Water, sanitation and hygiene-related diseases are responsible for 7% of all deaths and 8% of all disability adjusted live years (DALYs), as well as the loss of 320 million days of productivity in developing countries. Though laboratory and field trials have shown that household water treatment (HWT) technologies can quickly improve the microbiological quality of drinking water, questions remain about the effectiveness of these technologies under real-world conditions. Furthermore, the value that rural communities attach to HWT is unknown, and it is not clear why, in spite of the fact that rural African households need household water treatment (HWT) most, they are the least likely to use them. The primary objective of this multi-level study was to assess the post-implementation effectiveness of selected HWT technologies in the Nyanza and Western Provinces of Kenya. The study was carried out in the rainy season between March and May, 2011 using a mixed method approach. Evidence was collected in order to build a case of evidence of HWT effectiveness or ineffectiveness in a post-implementation context. A quasi-experimental design was used first to conduct a Knowledge, Attitudes and Practices (KAP) survey in 474 households in ten intervention and five control villages (Chapter 3). The survey assessed the context in which household water treatment was being used in the study villages to provide real-world information for assessing the effectiveness of the technologies. An interviewer-administered questionnaire elicited information about the water, sanitation and hygiene-related KAP of the study communities. A household water treatment (HWT) survey (Chapter 4) was carried out in the same study households and villages as the KAP study, using a semi-structured questionnaire to gather HWT adoption, compliance and sustained use-related information to provide insight into the perceived value the study households attach to HWT technologies, and their likelihood of adoption of and compliance with these technologies. The drinking water quality of 171 (one quarter of those surveyed during KAP) randomly selected households was determined and tracked from source to the point of use (Chapter 5). This provided insights into HWT effectiveness by highlighting the need for HWT (as indicated by source water quality) and the effect of the study households’ KAP on drinking water quality (as indicated by the stored water quality). Physico-chemical and microbiological water quality of the nineteen improved and unimproved sources used by the study households was determined, according to the World Health Organisation guidelines. The microbiological quality of 291 water samples in six intervention and five control villages was determined from source to the point-of-use (POU) using the WHO and Sphere Drinking Water Quality Guidelines. An observational study design was then used to assess the post-implementation effectiveness of the technologies used in 37 households in five intervention villages (Chapter 6). Three assessments were carried out to determine the changes in the microbiological quality of 107 drinking water samples before treatment (from collection container) and after treatment (from storage container) by the households. The criteria used to assess the performance of the technologies were microbial efficacy, robustness and performance in relation to sector standards. A Quantitative Microbial Risk Assessment (QMRA) was then carried out in the HWT effectiveness study households to assess the technologies’ ability to reduce the users’ exposure to and probability of infection with water-borne pathogens (Chapter 7). The KAP survey showed that the intervention and control communities did not differ significantly in 18 out of 20 socio-economic variables that could potentially be influenced by the structured manner of introducing HWT into the intervention villages. The majority of the intervention group (IG) and the control group (CG) were poor or very poor on the basis of household assets they owned. The predominant level of education for almost two-thirds of the IG and CG respondents was primary school (completed and non-completed). Though very few were unemployed in IG (8.07%) and CG (14.29%), the two groups of respondents were predominantly engaged in subsistence farming — a low income occupation. With regard to practices, both groups had inadequate access to water and sanitation with only one in two of the households in both IG and CG using improved water sources as their main drinking water source in the non-rainy season. One in ten households in both study groups possessed an improved sanitation facility, though the CG was significantly more likely to practice open defecation than the IG. The self-reported use of soap in both study groups was mainly for bathing and not for handwashing after faecal contact with adult or child faeces. Despite the study groups' knowledge about diarrhoea, both groups showed a disconnection between their knowledge about routes of contamination and barriers to contamination. The most frequent reason for not treating water was the perceived safety of rain water in both the IG and CG.
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