Barriers and Enabling Factors for Central and Household Level Water Treatment in a Refugee Setting: A Mixed-Method Study among Rohingyas in Cox’s Bazar, Bangladesh

Abstract

Water chlorination is widely used in emergency responses to reduce diarrheal diseases, although communities with no prior exposure to chlorinated drinking water can have low acceptability. To better inform water treatment interventions, the study explored acceptability, barriers, and motivating-factors of a piped water chlorination program, and household level chlorine-tablet distribution, in place for four months in Rohingya refugee camps, Cox’s Bazar, Bangladesh. We collected data from June to August 2018 from four purposively selected refugee camps using structured observation, key-informant-interviews, transect-walks, group discussions, focus-group discussions, and in-depth-interviews with males, females, adolescent girls, and community leaders. Smell and taste of chlorinated water were commonly reported barriers among the population that had previously consumed groundwater. Poor quality source-water and suboptimal resultant treated-water, and long-queues for water collection were common complaints. Chlorine-tablet users reported inadequate and interrupted tablet supply, and inconsistent information delivered by different organisations caused confusion. Respondents reported fear of adverse-effects of "chemicals/medicine" used to treat water, especially fear of religious conversion. Water treatment options were reported as easy-to-use, and perceived health-benefits were motivating-factors. In vulnerable refugee communities, community and religious-leaders can formulate and deliver messages to address water taste and smell, instil trust, allay fears, and address rumours/misinformation to maximise early uptake.

Field trial of an automated batch chlorinator system at two shared shallow tubewells among camps for forcibly displaced Myanmar nationals (FDMN) in Cox's Bazar, Bangladesh

“…Recently, it was reported that water sources in FDMN-camps were unevenly distributed. Many people walk long distances through densely inhabited camps after collecting water (30,31), providing opportunity for contamination due to unsafe handling during transport. Furthermore, household storage containers in humanitarian settings often had observed faecal contamination likely due to insu cient regular cleaning (32).…”

Field Trial of an Automated Batch Chlorinator System at Two Shared Shallow Tubewells among Camps for Forcibly Displaced Myanmar Nationals (FDMN) in Cox’s Bazar, Bangladesh

“…One of the investigators (NA), along with the field research team, conducted initial scoping visits to the selected camps and performed preliminary water quality assessments measuring iron, turbidity, and total dissolved solids (TDS) using digital field-test kits. We selected four underground shallow tubewells (less than 76 m) from the selected Camps [ 14 ] with different water physicochemical properties (tubewell ID-13 and tubewell ID-17 from Camp 1 and tubewell ID-2 and tubewell ID-5 from Camp 2) and based on the following eligibility criteria: (1) water point shared by 90–100 households, (2) water extracted by a manual underground shallow tubewell, (3) the tubewells were the primary drinking water source for the families/users, and (4) had sufficient space around the platform of the tubewell for Zimba installation.…”

“…Point-of-use (POU) chlorination is common in humanitarian settings due to the availability of chlorine products, ease of use, cost-effectiveness, efficacy in inactivating viral and bacterial pathogens, and maintenance of residual chlorine in treated water that protects against recontamination during storage [ 12 ]. However, regardless of substantial benefits, several studies revealed that successful chlorination programs in humanitarian settings are challenging owing to several reasons [ 13 , 14 , 15 , 16 , 17 ]. Previous studies from Bangladesh suggested that the taste and smell of chlorine in water, the time required for daily water treatment, personal motivation, knowledge, and behavior change are considerable barriers to POU treatment uptake, resulting in inconsistent and inaccurate practices [ 14 , 17 , 18 ].…”

“…However, regardless of substantial benefits, several studies revealed that successful chlorination programs in humanitarian settings are challenging owing to several reasons [ 13 , 14 , 15 , 16 , 17 ]. Previous studies from Bangladesh suggested that the taste and smell of chlorine in water, the time required for daily water treatment, personal motivation, knowledge, and behavior change are considerable barriers to POU treatment uptake, resulting in inconsistent and inaccurate practices [ 14 , 17 , 18 ]. Chlorine-based POU methods usually require optimization of chlorine for a customized dosage dependent on household storage container sizes (i.e., for 5 L, 10 L or 20 L) [ 19 , 20 ].…”

“…A recent study conducted to explore treatment efficacy and barriers of drinking water at Rohingya camps, Cox’s Bazar, suggested that although 71% of households in the Camp reported that they used treated water for drinking, only 6.6% of household stored water samples met the WHO recommendation (0.2–2 mg/L) for free residual chlorine levels (mean = 0.09 mg/L). More than 90% of household stored water had lower than recommended (<0.2 mg/L) free residual chlorine [ 14 ]. Additionally, centralized chlorinated piped water systems are expensive and require a consistent electricity supply which is not common in humanitarian settings [ 21 ].…”