Unreliable water supplies and household coping strategies in peri-urban South Africa

Many developing countries face severe challenges with the reliability of water supplies. These supplies are often characterised by intermittence, low pressure and poor water quality. Despite its contribution towards water-related illness and the significant coping burden it imposes on households, water supply reliability remains a difficult attribute to measure. A key challenge is the lack of a universal definition of water supply reliability. The issue of unreliability in water supply and the financial cost it imposes on households is of profound relevance in South Africa – a country whose social policies include a Free Basic Water policy which entitles all households to a free lifeline supply of 6,000 litres per month. This thesis examines household experiences of unreliable water supplies and in particular, explores the question as to what constitutes a reliable water supply, and household responses to unreliable water supplies. The analysis draws on literature reviews and a household survey conducted in peri-urban communities in the Limpopo Province of South Africa in 2012. A systematic review of definitions and assessment criteria used in studies of water supply reliability demonstrates that there is no consensus on what constitutes a reliable water supply. Assessment criteria also vary greatly, with the most common criterion in urban settings being the duration and/or continuity of supply in hours per day. In rural settings, the proportion of functional water systems is commonly assessed. A discrete choice experiment was conducted to elicit households’ preferences for a reliable water supply. Results indicate that overall, households value notification of interruptions and having water available for longer durations during the day, and would be willing to pay for these improvements. However, there is some heterogeneity in these preferences as wealthier households, who have drilled their own wells and are no longer dependant on the public supply are less willing to pay for improvements in the water supply. Findings from a systematic review of household strategies to cope with unreliability reveal that relatively wealthy households incur significant direct costs from strategies such as drilling wells and installing water storage tanks, poor households expend time and energy in collecting water from other sources. Income, level of education, land tenure and extent of unreliability are the main determinants of which strategies are adopted. Results from the survey in Limpopo highlight that Free Basic Water is not actually free; households spend significant proportions of their income on buying water, ii drilling wells and treating the water prior to consumption. Coping costs increase with wealth status and are higher in communities without alternative water sources such as springs. Notably, for many households the lifeline supply of 6,000 litres per month is unmet. The findings from this thesis highlight the need for consensus on the definition, and assessment approach for water supply reliability. Further, the analysis of households’ responses to unreliable water supplies in South Africa draws attention to how poor reliability negates the Free Basic Water policy. Without reliable water supply services, the objectives of improving public health and promoting equity cannot be met

Reliability of water supplies in low and middle-income countries: A structured review of definitions and assessment criteria

The unreliability of water supplies in developing countries is a widely recognized concern. However, unreliability means different things in the variety of literature on water supplies, and no unified definition or assessment criteria exist. We review definitions of water supply reliability used in existing literature, as well as the various ways in which it is assessed. Thirty-three papers were selected for review that reported on reliability of domestic water supply and if they were based on empirical research in developing countries. Explicit definitions of reliability are given in four out of the 33 papers reviewed. These definitions vary, but features common in them are the functionality of the water supply system itself, and the extent to which it meets the needs of water users. Assessment criteria also vary greatly, with the most common criterion in urban settings being the duration / continuity of supply in hours per day, while in rural settings, the proportion of functional water systems is commonly used. The heterogeneity in the definitions and assessment criteria found in the review is perhaps indicative of a multi-attribute nature of the concept of reliability and any unifying definition and assessment criteria might do well to take this into account

A re-assessment of the safety of silver in household water treatment: rapid systematic review of mammalian in vivo genotoxicity studies

Background: Despite poor evidence of their effectiveness, colloidal silver and silver nanoparticles are increasingly being promoted for treating potentially contaminated drinking water in low income countries. Recently, however, concerns have been raised about the possible genotoxicity of particulate silver. Objectives: The goal of this paper was to review the published mammalian in vivo genotoxicity studies using silver micro and nanoparticles. Methods: SCOPUS and Medline were searched using the following search string: (“DNA damage” OR genotox* OR Cytotox* OR Embryotox*) AND (silver OR AgNP). Included papers were any mammalian in vivo experimental studies investigating genotoxicity of silver particles. Studies were quality assessed using the ToxRTool. Results: 16 relevant papers were identified. There were substantial variations in study design including the size of silver particles, animal species, target organs, silver dose, route of administration and the method used to detect genotoxicity. Thus, it was not possible to produce a definitive pooled result. Nevertheless, most studies showed evidence of genotoxicity unless using very low doses. We also identified one human study reporting evidence of “severe DNA damage” in silver jewellery workers occupationally exposed to silver particles. Conclusions: With the available evidence it is not possible to be definitive about risks to human health from oral exposure to silver particulates. However, the balance of evidence suggests that there should be concerns especially when considering the evidence from jewellery workers. There is an urgent need to determine whether people exposed to particulate silver as part of drinking water treatment have evidence of DNA damage

A study to explore the impact of socio-demographic factors on the response to antiretroviral therapy in Gauteng Department of Health

Objectives The study aims to describe the socio-demographic characteristics, clinical outcomes of the patients in the Gauteng public sector roll-out programme and establish the association between these. There are contradictory results from international studies on these associations, in the absence of SA results. Methods This is a retrospective cohort, exploratory, secondary data, record review study and a comparison between two sites. Routinely collected socio-demographic data and clinical data were used to establish the impact of socio-demographic factors on response to HAART. This was collected for patients who enrolled from April 2004 to August 2004. Chris Hani Baragwanaath (CHB) had 494 records, Helen Joseph (HJ) had159 records collected. Exposure variables (age, sex, marital status, education level, residential area, employment, baseline viral load and baseline cd4 count). Outcome variables were (CD4 and Viral load at 3 months, 6 months and 12 months). Data Analysis T tests were used for comparing means; logistic regression was used to find the effect of ordered exposure variables and binary outcome. Chi square and fishers exact were used to find frequencies and association between the categorical variables. Regression was used to find the association between the continuous exposure variables and the continuous outcome variables. In a multivariate model, to assess the effect of the exposure variables to the outcome variables Multivariate regression was used. Statistical significance was assessed at the 5% significance level, giving 95% confidence interval. Results The majority of the patients (653) were female, African, unemployed and were literate. At CHB, at the end of the first year, three quarters were still on treatment however; just under a fifth (19%) had died. The majority responded well to treatment and had a mean baseline CD4 count of 58.9cells/mm3 (CHB) and 78.4cells/mm3 (HJ) and mean CD4 count of 245 (CHB) and 268 (HJ) after 12 months. increasing age, and being widowed, lowers the immunological response. Employment, education, sex and had no impact on response. Conclusion • There is positive virological and immunological response to HAART in Gauteng ARV roll-out programme despite the low socio economic status of the majority of the patients. • Provision of free antiretroviral drugs and access to the disability grant has assisted in mitigating the effects of HIV/ AIDS on the socio-economically disadvantaged. • The elderly and the widowed might need close monitoring as their response appears to be lower than the others. • The group with no schooling is not well represented in this sample; the question is whether the HIV/AIDS prevention messages and treatment is accessible for this group. This needs further research

Oral heparin: status review

Unfractionated heparin and low molecular weight heparin are the most commonly used antithrombotic and thromboprophylactic agents in hospital practice. Extended out-of-hospital treatment is inconvenient in that these agents must be administered parenterally. Current research is directed at development of a safe and effective oral antithrombotic agent as an alternative for the effective, yet difficult to use vitamin K antagonists. A novel drug delivery technology that facilitates transport of drugs across the gastrointestinal epithelium has been harnessed to develop an oral dosage form of unfractionated heparin. Combining unfractionated heparin with the carrier molecule, sodium N-(8 [2-hydroxybenzoyl]amino) caprylate, or SNAC has markedly increased the gastrointestinal absorption of this drug. Preclinical and clinical studies to-date suggests that oral heparin-SNAC can confer a clinical efficacious effect; further confirmation is sought in planned clinical trials

Cholera and household water treatment why communities do not treat water after a cholera outbreak: a case study in Limpopo Province

Background: Cholera is one of the common diseases in developing countries caused by consumption of contaminated and untreated drinking water. A study was conducted 7 months after a cholera outbreak in Vhembe district, Limpopo, South Africa. The aim of the study was to assess if the communities were still conforming to safe water practices after an outbreak of cholera. Methodology: One hundred and fifty-two (152) participants from 11 villages were recruited to form 21 focus groups, with a mean of 7. The interview transcripts were coded and arranged based on the study themes. Results: Of the 21 groups in 11 villages, three villages were using water from boreholes, six were using river water and three were using mixed sources which included river, canal and spring water, three depended on municipal tanks and only six were using tap water. Only 19% of the respondents treated their water, even though the majority of communities reported treatment of water as a priority. Four villages claimed they never received environmental health education at all, while most of the villages confirmed they received education during a cholera outbreak. Conclusion: Regardless of the outbreak and health education efforts done, communities continued using unprotected water sources without any form of treatment, as they perceived it to be unimportant. Sustainable water supplies and environmental health education should be continued after an outbreak as it is important for public health gains

Design and Characterization of a Silk-Fibroin-Based Drug Delivery Platform Using Naproxen as a Model Drug

The objective of this proof-of-concept study was to develop a platform for controlled drug delivery based on silk fibroin (SF) and to explore the feasibility of using SF in oral drug delivery. The SF-containing matrixes were prepared via spray-drying and film casting, and the release profile of the model drug naproxen sodium was evaluated. Attenuated total reflectance Fourier transform infrared spectroscopy (FTIR) has been used to observe conformational changes in SF- and drug-containing compositions. SF-based films, spray-dried microparticles, and matrixes loaded with naproxen were prepared. Both FTIR spectra and in vitro dissolution data demonstrated that SF β-sheet conformation regulates the release profile of naproxen. The controlled release characteristics of the SF-containing compositions were evaluated as a function of SF concentration, temperature, and exposure to dehydrating solvents. The results suggest that SF may be an attractive polymer for use in controlled drug delivery systems

Opportunities to advance water safety through regulation of rural water services (REACH Discussion document)

Regulation of drinking water quality is typically considered a more advanced area of water services regulation, compared to economic or service quality regulation. However, regulations are poorly differentiated to address the challenges experienced in water service delivery in rural areas, which are characterised by small water systems. Long travel distances, low recovery of user fees, and unreliable supply chains have limited rural water sustainability, particularly in Sub-Saharan Africa. Historical project based funding in many rural areas has focused on delivery of boreholes and small improved water systems, where water safety costs may be included in the implementation phase but with limited ongoing water safety management. Developing and implementing regulations in this context has to consider the low level of resources available, both financial and capacity, and the baseline performance of the water systems. Supportive regulatory approaches are needed to build capacity and encourage iterative improvements towards the delivery of safe drinking water, including advancing water safety planning under increasingly variable conditions driven by climate change. This discussion document by government, regulators, service providers and researchers, drawing particularly on experiences in Bangladesh, Kenya, England and Wales, highlights four principles: 1. Regulatory models must reflect that water service provision is changing 2. Scaling regulation to rural systems requires differentiated approaches 3. Regulation needs to incentivise improvement in water safety 4. Effective implementation requires building shared valu

How Do Households Respond to Unreliable Water Supplies? : A Systematic Review

Although the Millennium Development Goal (MDG) target for drinking water was met, in many developing countries water supplies are unreliable. This paper reviews how households in developing countries cope with unreliable water supplies, including coping costs, the distribution of coping costs across socio-economic groups, and effectiveness of coping strategies in meeting household water needs. Structured searches were conducted in peer-reviewed and grey literature in electronic databases and search engines, and 28 studies were selected for review, out of 1643 potentially relevant references. Studies were included if they reported on strategies to cope with unreliable household water supplies and were based on empirical research in developing countries. Common coping strategies include drilling wells, storing water, and collecting water from alternative sources. The choice of coping strategies is influenced by income, level of education, land tenure and extent of unreliability. The findings of this review highlight that low-income households bear a disproportionate coping burden, as they often engage in coping strategies such as collecting water from alternative sources, which is labour and time-intensive, and yields smaller quantities of water. Such alternative sources may be of lower water quality, and pose health risks. In the absence of dramatic improvements in the reliability of water supplies, a point of critical avenue of enquiry should be what coping strategies are effective and can be readily adopted by low income households

Systematic risk management approach of household drinking water from the source to point of use

The Water Safety Plan (WSP) approach is being widely adopted as a systematic approach to improving the safety of drinking water. However, to-date the approach has not been widely used for improving the safety of drinking water in those settings where people have to collect water away from their home. Most rural areas in South Africa still consume unsafe water despite WSP implementation and improved water sources provided by Municipalities. This study used HACCP to assess drinking water used in households to determine systematic procedures, which could be used to control risks. The process includes assessment of risks associated to household water service level (availability, accessibility and potability) and risks of water contamination from the collection to point of consumption. Observations and questionnaires were used to collect data in households to systematically determine and identify risks of drinking water consumption. The results show intermittent water supply, access to unsafe water, whilst poor hygiene practices contribute to household water contamination. This approach could assist in identifying hazards as well as critical control points to reduce risks and improve management of drinking water safety in households