants commonly implicated dirty (or contaminated) water as the leading cause of diarrhea, followed by spoiled food and dirt. Participants also noted that hygiene—hand washing, food washing, and keeping the environment clean—was another important correlate of preventing diarrhea. Traditional (and biomedical) conditions were rarely mentioned, perhaps indicating that previous educational efforts stressing water and the environment as diarrhea risks have proven effective in this community. This kind of educational effectiveness was not demonstrated with regard to conceptions related to malaria, which were similarly assessed in this population; that study found that accurate biomedical conceptions were mixed with inaccurate conceptions.32 Further evidence of relatively accurate respondent perceptions is provided by participants’ frequent reports of boiling water before consumption, the most common method of making water safer before the current campaign.
Most campaign attendees received one or both of the water filter types, and most study participants continued to use them through the time of assessment. The devices were well accepted, as described by the advantages and benefits that participants reported, including improvements in clean water, decreases in diarrheal disease, and increased savings as a result of not having to buy firewood and chemical purifiers. Participants noted a range of filter usage environments: at home, working in the fields, traveling, and on safari.
Participants mentioned several disadvantages of using the filters. Although these were few in number, they represent important considerations for potential product improvement, which might enhance participant usage of the filters even more. Improving the flow of water in the personal straws would address the reluctance among some participants to use the straws because of the effort required to extract water orally. It might also be useful to provide a mechanism for repair of malfunctioning devices, perhaps by educating local village experts in the technologies. Some studies have shown that filter usage can decline over time,19,30 so increasing sustainability should be a component of projects that involve point-of-use filtration.
The provision of safe drinking water for individuals and households is a crucial global health concern. The favorable reaction to these novel devices for improving consumption of safe, filtered water provides evidence that households and individuals may find these strategies acceptable and sustainable. In light of the worldwide obstacles to accessing safe water, the difficulty in achieving MDGs for safe water in Africa, and the lack of effective strategies for addressing the problems of unsafe water and diarrhea, the provision of individual and household filtration devices may be a feasible, effective solution.
Acknowledgments
The Integrated Prevention Campaign, the analysis detailed in this article, and the production of this article were funded by grants from Vestergaard-Frandsen, the company that manufactured and donated the water filters that were distributed as part of the Integrated Prevention Campaign. Other than funding, Vestergaard-Frandsen did not participate in analysis or manuscript development except to ensure accurate description of the campaign and the products distributed within it.
The authors thank the local and regional partners and communities in Kenya that participated in the Integrated Prevention Campaign.
Human Participant Protection
The institutional review board of the Kenya Medical Research Institute approved the study protocol.
References
- 1.United Nations Educational, Scientific, and Cultural Organization, World Water Assessment Programme The United Nations World Water Development Report 3: Water in a Changing World. Paris, France: United Nations Educational, Scientific, and Cultural Organization; 2009 [Google Scholar]
- 2.United Nations. The Millennium Development Goals Report 2009. New York, NY: United Nations; 2009 [Google Scholar]
- 3.Mintz ED, Reiff FM, Tauxe RV. Safe water treatment and storage in the home: a practical new strategy to prevent waterborne disease. JAMA. 1995;273(12):948–953 [PubMed] [Google Scholar]
- 4.Quick RE, Venczel LV, Mintz ED, et al. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiol Infect. 1999;122(1):83–90 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Quick RE, Kimura A, Thevos A, et al. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. Am J Trop Med Hyg. 2002;66(5):584–589 [DOI] [PubMed] [Google Scholar]
- 6.Semenza JC, Roberts L, Henderson A, Bogan J, Rubin CH. Water distribution system and diarrheal disease transmission: a case study in Uzbekistan. Am J Trop Med Hyg. 1998;59(6):941–946 [DOI] [PubMed] [Google Scholar]
- 7.United Nations Children's Fund, World Health Organization. Diarrhoea: Why Children Are Still Dying and What Can Be Done. New York, NY: United Nations Children's Fund, World Health Organization; 2009 [Google Scholar]
- 8.Cairncross S, Valdmanis V. Water supply, sanitation, and hygiene promotion. In: Jamison DT, Breman JG, Measham AR, et al., Disease Control Priorities in Developing Countries. 2nd ed Washington, DC: World Bank, Oxford University Press; 2006:771–792 [Google Scholar]
- 9.Pruss-Ustun A, Bos R, Gore F, Bartram J. Safer Water, Better Health: Costs, Benefits, and Sustainability of Interventions to Protect and Promote Health. Geneva, Switzerland: World Health Organization; 2008 [Google Scholar]
- 10.World Health Organization, United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation Progress on Drinking Water and Sanitation: Special Focus on Sanitation. Geneva, Switzerland, and New York, NY: World Health Organization, United Nations Children's Fund; 2008 [Google Scholar]
- 11.Whittington D, Hanemann WM, Sadoff C, Jeuland M. Copenhagen Consensus 2008 Challenge Paper: Sanitation and Water. Copenhagen, Denmark: Copenhagen Consensus Center; 2008 [Google Scholar]
- 12.Hunter PR. Household water treatment in developing countries: comparing different intervention types using meta-regression. Environ Sci Technol. 2009;43(23):8991–8997 [DOI] [PubMed] [Google Scholar]
- 13.Arnold B, Arana B, Mausezahl D, Hubbard A, Colford JM. Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol. 2009;38(6):1651–1661 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Schmidt WP, Cairncross S. Household water treatment in poor populations: is there enough evidence for scaling up now? Environ Sci Technol. 2009;43(4):986–992 [DOI] [PubMed] [Google Scholar]
- 15.Sobsey MD, Stauber CE, Casanova LM, Brown JM, Elliott MA. Point of use household drinking water filtration: a practical, effective solution for providing sustained access to safe drinking water in the developing world. Environ Sci Technol. 2008;42(12):4261–4267 [DOI] [PubMed] [Google Scholar]
- 16.Duke WF, Nordin RN, Baker D, Mazumder A. The use and performance of BioSand filters in the Artibonite Valley of Haiti: a field study of 107 households. Rural Remote Health. 2006;6:570. [PubMed] [Google Scholar]
- 17.Stauber CE, Ortiz GM, Loomis DP, Sobsey MD. A randomized controlled trial of the concrete biosand filter and its impact on diarrheal disease in Bonao, Dominican Republic. Am J Trop Med Hyg. 2009;80(2):286–293 [PubMed] [Google Scholar]
- 18.Du Preez M, Conroy RM, Wright JA, Moyo S, Potgieter N, Gundry SW. Use of ceramic water filtration in the prevention of diarrheal disease: a randomized controlled trial in rural South Africa and Zimbabwe. Am J Trop Med Hyg. 2008;79(5):696–701 [PubMed] [Google Scholar]
- 19.Boisson S, Schmidt WP, Berhanu T, Gezahegn H, Clasen T. Randomized controlled trial in rural Ethiopia to assess a portable water treatment device. Environ Sci Technol. 2009;43(15):5934–5939 [DOI] [PubMed] [Google Scholar]
- 20.Walters A. A Performance Evaluation of the LifeStraw: A Personal Point of Use Water Purifier for the Developing World [master's thesis] Chapel Hill: University of North Carolina; 2008 [Google Scholar]
- 21.Elsanousi S, Abdelrahman S, Elshiekh I, et al. A study of the use and impacts of LifeStraw in a settlement camp in southern Gezira, Sudan. J Water Health. 2009;7(3):478–483 [DOI] [PubMed] [Google Scholar]
- 22.Ngwenya BN, Kgathi DL. HIV/AIDS and access to water: a case study of home-based care in Ngamiland, Botswana. Phys Chem Earth. 2006;31(15–16):669–680 [Google Scholar]
- 23.Lule JR, Mermin JH, Malamba S, et al. Effect of safe water and cotrimoxazole on diarrhea among people with HIV and their family. Abstract presented at: 13th International Conference on AIDS and STIs in Africa; September 21–26, 2003; Nairobi, Kenya. Abstract 776099 [Google Scholar]
- 24.Lule JR, Mermin J, Ekwaru JP, et al. Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. Am J Trop Med Hyg. 2005;73(5):926–933 [PubMed] [Google Scholar]
- 25.Kenya National Bureau of Statistics, ICF Macro Kenya Demographic and Health Survey 2008–09. Calverton, MD: Kenya National Bureau of Statistics, ICF Macro; 2010 [Google Scholar]
- 26.Mbagaya GM, Odhiambo MO, Oniango RK. Mother's health seeking behavior during child illness in a rural western Kenya community. Afr Health Sci. 2005;5(4):322–327 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Lugada E, Millar D, Haskew J, et al. Rapid implementation of an integrated large-scale HIV counseling and testing, malaria, and diarrhea prevention campaign in rural Kenya. PLoS ONE. 2010;5(8):e12435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Ryan GW, Bernard HR. Data management and analysis methods. : Denzin NK, Lincoln YS, eds. Collecting and Interpreting Qualitative Materials. 2nd ed Thousand Oaks, CA: Sage Publications; 2003 [Google Scholar]
- 29.Brown J, Sobsey MD, Loomis D. Local drinking water filters reduce diarrheal disease in Cambodia: a randomized, controlled trial of the ceramic water purifier. Am J Trop Med Hyg. 2008;79(3):394–400 [PubMed] [Google Scholar]
- 30.Brown J, Proum S, Sobsey MD. Sustained use of a household-scale water filtration device in rural Cambodia. J Water Health. 2009;7(3):404–412 [DOI] [PubMed] [Google Scholar]
- 31.Othero DM, Orago AS, Groenewegen T, Kaseje DO, Otengah PA. Home management of diarrhea among underfives in a rural community in Kenya: household perceptions and practices. East Afr J Public Health. 2008;5(3):142–146 [DOI] [PubMed] [Google Scholar]
- 32.Dye TDV, Apondi R, Lugada E, Kahn J, Smith J, Othoro-Watta C. “Before we used to get sick all the time”: perceptions of malaria and use of long-lasting insecticide-treated bednets (LLINs) in a rural Kenyan community. Malar J. 2010;9:345. [DOI] [PMC free article] [PubMed] [Google Scholar]