Week 5 Assessing the Impact of HWTS

8/11/2019 Week 5 Assessing the Impact of HWTS

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WHO HWTS Performance Reco

WHO International Scheme to E

HWT

WHO/UNICEF International Net

HWTS

More information and links
http://www.who.int/water_sanitation_health/publications/2011/household_water/en/http://www.who.int/household_water/scheme/en/http://www.who.int/household_water/scheme/en/http://www.who.int/household_water/network/en/http://www.who.int/household_water/network/en/http://www.who.int/household_water/network/en/http://www.who.int/household_water/network/en/http://www.who.int/household_water/scheme/en/http://www.who.int/household_water/scheme/en/http://www.who.int/water_sanitation_health/publications/2011/household_water/en/


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Effective and consistent use

Introduction to Household Water Treatment and Safe Storage, Mo

Dr. Richard Johnston


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Introduction

Unsafewater

CoEffectiveOption


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768 million people usedrinking-water sources

Many improved drinkin

sources yield microbia

contaminated water

Resource contamination Collection and storage

Estimates of 1.8 billion

water that is faecally c

Unsafe water


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Effective options


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Efficacy: How well it wcontrolled conditions

Effectiveness: How we

the real world

Household chlorination 2009: No significant differen

between households with an

chlorination

2014: Faecal indicators in ar

households practicing chlori

Turbidity, raw water contamin

treatment contamination

Effective use

Sources: (McLaughlin, 2009), (Levy, 2


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Effective use, objective Residual chlorine

LRV

Consistent use, longitu Need repeat visits

Long-term use One to five years after interv

Consistent use, compl

adherence



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Effective use, objective Residual chlorine

LRV

Consistent use, longitu Need repeat visits

Long-term use One to five years after interv

Consistent use, compl

adherence


Source: Brown J, Clasen T. High Adherence Is Necessary to Realize

Health Gains from Water Quality Interventions. PLoS One. 2012.

Effi d li
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735


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Efficacy and compliance

Source: Enger KS, Nelson KL, Rose JB, Eisenberg JN. The joint effects of efficacy and compliance: a

water treatment effectiveness against childhood diarrhea. Water Research. 2013;47(3):1181-90.

E l f hi h li
http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469http://www.sciencedirect.com/science/article/pii/S0043135412008469


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Biosand filters in Camb 88% of households still usin

Self-reported + inspection of

LifeStraw Family in Za 96% consistent users, 95%

Filter observed, reservoir co

self-report

LifeStraw Family in Co 68% consistent users after 8

Nearly all reported drinking u

Examples of high compliance

E l f hi h li


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SODIS in Zimbabwe Self-reported, calculated, observed

65+% confirmed use after 26 months

If received household visits

Chlorine in Haiti 56% practicing, up to 8 years after intervention Free chlorine residual

Biosand filters in Camb 88% of households still usin

Self-reported + inspection of

LifeStraw Family in Za 96% consistent users, 95%

Filter observed, reservoir co

self-report

LifeStraw Family in Co 68% consistent users after 8

Nearly all reported drinking u

Examples of high compliance

Examples of low compliance


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Ceramic water filters in 31% in regular daily use (int

Highly dependent on time si

LifeStraw Personal in 34% reported use in last we

SODIS in Bolivia 32% compliance

Self-reported confirmed by o




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Combined treatment in Guatemala 6 months after intervention, 5% had purchased

sachets

Ultraviolet radiation in Mexico 40% exclusive use of Mesita Azul

Thermal disinfection in Bangladesh 21/101 reported use of chulli

17 reported inconsistent or wrong use

Ceramic water filters in 31% in regular daily use (int

Highly dependent on time si

LifeStraw Personal in 34% reported use in last we

SODIS in Bolivia 32% compliance

Self-reported confirmed by o


Factors impacting compliance


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Personal factors Behavior change

External factors Supply chains

Supportive policy environme

Etc

Different for different s

sub-populations

Factors impacting compliance

Diffusion of Innovations


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Five stages of innovation process Five attributes of innov

Diffusion of Innovations

Knowledge

Persuasion

Decision

Implementation

Confirmation

UptakeRelative

advantage

Compatibility

Complexity

Source: Rogers, 2003

RANAS psychological model


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Risks

PerceivedVulnerability

Perceived Severity

Factual Knowledge

Abilities

Action knowledge

Self-efficacy

Self-regulation

Actioncontrol/planning

Coping planning

Remembering

Commitment

RANAS psychological model

Source: Mosler, 2012

IBM WASH


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Three classes of facto Contextual

Psychosocial

Technology

Five levels Societal/Structural

Community Interpersonal/Household

Individual

Habitual

IBM-WASH

Source: Dreibelbis, 2

Behavior Change Reviews


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Behavior Change Reviews

Monitoring and Evaluation Toolkit
http://www.biomedcentral.com/1471-2458/13/1015http://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.biomedcentral.com/1471-2458/13/1015https://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0CEsQFjAF&url=http://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdf&ei=AFBOU4z8O46Y0QWPlIHoDg&usg=AFQjCNG0Jy3hqk431uHUmBthXozwmwYF3A&sig2=9mhlPrfIxWXq2roGlc9HPg&bvm=bv.64764171,d.d2k


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Monitoring and Evaluation Toolkit

Monitoring and Evaluation Toolkit Indicators
http://www.who.int/household_water/resources/toolkit_monitoring_evaluating/en/


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Knowledge of c

Demonstration

Demonstration extraction

Frequency of nomost vulnerable

Consistently trewater with HWT

Use of improvewater source

Correct,consistent

use and

storage


Reported andobserved use

Correct, consistentuse and storage

Knowledge andbehavior

Otherenvironmental

health interventions

Water quality



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Householdsusing HWTSto improve household dwater (effe

Householdschlorine resdrinking-wa

Waterquality


Reported andobserved use

Correct, consistentuse and storage

Knowledge andbehavior

Otherenvironmental

health interventions

Water quality

Additional Resources: Compliance


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Boisson, S. et al. (2009). "Randomized Controlled Trial in Rural Ethiopia to Assess a

Portable Water Treatment Device." Environmental Science & Technology 43(15): 5934-

5939.

Boisson, S., et al. (2010). "Field Assessment of a Novel Household-Based Water

Filtration Device: A Randomised, Placebo-Controlled Trial in the Democratic Republic of

Congo." PloS One 5(9): e12613.

Brown J, Clasen T. High Adherence Is Necessary to Realize Health Gains from Water

Quality Interventions. PLoS One. 2012.

Enger, K.et al. (2013). "The joint effects of efficacy and compliance: a study of household

water treatment effectiveness against childhood diarrhea." Water Res 47(3): 1181-1190.

Gruber, J. et al. (2013). "A Stepped Wedge, Cluster-Randomized Trial of a Household

UV-Disinfection and Safe Storage Drinking Water Intervention in Rural Baja California

Sur, Mexico." Am J Trop Med Hyg 89(2): 238-245

Gupta, S. et al. (2008). "The chulli water purifier: acceptability and effectiveness of an

innovative strategy for household water treatment in Bangladesh." American Journal of

Tropical Medicine and Hygiene 78(6): 979-984.

Harshfield, E., et al. (2012). "Evaluating the sustained health impact of household

chlorination of drinking water in rural Haiti." Am J Trop Med Hyg 87(5): 786-795.

Levy K, et al. Household effectiveness vs. laboratory effica

Water research. 2014;54:69-77.

Luby, S. et al. (2008). "Difficulties in bringing point-of-use w

Guatemala." American Journal of Tropical Medicine and H

Musezahl, D. et al. (2009). "Solar Drinking Water Disinfec

Childhood Diarrhoea in Rural Bolivia: A Cluster-Randomiz

Medicine 6(8): e1000125.

McGuigan, K. et al. (2011). "High Compliance Randomized

Disinfection of Drinking Water and Its Impact on Childhood

Environmental Science & Technology 45(18): 7862-7867.

McLaughlin L et al. An observational study on the effective

chlorination. Journal of Environmental Health. 2009;71(8):

Mosler, H.-J., et al. (2013). "Achieving long-term use of so

Zimbabwe." Public health 127(1): 92-98.

WSP (2010) Use of BioSand Filters in Cambodia.

WSP/UNICEF (2007). Use of Ceramic Water Filters in Cam

Additional Resources: Compliance

Additional Resources: Behavior change
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttp://www.unicef.org/eapro/WSP_UNICEF_FN_CWP_Final.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttps://www.wsp.org/sites/wsp.org/files/publications/WSP_biosand_cambodia.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.sciencedirect.com/science/article/pii/S0033350612003253/pdfft?md5=778bdb1716e3ce1bac1e27c3b812acbb&pid=1-s2.0-S0033350612003253-main.pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881824/http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000125http://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.bu.edu/sph/files/2012/12/Harshfield_2012_Evaluating_the_sustained_health_impact_of_household_chlorination_of_drinking_water_in_rural_Haiti.pdfhttp://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036735http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012613


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Dreibelbis R et al. The Integrated Behavioural Mode

Hygiene: a systematic review of behavioural models

designing and evaluating behaviour change interven

restricted settings. BMC public health. 2013;13:1015

Figueroa ME, Kinkaid DL. Social, Cultural and Behav

Household Water Treatment and Storage. Baltimore

School of Public Health, Center for Communication P

Mosler, H.-J., et al. (2013). A guideline for behavior c

Mosler H-J. A systematic approach to behavior chanwater and sanitation sector in developing countries:

review, and a guideline. International Journal of Env

2012;22(5):431-49.

Rogers E. The Diffusion of Innovations. 5th ed. New

Additional Resources: Behavior change

Conclusion
http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.eawag.ch/forschung/ess/gruppen/ehpsy/Behavioural_march_2013.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.jhuccp.org/sites/default/files/Household%20Water%20Treatment%20and%20Storage%202010.pdfhttp://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015http://www.biomedcentral.com/1471-2458/13/1015


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Health gains require efconsistent use (and un Perceptions

Effective use can be m

Consistent use is hard

Frameworks Behavioural change

Other factors

Promote and monitor a

Conclusion


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Health impact


Dr. Sophie Boisson, London School of Hygiene & Tropical Medicine

Introduction


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Unsafewater

CEffectiveOption

Introduction

Transmission of faecal-oral pathogens


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Transmission for fecal-

pathogens is complex

HWTS addresses only

pathway

How much diarrhoea c

prevented by improvingquality alone?

Transmission of faecal oral pathogens

Source: WEDC, Adapted from Wagner & Lanoix (1958)

Systematic reviews on health impact


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Systematic reviews on health impact

0 20 40

Flocculation/disinfection

Solar disinfection

Filtration

Chlorination

Household

Source

Water supply

Water quality

% Reduction in

Measuring impact: evaluation designs


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Intervention studies Randomised control trials

Unit of randomisation can b

household or village

Outcome can be blinded

Observational studies

Before/ After Case control studies

Ecological studies

Modelling studies

g p g

Measuring impact: outcome is diarrhoea


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Function of stool con

frequency WHO definition: passase o

stools within 24-h period

Potential issues Reporting bias

Placebo effect

Hawthorne effect

Respondent fatigue

g p

Boisson et al (2013)

Blinded versus non-blinded trials


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Different magnitude of e Open trials report diarrhea re

range of 30-40% Blinded trial report no effect

Lack of blinding of subj

outcomes risk exaggera

magnitude of impact by

2008)

Adjusting for bias (Hun Went from 44% to 15% redu

adjustmentClasen et al (2006)

Potential explanation for variability


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Setting with different transmission dynamics Transmission routes

Pathogens

Treatment methods not effective against all class

of pathogens

Different levels of compliance Impact on diarrhea diminishes over time (Arnold 2006, Hunter

2009) Efficacy versus effectiveness trials Evaluation of 3-year HWT and HWWS in GuatemalaResidual

chlorine 9% intervention vs 3% in control (Arnold 2009)

CRT of SODIS among 22 rural communities in Bolivia 32%

(Mausezhal 2009)

Alternatives to improve measurement?


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Blinded RCTs Challenges to blind effectively

Potentially unethical

Alternative health outcomes Nutritional indicators

Weight-for-age (malnutrition, diarrhoea)

Height-for-age (stunting)

Environmental enteropathy

Pathogen identification

Schmidt et al (2010)

Conclusion


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Significant health gainsreductions in diarrhoea

an overestimation

Measuring impact on h

possible but can be co

expensive

Routine monitoring an

should focus on use be

attempting to measure

Additional ressources: Reviews


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Systematic reviews

Arnold, B. F. & J. M. Colford, Jr. (2007) Treating water with chlorine at point-of-

use to improve water quality and reduce child diarrhea in developing countries:

a systematic review and meta-analysis.Am J Trop Med Hyg,76,354-64.

Clasen, T., I. Roberts, T. Rabie, W. Schmidt & S. Cairncross (2006)

Interventions to improve water quality for preventing diarrhoea. Cochrane

Database Syst Rev,3,CD004794.

Esrey, S. A., R. G. Feachem & J. M. Hughes (1985) Interventions for the control

of diarrhoeal diseases among young children: improving water supplies and

excreta disposal facilities. Bulletin of the World Health Organization,63,757-72.

Fewtrell, L., R. B. Kaufmann, D. Kay, W. Enanoria, L. Haller & J. M. Colford, Jr.(2005) Water, sanitation, and hygiene interventions to reduce diarrhoea in less

developed countries: a systematic review and meta-analysis. Lancet Infect Dis,

5,42-52.

Waddington, H. S., B. White, H. Fewtrell, L. 2009. Water, Sanitation and

Hygiene Interventions to Combat Childhood Diarrhoea in Developing Countries.

International Initiative for Impact Evaluation (3ie).

Further discussions abou

for health impact of HWT

Clasen T, Bartram J, Colford J, Luby S, Quick Ron Household water treatment in poor popula

evidence for scaling up now?. Environ Sci T

author reply 55455546. doi: 10.1021/es9008147

Hunter, P. R. (2009) Household Water Treatment

Comparing Different Intervention Types Using M

Sci Technol. 43(23):8991-7

Schmidt, W. P. & S. Cairncross (2009) Household

populations: is there enough evidence for scalin

Technol,43,986-92.

Additional ressources: studies cited


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Arnold, B., B. Arana, D. Mausezahl, A. Hubbard & J. M. Colford, Jr. (2009) Evaluation of a pre-existing, 3-year

household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol.

Boisson S, Stevenson M, Shapiro L, Kumar V, Singh LP, et al. (2013) Effect of Household-Based Drinking WaterChlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo-

Controlled Trial. PLoS Med 10(8): e1001497. doi:10.1371/journal.pmed.1001497

Boisson S, Kiyombo M, Sthreshley L, Tumba S, Makambo J, et al. (2010) Field assessment of a novel

household-based water filtration device: a randomised, placebo-controlled trial in the Democratic Republic of

Congo. PLoS One 5: e12613 doi:10.1371/journal.pone.0012613

Mausezahl, D., A. Christen, G. D. Pacheco, F. A. Tellez, M. Iriarte, M. E. Zapata, M. Cevallos, J. Hattendorf, M.

D. Cattaneo, B. Arnold, T. A. Smith & J. M. Colford, Jr. (2009) Solar drinking water disinfection (SODIS) to

reduce childhood diarrhoea in rural Bolivia: a cluster-randomized, controlled trial. PLoS Med,6,e1000125.

Schmidt, W. P., S. Boisson, B. Genser, M. L. Barreto, K. Baisley, S. Filteau & S. Cairncross (2010) Weight-for-

age z-score as a proxy marker for diarrhoea in epidemiological studies. J Epidemiol Community Health, 64,

1074-9.

Schmidt, W. P., B. F. Arnold, S. Boisson, B. Genser, S. P. Luby, M. L. Barreto, T. Clasen & S. Cairncross (2011)

Epidemiological methods in diarrhoea studies--an update. Int J Epidemiol,40,1678-92.


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Economic analysis of HWTS



5.4 Cost-effectiveness


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Cost benefit analysis Money for money

Cost effectiveness ana Money for DALYs

Willingness to Pay

Money for HWTS

Cost-benefit analysis


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Five interventions Meeting the Water MDG Tar

Meeting the Water and Sani Universal access to basic wa

Universal basic access + HW

Regulated piped water and s

Benefits Reduced diarrheal disease

Reduced costs of managing

Increased productivity from

Time savings

Cost-benefit analysis results


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0

5

10

15

20

25

30

35

40

45

50

AMR-B EMR-B EUR-B SEAR-B WPR-B EUR-C EMR-D AMR-DSEAR-D AFR-D

Benefit-Costratio

Water and San

Universal basic

Universal basic

Water MDG

Regulated

Hutton, Haller, & Bartram, 2007. Global cost-benefit analysis of water supply and sanitation interventions. Jou
http://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdfhttp://www.iwaponline.com/jwh/005/0481/0050481.pdf


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Another cost-effectiveness analysis


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Chlorine, SODIS lowes Filters, flocculation/dis

expensive than sourceimprovements

Cost per DALY averted


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Bangladesh study Luoto et al. 2012

2-month free trials of fooptions in rotation WaterGuard liquid chlorine

Aquatabs chlorine tablets

PuR flocculant disinfectant

Crystal Pur ceramic candle f

Bidding auction metho

Very low willingness to

Conclusion
http://pubs.acs.org/doi/abs/10.1021/es2027967http://pubs.acs.org/doi/abs/10.1021/es2027967http://pubs.acs.org/doi/abs/10.1021/es2027967http://pubs.acs.org/doi/abs/10.1021/es2027967http://pubs.acs.org/doi/abs/10.1021/es2027967


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Cost benefit analysis

Cost effectiveness ana

Willingness to Pay


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HWTS Selection



5.5 HWTS Selection


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Decision-making at dif

Establish context

Define objectives

Assess options agains

Context


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Water to be treated Quality (turbidity, level of con

Quantity, level of access

Wealth, education of ta

Access to markets, inf

Policy environment

Nature of supporting o

Define objectives


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WHO WPRO Training

Prof. Mark Sobsey et a

Netherlands Water Pa

PATH

Water Resource Quali

WHO WPRO Training Manual


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How well does the technology perform?

Effectiveness

How well does the technology fit into peop

Appropriateness

What will people think of the technology?

Acceptability

What are the costs for the household?

Cost

What is required to get the technology intohomes?

Implementation

Sobsey: criteria for sustainable HWTS


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Able to consistently produce sufficient quantities of water to meet daily household needs.

Quantity

Effective for treating many different water sources aincluding turbid and high organic content waters.

Quality

Requires relatively small user time to treat water, thcontributing to already substantial household labor t

Ease of use

Relatively insensitive to income fluctuations, not caustop treating water because they cannot afford to puor continuously replace it.

Low cost

Have a reliable, accessible and affordable supply chareplacement units or parts for which consumers are

Supply chains

Netherlands Water Partnership


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Continuity of water quality and quantity

Adaptability to part time operations

High potential of local production

Robustness User safety during operation

Possibility of water quality checking by user

Amount of experience in technology applicatio

Performance

Operated and maintained at local level

Accessible spare parts

Social benefits to user

Acceptable intensity and frequency of operati

People

Low dependency on fuels and chemicals

Isolation or reuse of the waste product

Planet

www.aquaforall.nl/documents/aqua4all/downloads/

smart_disinfection_solutions.pdf
http://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdfhttp://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdfhttp://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdfhttp://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdfhttp://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdfhttp://www.aquaforall.nl/documents/aqua4all/downloads/smart_disinfection_solutions.pdf


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PATH Safe Water Project


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Ease of operation

Time to treatTaste & odor

Clarity

Ease of maintenance

Cost of operation and mainte

Acceptability

Availability

Affordability

Safe Water Project HWTS Design Guidelines

Perspectives magazine http://sites.path.org/water/

Stephen Himley MPH

Development of a Tool To EvaluateHousehold Water Treatment and Safe

Storage Technologies Via the Analytic

Hierarchy Process and Expert Elicitation

Based on Factors Influencing Acquisition

and Continued Use

What to do with multiple criteria?
http://www.path.org/projects/safe_water.phphttp://www.path.org/hwts-design-guidelines/index.phphttp://sites.path.org/water/https://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CDMQFjAB&url=https://catalyst.uw.edu/workspace/file/download/20c74e61128fa2cd2b4f6834284e46c640241ead9b6be43e6e16e006cf0bf04d&ei=K5RXU7yoBojQtQakkAE&usg=AFQjCNEHkororPULYmiGZUOPZS8lW9QHDA&sig2=sK_yCdaKsxMOHGOyvL8Svw&bvm=bv.65177938,d.Ymshttps://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CDMQFjAB&url=https://catalyst.uw.edu/workspace/file/download/20c74e61128fa2cd2b4f6834284e46c640241ead9b6be43e6e16e006cf0bf04d&ei=K5RXU7yoBojQtQakkAE&usg=AFQjCNEHkororPULYmiGZUOPZS8lW9QHDA&sig2=sK_yCdaKsxMOHGOyvL8Svw&bvm=bv.65177938,d.Ymshttps://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CDMQFjAB&url=https://catalyst.uw.edu/workspace/file/download/20c74e61128fa2cd2b4f6834284e46c640241ead9b6be43e6e16e006cf0bf04d&ei=K5RXU7yoBojQtQakkAE&usg=AFQjCNEHkororPULYmiGZUOPZS8lW9QHDA&sig2=sK_yCdaKsxMOHGOyvL8Svw&bvm=bv.65177938,d.Ymshttps://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CDMQFjAB&url=https://catalyst.uw.edu/workspace/file/download/20c74e61128fa2cd2b4f6834284e46c640241ead9b6be43e6e16e006cf0bf04d&ei=K5RXU7yoBojQtQakkAE&usg=AFQjCNEHkororPULYmiGZUOPZS8lW9QHDA&sig2=sK_yCdaKsxMOHGOyvL8Svw&bvm=bv.65177938,d.Ymshttps://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CDMQFjAB&url=https://catalyst.uw.edu/workspace/file/download/20c74e61128fa2cd2b4f6834284e46c640241ead9b6be43e6e16e006cf0bf04d&ei=K5RXU7yoBojQtQakkAE&usg=AFQjCNEHkororPULYmiGZUOPZS8lW9QHDA&sig2=sK_yCdaKsxMOHGOyvL8Svw&bvm=bv.65177938,d.Ymshttp://sites.path.org/water/http://www.path.org/hwts-design-guidelines/index.phphttp://www.path.org/projects/safe_water.phphttp://www.path.org/projects/safe_water.phphttp://www.path.org/projects/safe_water.php


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Landscaping

Formal optimization

Decision trees

Landscaping

PATH T h l A t d R ki T l (TA


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PATH Technology Assessment and Ranking Tool (TA

18 dimensions

15 systems

Formal: Multi-Criteria Decision Analysis


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5. Weighting

6. Calculate totals

7. Examine results

8. Sensitivity an

1. Establish decisioncontext

2. Identify options

3. Identify objectives,criteria

4. Scoring

Source: Osterwalder et al. 2014

Scoring example (Himley MPH)
http://www.sciencedirect.com/science/article/pii/S0048969713012163http://www.sciencedirect.com/science/article/pii/S0048969713012163


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Lowest Criterion Element Poor Score Fair Score Good Score Exc

Time to treat(Acceptability), [t]

t >20 minutes 10 < t < 20 minutes 5 < t < 10 minutes t <

Increase score one level if time to treat > 6 liters is same as for 2 liters

Taste & odor(Acceptability),[h = free chlorine or total

bromine]

h > 2.0mg/L 1.0 < h < 2.0 mg/L 0.3 < h < 1.0 mg/L h 10 NTU 5 < T < 10 NTU 1 < T < 5 NTU T 20 minutes

I < ergste

Ease of Maintenance(Acceptability),[f = frequency ofmaintenance]

f < weekly & burdensome (> 5min.)

weekly < f < monthly &burdensome (> 10 min.)

f > monthly & burdensome(> 20 min.) - or -f < weekly & notburdensome (< 5 min.)

weburf > bur

Cost of Operating andMaintenance(Acceptability)

Lower Segment

> $18.25/yrLow Segment> $73.00/yr

Interpolate

Low

< $Low< $

Affordability

Lower Segment> $18.25/yrLow Segment> $73.00/yr

Interpolate

Low< $Low< $

Availability N = 0 or V = 0 LInterpolate(N = number of durables; V = volume of liters treated byFMCG)

N >

Weighting example (Himley MPH)


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0%

20%

40%

60%

80%

100%

Ease

ofO

peratio

n

Timeto

Treat

Taste

&Odor

Clarity

E a

Weight

Rural Lower Rural Low

Urban Lower Urban Low

0%

20%

40%

60%

80%

100%

Acceptability Availability Affordability

Weight

Rural Lower Rural Low

Urban Lower Urban Low

Total score example (Himley MPH)

Non-turbid water Turbid water


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0% 20% 40% 60% 80% 100%

Filt_CerFilt+BrFilt+Cl

Cl_TabCl_Liq

Floc+ClRural Lower: Ideal

Filt_Cer

Filt+BrFilt+Cl

Cl_TabCl_Liq

Floc+ClUrban Lower: Ideal


Cl_TabCl_Liq

Floc+ClRural Low: Ideal

Filt_Cer

Filt+BrFilt+Cl

Cl_TabCl_Liq

Floc+ClUrban Low: Ideal

Score

Acceptability

Availability

Affordability

0% 20% 40% 60% 80%


Cl_TabCl_Liq

Floc+ClRural Lower: Ideal

Filt_Cer

Filt+BrFilt+Cl

Cl_TabCl_Liq

Floc+ClUrban Lower: Ideal


Cl_TabCl_Liq

Floc+ClRural Low: Ideal

Filt_Cer

Filt+BrFilt+Cl

Cl_TabCl_Liq

Floc+ClUrban Low: Ideal

Score

Non-turbid water Turbid water

Decision trees


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Is water mud

NO

Are products from outside the commuavailable in the market or through human

response?

NOIs wood or fuel available?

NOPromote straining,

SODIS, 3 potmethod, or

filtration withfrequent cleaning.

YESPromote straining

and boiling. Alsopromote

responsible woodcollection andreforestation

YESIs water clou

NOUse a normal

dose of chemicaldisinfection

Usdose

d

Promote safe water storage

Source: after IFRC, 2008

Conclusion


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HWTS Selection is com

Context-specific

Importance of criteria Ranking (weighting)

Informal, formal metho


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Conclusion



WASH in developing countries MOOC series


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Household Wate

and Safe S

Strategic EnvirSanitation P

Water Su

and Treat

Municipa

Waste Mana

Excreta and W

Managem

www.san

WASH in developing countries MOOC II
http://www.sandec.ch/http://www.sandec.ch/


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Planning & Design of

Systems and Techno

Dr. Christoph Luethi

Affordable and context

sanitation solutions

Recommended: General background in envir

engineering, urban planning


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www.coursera.org/course/water
http://www.coursera.org/course/waterhttp://www.coursera.org/course/water


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Starting May 26!

Why, What, How


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Week 1

Background

Disease

Contamination

Week 2

Water Safety

Sedimentation

Filtration

Week 3

Disinfection

Safe storage

Week 4

Implementation

Strategies

Vulnerable groups

Thanks!


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Thanks!


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Colleagues at Eawag Fabian Suter, La Zaretti

Sara Marks, Regula Meierhof

Heiko Gebauer, Hans-Joachim

Peg Fortenberry, Procte

Alison Hill, Vestergaard-

Rachel Peletz, Aquaya I

Ryan Rowe, UNC Water

EPFL

Coursera

Documents

Week 5 Assessing the Impact of HWTS