New mothers readily adopt and sustain use of a household water treatment product

In 2007 the US Centers for Disease Control and Prevention reported remarkable uptake of WaterGuard, a chlorine water treatment product, when it was introduced as part of a free hygiene kit at antenatal clinics (ANC) in Malawi. Before the project began, awareness was already high thanks to social marketing efforts by Population Services International: almost 90% of program participants and their friends and relatives had heard of WaterGuard and 59% had tried it. However, only 2% were currently using it. Nine months later, 61% of program participants were using WaterGuard, as were 25% of their friends and relatives with young children. Three years later 26% of participants and 18% of their friends and relatives were continuing to buy and use WaterGuard, and many others were treating their water with a free chlorine solution supplied by the government.

Free trial and intensive education prompt women to act

What explains the success of the Malawi ANC program in moving women along the behavior change continuum—from awareness to sustained use of WaterGuard? To answer this question PATH interviewed women who participated in the ANC program, their husbands, friends, and relatives, along with health care workers and vendors. The interviews targeted both women who were still using WaterGuard regularly, as well as others who were not.

The interviews explored four primary barriers to using WaterGuard: affordability, awareness, taste and smell, and availability. When families cannot afford water treatment products, they may switch to the free government chlorine solution or simply drink untreated water. Lack of awareness represents another barrier, both of the need to treat water and how to use the product. Additionally, some people dislike the taste and smell of chlorine products. Finally, some families may find that the product is simply unavailable when they need it.

The intervention succeeded because it addressed the initial barriers of availability and affordability. The free trial offer at ANC consultations, which included a sample of WaterGuard, a safe storage container, and up to three refills, made WaterGuard affordable and available. While this trial period let women experience firsthand how easy the product was to use and how much it could improve their family’s health, it also gave them time to get used to the taste, which over time some users came to associate with treated or safe water. At the same time, a heavy emphasis on education raised awareness at a time in women’s lives when they are especially open to messages about protecting their families from disease. Health workers taught pregnant women about the health benefits of safe water as part of their antenatal care, and outreach workers made follow-up home visits to reinforce the message. Careful instruction about how to use WaterGuard also reduced the chance of overdosing, which contributes to the strong smell and taste of chlorine.

“Making the kits available and affordable at a key point in a woman’s life contributed to initial uptake and trial.”

Social reinforcement encourages continued use of WaterGuard

Key to the program’s long-term impact was the way it leveraged interpersonal communication of all kinds—and the social support it represents—for behavior change. Health workers were a primary influence on the decision to use WaterGuard. Indeed, the more home visits women received from health workers, the more likely they were to use the product. The interviews also found that women who consistently use WaterGuard benefit from the active support and encouragement of their husbands and are more likely to have spoken with friends and relatives about treating drinking water. One woman explained, “I discuss about WaterGuard and water treatment with friends especially when we meet at places where we draw water. We discuss and remind each other to treat our water with WaterGuard as soon as we get home and there has been a positive feedback since we talked…”

Three years after the ANC program’s inception, interviewers documented fundamental changes in thinking, expectations, and social norms among women who consistently use WaterGuard. Water treatment has become part of their daily routine, and they plan ahead to ensure that they never run out of the product. Family members ask for treated water and notice when the water is not treated. Even perceptions of WaterGuard’s cost have changed, as people realize that investing in WaterGuard keeps their family healthy and saves money on medical bills. One woman summed up: “I have seen a big change in my family [since] I started using WaterGuard…my family is now happy. My children ask if the water has WaterGuard before they drink it. They will grow up with this attitude that my mum treats drinking water with WaterGuard.”

A full summary of the qualitative research findings, survey results, and a complementary cost study of the Malawi ANC program will be posted on our website within the next several months. Although PATH helped fund an assessment of the ANC project with support from the United States Agency for International Development (USAID), credit goes to the US Centers for Disease Control and Prevention (CDC), the Republic of Malawi Ministry of Health (MOH), Population Services International (PSI), and The United Nations Children’s Fund (UNICEF) for designing and implementing the highly successful project.

Photos: US Centers for Disease Control and Prevention.