Distribution of Aquatabs through Commune Health Collaborators in Can Tho, Vietnam

Transcription

1 Distribution of Aquatabs through Commune Health Collaborators in Can Tho, Vietnam August 2011 Prepared by: Abt Associates Inc. Prepared for: PATH This publication was prepared by Ha Nguyen, Quyen Bui, Erica James, and Slavea Chankova of Abt Associates for the Safe Water Project implemented by PATH with a grant from the Bill & Melinda Gates Foundation.

2 Abt Associates is a mission driven, global leader in research and program implementation in the fields of health, social and environmental policy, and international development. Known for its rigorous approach to solving complex challenges, Abt Associates was ranked as one of the top 25 global research firms in The employeeowned company has multiple offices in the U. S. and program offices in nearly 40 countries. Abt Associates Inc Montgomery Ave., Suite 800 Bethesda, Maryland USA

3 Table of Contents Acronyms... 5 Acknowledgements... 6 Executive Summary Introduction Pilot Description Promotion of Safe Water Treatment and Aquatabs by PATH PSI s promotion of SafeWat Evaluation Approach Objectives of the Evaluation Evaluation Methods Household Sample Survey Qualitative Assessment Socio Demographic Characteristics of Surveyed Respondents and Households General Knowledge, Attitude, and Practice on HWTS Sources of Drinking Water Water Quality Perceptions Knowledge and Practice of Water Treatment mmethods Potential Market for Chlorine-based Products and Aquatabs Water Storage Exposure to Education and Promotion Messages The Effects of Pilot Interventions Product Awareness and Sources of Information Product Uptake and Use Triggers and Barriers to Trial and Continued Use The Effects of the Free Water Storage Containers The Role of the Health Staff Limitations of the Research Conclusions Recommendations Annex... 39

4 Table of Figures & Tables Figure 1. Chronology of the pilot activities... 8 Figure 2. Comparison of asset wealth distribution in the pilot area with Figure 3. Frequency of exposure to media among respondents Figure 4. Main source of cooking/drinking water - Dry season Figure 5. Assessment of safety of water the household is currently using Figure 6. Exposure to safe water messages Figure 7. Source of information for "water treatment at home" Figure 8. Source of information on among non-users who are aware of the methods Figure 9. Source of supply when Aquatabs were first obtained Figure 10. Uptake and use of Aquatabs and Safewat Figure 11. Uptake and use of Aquatabs and Safewat in basic and enhanced communes Figure 12. Reasons for not trying methods among aware non-users Figure 13. Reasons for stopping using methods Figure 14. Reasons for continuing to use product Table 1. Summary of Intervention Schema in Vinh Thanh and Co Do... 9 Table 2. Assumptions used in determining sample size Table 3. Sample Size and Distribution for Household Surveys Table 4. Sample Size for Qualitative Study Table 5. Background Characteristics of Survey Respondents and Households 13 Table 6. Main Sources of Cooking/Drinking Water in Dry and Rainy Season (% of households) Table 7. Awareness and Practice of Water Treatment Methods (percent of respondents) Table 8. Attitude Toward Boiling, Mineral Pot, and Chlorine-based Products. 19 Table 9. Determinants of Positive Attitude Toward Chlorine-based Products 20 Table 10. Availability and Characteristics of Drinking Water Storage Device.. 21 Table 11. Awareness of Aquatabs and Safewat Table 12. The Effects of the 20L Containers... 29

5 Acronyms CHS FGD HWTS IDI PSI SWP Commune Health Station Focus Group Discussion Household Water Treatment and Storage In depth Interviews Population Services International Safe Water Project

6 Acknowledgements Many individuals contributed to the design and implementation of the study, provided feedback on the presentation of the study results, and contributed valuable comments on an earlier draft of this report. The authors would like to acknowledge the contributions of Ramakrishnan Ganesan, Samantha Bastian, Lorelei Goodyear, Elizabeth Blanton, Tim Elliot, Debbie Tran, Hoa Vo, and Siri Wood, as well as of the field team from Nielsen Vietnam, who carried out the interviews.

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8 Executive Summary Introduction The PATH Safe Water Project (SWP) aims to develop sustainable distribution models for ensuring access to Household Water Treatment and Storage (HWTS) products, together with promoting sustained use of those products over time by low income populations. Pilot commercial models are implemented in several countries to assess and refine various HWTS products and business approaches. The Vietnam model relies on community level promotion activities and uses the existing extensive network of Commune Health Station (CHS) collaborators as the key distribution channel of Aquatabs. Its intended priority target group consists of poor households and households with children aged under five. Pilot Description PATH s sale and promotion of Aquatabs in two districts of Can Tho province, Vietnam, comprised many activities including community promotion events to introduce the product, posting of billboards to announce the product, testimonials by well known people broadcast on national TV, community level interactive information events, and door to door sales by CHS collaborators. To test the added effects of the availability of water storage, 200 water containers were given out for free in 11 of the 21 pilot communes. In the same area, PATH s pilot took place concurrently with the marketing of another chlorine based product, Safewat, by Population Services International (PSI). Evaluation Approach The study explored the knowledge, attitude, and practice of HWTS in the pilot area, as well as evaluates the effects of PATH s interventions on the uptake and use of Aquatabs. A sample survey of 1,014 households was conducted toward the end of the pilot, together with a qualitative assessment of users and health collaborators. As part of the household survey, water testing was conducted to check for chlorine residuals in respondents drinking water. Findings The study revealed that the population in the pilot area was wealthier and more educated than the average in Can Tho province and in Vietnam as a whole. Exposure to TV was frequent and nearly universal. The most common sources of cooking and drinking water were bottled, rain, and tap water. The use of rain and tap water varied greatly by wealth status, while bottled water appeared to be popular among both the rich and the poor. Boiling was the predominant method of treating drinking water, and was typically used in combination with other methods, ABT ASSOCIATES INC. 3

9 such as alum and filter. About 20 percent of the surveyed population was aware of a chlorinebased product. The uptake and use of Aquatabs and Safewat among the pilot population were quite low, as was awareness of the two products. The most important barriers to acceptability of Aquatabs among consumers were the strong and unpleasant smell of the treated water and concerns about long term health effects. Consumers rated Aquatabs high on convenience and cost. The uptake and use of Aquatabs were higher in the communes that received the free water storage containers. However, due to the product s low prevalence, it was not possible to obtain conclusive evidence on the effects of the containers alone on the uptake and use of Aquatabs. The use of CHS collaborators as the sales channel for Aquatabs has proven to be a good choice due to people s trust in health staff. However, the incentive structure for health collaborators did not encourage their efforts to increase sales revenue. Additionally, the arrangement whereby the collaborators worked in the unfamiliar catchment areas greatly limited the effects of their door to door sales. Limitations of the Study The household survey was designed with optimistic assumptions on the uptake and use of Aquatabs. It chose to target the general population rather than exclusively those attending the community events. Due to the small update and use rates, the survey did not capture adequate number of users to provide rich information on the pilot. Recommendations Various recommendations are proposed for any efforts to expand or replicate the pilot in the future. Key recommendations include: (1) improving the product s attractiveness (smell of treated water), (2) adopting strategic marketing strategies (focusing on TV, the most common media channel; drilling on simple but effective messages to change knowledge; and providing testimonials to reinforce consumers trust in the product), and (3) continuing the model of door to door sales by health staff, but revising the incentive structures and health staff responsibilities. ABT ASSOCIATES INC. 4

10 1. Introduction The PATH Safe Water Project (SWP) aims to develop sustainable distribution models for ensuring access to Household Water Treatment and Safe Storage (HWTS) products, together with promoting sustained use of those products over time by low income populations. Pilot commercial models are implemented in several countries to assess and refine various HWTS products and business approaches. The primary objective of the pilots is to assess various distribution models for reaching lower income populations with products that are already commercially available and effective. The pilots seek to answer six key questions: 1. What is the uptake rate among target consumers of HWTS products made available through commercial distribution channels and marketing? 2. What is the extent of consistent and correct use among target consumers of HWTS products made available through commercial distribution channels and marketing? 3. What are the triggers and barriers to trial and use of HWTS products made available through commercial distribution channels and marketing? 4. Can commercial partners earn a profit from sales to target consumers? 5. Will commercial partners continue and/or scale up the SWP pilot business model to reach target consumers? 6. What other efforts/inputs/incentives are needed to stimulate supply and demand for HWTS to target consumers? Since October 2010, PATH Vietnam has been conducting an intervention to promote Aquatabs, a chlorine based tablet that purifies drinking water, in two districts (Co Do and Vinh Thanh) of Can Tho province, in the Mekong River Delta region. The intervention was conducted in collaboration with Zuellig Pharma, one of the largest distributors of pharmaceutical products in Vietnam, and the two district medical centers. The Vietnam model relied on community level promotion activities and used the existing extensive network of Commune Health Station (CHS) collaborators as the key distribution channel. Its intended priority target group consisted of poor households and households with children aged under five. Concurrently, Population Services International (PSI) was marketing SafeWat, a liquid chlorine safe water product, in the same districts, as well as throughout the entire province of Can Tho and a neighboring province, An Giang. Unlike PATH s focus on low income populations, PSI s marketing strategy did not target any specific population group. Its main distribution channels were retailers and pharmacies. ABT ASSOCIATES INC. 5

11 The current report presents the results of an assessment of the general HWTS practice and the interventions conducted by PATH in Co Do and Vinh Thanh districts. The assessment was conducted by Abt Associates in May 2011 under an agreement with PATH. Assessment findings help to answer 1, 2, 3, and 6 of the six key questions above. ABT ASSOCIATES INC. 6

12 2. Pilot Description 2.1. Promotion of Safe Water Treatment and Aquatabs by PATH Prior to October 2010, Aquatabs in Can Tho province were available in only a few pharmacies and retailers in the provincial capital, Ninh Kieu city. At the commune level, most drug sales were from CHSs and public and private pharmacies. Virtually no CHS sold Aquatabs and the sale by pharmacies was deemed very small, if any. Likewise, no social marketing activity was conducted to promote Aquatabs. PATH s intervention started in October 2010 with a half day introductory workshop with the district medical centers of Co Do and Vinh Thanh, followed by a two day training of CHS collaborators on water treatment, Aquatabs, and sales of Aquatabs. The collaborators later received training on the use of a sales promotion flip book to help them with sales. Shortly after the introductory workshops, community promotion activities were launched, which included the following. One day Promotion Events One or several one day events were organized in each of the 21 communes of the two districts, with each event attended by 200 households. During the event, CHS collaborators used edutainment methods to educate households on proper hygiene and sanitation, as well as how to properly use Aquatabs; promotional items such as umbrellas, pens, and product leaflets were given away. The households in attendance were provided with a free month's supply of Aquatabs for trial at home. The events were meant to specifically target poor households and households with children under five. However, this proved to be logistically difficult and so not all invited households were in the two priority groups. In most events the 200 household target was challenging to reach and therefore, the event was opened to anyone to attend. Distribution of Free 20L Water Containers In 11 out of 21 project communes (five in Co Do and six in Vinh Thanh), free 20L water containers were given out to attendees of the community events. Such enhanced intervention was expected to further encourage the practice of using safe water treatment and boost the sale of Aquatabs. For reasons of logistics, the selection of communes to receive free containers was not random. Rather, the project provided free containers to communes that volunteered to receive them. In most cases, these communes were located close to a main road, which made it easy to transport the containers. Roughly 200 containers were given out in each of the 11 enhanced intervention communes. ABT ASSOCIATES INC. 7

13 Monthly Household Visits and Sales of Aquatabs by CHS Collaborators After the community events there was a slight delay in the product reaching the country and in December 2010 CHS collaborators in each commune started monthly household visits to sell Aquatabs and continue relaying educational messages on the use of safe water. On average, each commune had three collaborators who received a travel stipend from PATH to perform these door to door sales. They also received a small mark up on each tablet sold. As originally planned, the visits would start out with households that had attended the promotion events and had begun to use the trial supply of Aquatabs. In practice, however, CHS collaborators typically selected an area where they knew the people. In addition, because preliminary feedback from CHSs was that some households did not like the taste of water treated with the supposedly tasteless Aquatabs, the CHS collaborators found it was easier to visit a home of persons who had not tried Aquatabs instead of visiting homes that already said they did not prefer the tablets and had not expressed interest in purchasing more. Promotional Activities Targeting Broad Communities Besides targeted house to house sales, a number of activities were conducted over the month of April 2011 to make Aquatabs widely known to the general population. These activities included (1) designing billboards to place in public places in the commune, such as schools and CHSs; (2) contracting with a famous TV star to advertise Aquatabs on national TV; and (3) organizing follow up interactive information events to reinforce the educational message. The chronology of PATH s pilot activities is described in Figure 1. Figure 1. Chronology of the Pilot Activities ABT ASSOCIATES INC. 8

14 2.2. PSI s promotion of SafeWat PSI placed billboards promoting the benefits of SafeWat and the importance of disinfecting water across their pilot areas (which covered the two PATH s pilot districts) and they held events in market areas around pharmacies/retail outlets where SafeWat was available. In addition, PSI distributed samples of water treated with SafeWat and gave out vouchers for free bottles (redeemable from the pharmacy/retailer). According to PSI, SafeWat is sold for VND 7,500, or about $0.375 per bottle. Table 1 summarizes the interventions conducted by PATH and PSI. Table 1. Summary of Intervention Schema in Vinh Thanh and Co Do Group 1: Basic Intervention Group 2: Enhanced Intervention SafeWat Target General population General population Sales channel Pharmacies and retailers Pharmacies and retailers Aquatabs Target Primary: Poor or with children under 5 Secondary: General population Primary: Poor or with children under 5 Secondary: General population Sales channel CHS collaborators (home visits) CHS collaborators (home visits) Storage container 20L Not available Free for people attending the community promotion event (intended for poor or with children under 5) 3. Evaluation Approach 3.1. Objectives of the Evaluation Given the interventions conducted by PATH and the concurrent PSI marketing activities in the same pilot area, the evaluation seeks to answer the following key questions: 1. What are the current knowledge, attitude, and practices of HWTS in the pilot area? In particular, what are the motivating factors and barriers for a positive attitude toward chlorine based products? 2. What impact does the interventions conducted by PATH and PSI have on the uptake, correct use, and consistent use of Aquatabs and Safewat? ABT ASSOCIATES INC. 9

15 3. What additional impact does making containers available for free have on the uptake, correct use, and consistent use of Aquatabs and Safewat? 3.2. Evaluation Methods Both quantitative and qualitative studies were conducted to address the research questions. While the quantitative study was designed to address all three questions, the qualitative assessment primarily addressed question Household Sample Survey A probability sampling survey of households was conducted in the two intervention districts at the beginning of May Because no marketing and sales efforts for Aquatabs or Safewat were in place in this area other than those implemented by PATH and PSI (as described above), it was expected that this endline survey would capture the effects of the interventions on the two products uptake and use. For this reason, no control group was selected to address the second research question: the counterfactual use of Aquatabs and Safewat would be zero. Survey sample size is determined to facilitate 80% power of detecting at least 4 percentage point difference in the consistent use of SWP between the basic and enhanced intervention groups described in table 1 at the 95% significance level. With assumptions on various rates of SWP uptake and use (table 2), a design effect of 1.5, and 5% spoiled questionnaires, the sample size required is 507 households for each group or 1,014 for the whole pilot area. Table 2. Assumptions used in determining sample size Assumptions on combined effects (use of Aquatabs or Safewat or both) Group 1: basic intervention Uptake: 5% Consistent use: 3% Correct use: 3% Group 2: enhanced intervention Uptake: 11% Consistent use: 7% Correct use: 7% Randomization of individual consumers into the basic and enhanced intervention group was not feasible due to the fact that the pilot was used concurrently to assess the implementation feasibility and commercial viability of the basic and enhanced sales models. The latter goal required entire communes to be covered by the same type of pilot intervention, ensuring that manner of distribution of the free containers reflected what a real life distribution in a scaled up intervention would look like. ABT ASSOCIATES INC. 10

16 The basic and enhanced intervention communes were not selected at random (due to logistical reasons with implementation mentioned above, which the research team was unable to control). This limited our ability to rigorously address the third question, evaluating the added effects of the free containers. Communes that volunteered to receive the enhanced intervention were likely different than communes that received the basic intervention on aspects that influence pilot outcomes. For example, the health staff might have stronger motivation to implement the pilot, or the social learning and information spread may be easier due to better access to main roads. As a result, differences in outcomes between the basic and enhanced intervention groups cannot be attributed solely to the availability of a free 20L container for the attendees of the launch meetings. The survey applied a one stage stratified random sampling method. Households were surveyed in all 21 pilot communes, with number of households surveyed in each commune being proportional to the total number of households in that commune. Table 3. Sample Size and Distribution for Household Surveys Districts Basic Enhanced Total number of households Number of households surveyed Total number of households Number of households surveyed Co Do 20, , Vinh Thanh 8, , Total 28, , The survey respondents were people in charge of treating drinking water in the households. Survey questionnaire covered background characteristics of the respondents and the households, general knowledge, attitudes, and practices related to HWTS, and interventionspecific information. In addition, free residual chlorine testing was conducted in all surveyed households Qualitative Assessment A qualitative assessment was conducted concurrently with the household survey in one basic and one enhanced intervention commune. The assessment included in depth individual interviews (IDI) and focus group discussions (FGD) with current users and lapsers of Aquatabs, as well as with CHS staff in charge of the pilot activities in the commune. These interviews and discussions explored the barriers to purchase and use of HWTS products and practices, attitudes, and beliefs associated with treating water at the household level, and the perceived ABT ASSOCIATES INC. 11

17 role of the intervention and other social or economic factors in influencing consistent water treatment and safe storage. The interviews also explored the experience of the CHS staff in implementing the intervention, the challenges they faced, and the solutions they used or proposed to use to address these challenges. Consumers: Table 4. Sample Size for Qualitative Study Segment IDI FGD Current users, free container 2 1 Current users, no free container 3 1 Lapsed users, free container 2 1 Lapsed users, no free container 5 2 CHS staff: CHS staff, free container 2 CHS staff, no free container 2 The definition of current and lapsed users was agreed upon in consultation with health collaborators based on their sales information and knowledge of typical customers. In particular, a current user of Aquatabs was defined as someone who uses at least three pills per week consistently over the last one month; and a lapsed user was defined as someone who has tried Aquatabs but has stopped for the past two months. 4. Socio Demographic Characteristics of Surveyed Respondents and Households Table 5 presents the background characteristics of surveyed respondents and their households. Nearly 24 percent of people treating drinking water in the surveyed households were male, more than 75 percent were older than 35, and nearly 92 percent were currently married. Nearly 60 percent of all respondents were either unemployed or working as casual laborers at the time of survey. ABT ASSOCIATES INC. 12

18 Table 5. Background Characteristics of Survey Respondents and Households Characteristics No. Percent Individual characteristics Male Age group < > Ethnic minority Currently married Occupation Unemployed/housework/retired Freelance, casual laborer Agriculture/forestry/fishery Services/trade/craft Civil servant Education Illiterate/never go to school Less than primary Primary completed Secondary completed High school/college Household characteristics Female headed household Have children under At least one member is member of a local community organization Officially designated poverty status* Note: Poverty status was officially designated based on the Government criteria. The same criteria are applied to the poor designation in the Vietnam Household Living Standards Survey. As Table 5 shows, the surveyed population was in a better position than the general population of Can Tho province and of Vietnam in several aspects. For example, 3.4 percent of the respondents reported that they were illiterate or never went to school. The corresponding figure in 2010 for Vietnam was 6 percent and for the Mekong River Delta 7.8 percent. 1 Roughly 5.4 percent of the surveyed households were considered poor according to the government 1 General Statistics Office of Vietnam Results of Vietnam Living Standard Survey ABT ASSOCIATES INC. 13

19 criteria, whereas the poverty rate in Vietnam in 2010 was 14.2 percent and in Can Tho was 7.2 percent. 1 Figure 2 compares the asset wealth distribution of the surveyed households in the pilot districts with the general distribution of Vietnam and Can Tho province. We computed an asset index for the surveyed households based on reported ownership of 61 durable assets and housing conditions, and standardized the index based on the wealth distribution in the Vietnam Household Living Standard Survey This allowed for a direct comparison of each quintile in the pilot areas with the corresponding quintile in the country and in Can Tho. Figure 2. Comparison of Asset Wealth Distribution in the Pilot Area, Can Tho Province, and Vietnam As the figure shows, more than 7 percent of the surveyed population was in the two poorest quintiles and roughly 10 percent was in the richest quintile. An overwhelming 54 percent of all surveyed population was in the second richest quintile. A higher share of the pilot area population fell into the three richest asset wealth quintiles than did the general population of Can Tho, while the proportion of the general population of Can Tho in these quintiles was also higher than that of the general population of Vietnam. Although the wealth index in this study was standardized against 2008 countrywide data, the overall picture is rather consistent with the one observed above in Table 4, that the pilot population was relatively better off than the population of Can Tho and of Vietnam. As Figure 3 shows, most respondents either never read newspapers or did so less than once a week. In contrast, more than 90 percent of respondents reported watching TV almost every day and another 9 percent at least once a week. These patterns suggest that access to electricity and TV, a rather high end consumer good, is high in the pilot area. They also highlight TV as a good channel of communication for behavior change efforts. ABT ASSOCIATES INC. 14

20 Figure 3. Frequency of Exposure to Media Among Respondents 100% 80% 60% 40% 20% 0% newspaper radio TV Almost every day At least once a week Less than once a week/not at all 5. General Knowledge, Attitude, and Practice on HWTS 5.1. Sources of Drinking Water Bottled water was the most common source of drinking and cooking water in the pilot areas. As shown in Table 6, about 37 percent 39 percent of the surveyed households reported using bottled water, followed by rainwater (25 percent 31 percent) and tap water (16 percent 18 percent). Note that nearly 94 percent of the surveyed households used the same method in both dry and rainy season. Table 6. Main Sources of Cooking/Drinking Water in Dry and Rainy Season (% of households) Main Source of Cooking/Drinking Water Dry Season Rainy Season Tap water Drilled wells Hand dug and protected wells Rain water Bottled water Rivers/lakes/ponds % of household that use the same source in both seasons 93.6 ABT ASSOCIATES INC. 15

21 Most of them usually boil water, the rest purchase the purified water can from the manufacturer (each costs 10,000 VND) for drinking purpose. If they have tap water, they will use it for other purposes such as showering, washing clothes If they live nearby the river, they will wash clothes in the river. Source: CHS staff, free containers Figure 4. Main Source of Cooking/Drinking Water, Dry Season There was a very strong wealth gradient in the use of safer/less safe water sources for cooking and drinking. As shown in Figure 4, the use of tap water increased largely with quintile, ranging from 2 percent in quintiles 1 and 2 to 40 percent in quintile 5. Conversely, while almost no household in quintile 5 reported relying on wells, rivers, or ponds, more than 30 percent of households in the two poorest quintiles reported doing so. Remarkably, bottled water accounted for a fairly large share of sources among all quintiles Water Quality Perceptions Among all the common sources of cooking and drinking water, bottled water was considered safest, with 80 percent of those currently using this method rating it as very safe (Figure 5). Conversely, roughly the same proportion of people relying on wells, rivers, and ponds considered this method very unsafe. Interestingly, 40 percent and 55 percent of the people using rain and tap water respectively also considered the method very unsafe. Figure 5. Assessment of Safety of Water the Household is Currently Using ABT ASSOCIATES INC. 16

22 They throw empty bottle, dead chicken in the river water. I don t dare use river water for cooking and drinking. At home, we always cleanse water by alum and boil before drinking Source: Current users, no free container Unlike the survey, the qualitative assessment provides mixed evidence on users trust in the safety of bottled water. While some people were convinced by the clear labels of the bottles, others raised doubt on the source typically private companies which may not have been inspected. bottled water is trustworthy because it s purified and the packaging is nice and clean and it s used in schools/clinics. Bottled water looks like this with clear labels and statement that is it purified water with inspection papers thus we drink it Source: Lapsed users, free containers Those factories are not inspected at all. They are all private companies people buying the machines and making the water, no inspection. Therefore I don t trust this source. Source: FGD, Co Do, Lapsed users, no free containers Yes, I have (concern of bottled water safety). Even though it has been filtered already, who knows if it is clean and hygienic or not. I just know it is transparent. Source: Current users, free containers 5.3. Knowledge and Practice of Water Treatment Methods In the pilot area, boiling was the single most common method of drinking water treatment. As Table 7 shows, 100 percent of respondents said they had heard of boiling, nearly 100 percent had ever used the method, and 65 percent reported using the method every day or almost every day over the last month. Other commonly known methods included alum, water ABT ASSOCIATES INC. 17

23 filtering, and allowing the water to settle. Nearly 20 percent of the surveyed respondents reported having heard of chlorine based products. However, among these, 34 percent reported having tried them and only 4 percent reported using a chlorine based product frequently over the last month. Table 7. Awareness and Practice of Water Treatment Methods (percent of respondents) Methods Ever Heard Of Ever Used* Used Yesterday** Used (Almost) Everyday Last Month** Boiling the water Alum Filter water using cloth, or net filter Allow the water to settle and decant Ceramic candle filter Chlorine/bleach tablet or liquid Mineral pot Iodine tablets or liquids Note: * Among households who ever heard of the method; ** Among households who ever used the method. It is noteworthy that using multiple water treatment methods was rather common. In fact, a typical pattern that emerged from the qualitative assessment among households relying on river water was to use alum to make the water clear and allow the mud to settle first, then boil the water for drinking purposes. Yes, I do worry (about dirty water). Sometimes people may serve us with non boiled water, which may cause stomachache or cholera or any other kinds of diseases. At home, we always clean water by alum and boil before drinking; even after using alum to clean water I don t feel safe 100 percent Source: Current users, no free container ABT ASSOCIATES INC. 18

24 I use alum to treat water. Water in this area contains a lot of contaminated compounds, they make food become black and hard. Sometimes I use salt to sterilize water when using for cooking, clean the water with alum and boil Source: Current users, no free container 5.4. Potential Market for Chlorine based Products and Aquatabs We explored respondents attitude toward several important treatment methods, including boiling, mineral pot, and chlorine based (Table 8). Attitude was measured by the expressed opinions toward 11 statements on the qualifications of the method, ranging from 1 (most negative) to 5 (most positive). As shown, water boiling got the highest average score. Chlorinebased products scored relatively high on convenience (quick and easy to use) and safety. Table 8. Attitude Toward Boiling, Mineral Pot, and Chlorine based Products Statement Boiling Mineral Pot Chlorine based Products N 1, Makes the taste and smell better Makes the water look clean Is easy to do/use Is quick to do or use Is affordable to do/use Is used in well to do households (R) Is used by well educated people (R) This method is in fashion these days Is used by young people (R) Is suitable for my household Makes the water safe to drink Average score Note: (R) Indicates that the item was reversely coded. Reported numbers are average scores of 5 point opinions regarding the statement, with 1 being most negative and 5 being most positive. Among people who reported being aware of a chlorine based product, we distinguished those having positive attitude toward the product (average score >3) and the remaining. The determinants of having a positive attitude were explored using a logistic regression, which includes a wide array of individual and household characteristics, as well as opinions on the social norms, availability, and knowledge of the product. A backward stepwise procedure was used to develop a parsimonious model, which removes all variables having insignificant association with the outcome of interest. ABT ASSOCIATES INC. 19

25 As shown in Table 9, people in quintiles 4 and 5 were less likely to have a positive attitude toward chlorine based products than people in quintiles 1 3, whereas compared with the two lowest education groups (have not gone to school or completed primary school), people having completed primary school were more likely to hold a positive attitude toward chlorine based products. Similarly, the higher the average knowledge score the respondent has, the more likely it is for him or her to hold a positive attitude toward chlorine based products.the results in Table 9 highlight the importance of education and communication efforts aimed at improving people s knowledge of the HWTS. Table 9. Determinants of Positive Attitude Toward Chlorine based Products Determinants Odds ratio P value Asset quintile (base=quintiles 1 3) Quintile Quintile Education (base=below primary school) Complete primary school Knowledge People can get sick from un safe water Diarrhea can be caused by drinking un safe water Water that looks clear is safe to drink (R) Water that comes from a pipe is safe to drink (R) I don t need to treat my drinking water because the water I get/collect is safe to drink (R) It is possible to tell if water is unsafe to drink just by looking at it (R) Water that tastes good is safe to drink (R) Diarrhea can be caused by drinking water that looks clear Water can be contaminated by germs that are too small to see Filtering water using a cloth, sieve, or net makes it safe to drink (R) Boiling water for one minute makes it safe to drink Adding chlorine to water makes it safe to drink Adding chlorine to water every day will reduce my child s diarrhea I don t need to treat my drinking water because the water I get/collect has already been made safe to drink (R) The drinking water of my household needs to be treated Note: The logistic regression additionally controls for age, gender, education, and employment of respondent, whether watched TV or listened to radio every day, age and gender of household head, type of intervention commune, whether household has children under 5, has a diarrhea incident the past 4 weeks, social norms and availability of water treatment methods. These variables are not included in Table 8 because they are not statistically significantly associated with the outcome at p<0.10 level. Knowledge, social norms, and availability of water treatment methods are multi item scales where individual items were measured on a semantic differential scale ranging from 1 (highly disagree) to 5 (highly agree). Sample includes people who were aware of a chlorine based product (N=198) (R) indicates that the item was reversely coded. ABT ASSOCIATES INC. 20

26 5.5. Water Storage The general practice of storing drinking water in the pilot area was rather positive, as shown in Table 10. Nearly all surveyed households reported having a storage device of some sort. Among these, about 82 percent are made from plastic, 22 percent have a narrow mouth, and nearly 100 percent have a hard lid. Table 10. Availability and Characteristics of Drinking Water Storage Device N % Having water storage device 1, Material of vessel Earthern/pottery Plastic Mouth of vessel Metal Wide mouth (can dip hand) Narrow mouth (cannot dip hand) Vessel has built in tap Ladle present Lid for vessel Yes, hard lid 1, Yes, cloth cover Exposure to Education and Promotion Messages Nearly 30 percent of surveyed respondents reported that they had seen or heard a message on water treatment at home, yet less than 15 percent had been discussed with on the same type of message (Figure 6). The difference between the former (general, non targeted exposure to promotion messages) and the latter (targeted communication) was similar for messages on water storage at home and water treatment and safety. Figure 6. Exposure to Safe Water Messages ABT ASSOCIATES INC. 21

27 As shown in Figure 7, TV was the most common source of non targeted promotion messages on water treatment at home, not surprising given the high frequency of TV watching among the study population. Health workers, family, friends, and neighbors, and, to a lesser extent, community groups, played an important role in discussing the water promotion messages with the respondents. Figure 7. Source of Information for "Water Treatment at Home" 6. The Effects of Pilot Interventions ABT ASSOCIATES INC. 22

28 6.1. Product Awareness and Sources of Information In general, awareness of Aquatabs and Safewat among the study population was rather low, 7.2 percent and 5.1 percent respectively (Table 11). However, awareness was significantly higher in the enhanced versus basic intervention communes. Given that PSI s marketing of Safewat is similar in both commune types, the higher awareness of Safewat recorded in the enhanced communes is a surprise. It could be that people pay more attention to any chlorinebased product as a result of being more aware of Aquatabs. Confusion between product brands is also a possibility, although surveyed respondents were prompted several times and shown the product picture when asked about awareness. Table 11. Awareness of Aquatabs and Safewat N Overall (%) Basic (%) Enhanced (%) P value Aware of Aquatabs Aware of Safewat Aware of Aquatabs or Safewat or both Among people who were aware of Aquatabs but had not tried them, the largest number reported CHS and CHS staff as the source of information, followed by friends, relatives, and neighbors (Figure 8). For Safewat, billboards were the most frequently cited source of information. These patterns are in line with the marketing activities of the two products. Figure 8. Source of Information Among Non users Who are Aware of the Methods ABT ASSOCIATES INC. 23

29 Similarly, among people who reported ever using Aquatabs, CHS was the most frequently cited source of the first supply, followed by door to door sales by CHS staff (Figure 9). The patterns confirm that most ever users obtained the product the first time in the community events. However, the health collaborators did reach out to sell to people who did not attend the community event as well. Figure 9. Source of Supply When Aquatabs Were First Obtained 6.2. Product Uptake and Use Figure 10 shows that 33 respondents reported that their households had tried Aquatabs. Among these, only seven reported still using the product; four claimed that they used Aquatabs most of the time over the course of last week (the week preceding the survey). The corresponding numbers for Safewat are much smaller. In fact, only one person said that his or her household was still using Safewat, but not most of the time last week. Figure 10. Uptake and Use of Aquatabs and Safewat ABT ASSOCIATES INC. 24

30 Figure 11 combines Aquatabs and Safewat and compares basic and enhanced intervention communes. As depicted, there is a rather substantial difference in the reported ever use, current use, and correct use of the two products between the two groups (correct use is measured by a non negative result of chlorine residual water tests). The difference in uptake (ever used) between the basic and enhanced intervention communes is statistically significant at p= For current use and correct use, a statistical test is impossible due to the small number of observations. Figure 11. Uptake and Use of Aquatabs and Safewat in Basic and Enhanced Communes 6.3. Triggers and Barriers to Trial and Continued Use ABT ASSOCIATES INC. 25

31 The main barriers to trial of Aquatabs and Safewat were stated by non users who were aware of chlorine based products (Figure 12). Besides the fact that some other methods were already being used, primary obstacles were concern about long term health effects and the smell of the treated water, reported by nine and eight people respectively. It is noteworthy that these people have not even tried the methods, so the smell concern must come from word of mouth and not from their own experience. Figure 12. Reasons for Not Trying Methods Among Aware Non users The qualitative assessment did not find any direct evidence pointing to concerns over the long term health effect of Aquatabs. However, there were hints that some people are not fully convinced of the safety of the tablets. For example, they would use water treated by Aquatabs themselves but not giving that to their children, because stomach of adults is much stronger than that of kids. Only if the company producing that pill has a mean to prove that the pill can kill 100% of bacteria can I believe in the full effects of the pill. Right now, I only hear the advertisement that the pill can kill bacteria, I can t see it so I don t know if in reality the pill can truly kill the bacteria. Source: Lapsed users, no free containers Similarly, the primary reason why users dropped Aquatabs was the unpleasant smell of the treated water, reported by 16 out of 26 lapsers (Figure 13). Note that the number reporting being out of supply, not knowing where to buy is rather non trivial, which raises the issue of product availability even in the height of the marketing period. ABT ASSOCIATES INC. 26

32 Figure 13. Reasons for Stopping Using Methods The qualitative assessment provides ample evidence supporting findings from the survey. The unpleasant smell of the water treated with Aquatabs was repeated many times by IDI and FGD participants as the biggest obstacle to using the product. kids don t like taste/smell. The first time my husband drank this water, he recognized abnormal smell. I explained for him. Then he told me to boil water for my kids Source: Lapsed users, no free containers smells like bleach, hospital water, chlorine, children don t want to use it Source: Lapsed users, free containers If it is not smelly, I will use it because it is convenient, cheap, and I don t spend my time to boil. Source: Lapsed users, no free containers On the positive side, those who were still using Aquatabs and Safewat cited safety of treated water, convenience, and reasonable cost as main reasons for continued use (Figure 14). Note that the numbers are still so small that one can hardly draw some definitive conclusions on the observed patterns. ABT ASSOCIATES INC. 27

33 Figure 14. Reasons for Continuing to Use Product Using Aquatabs for the drilled well water and followed my uncle s guide, I feel more secure. It helps to remove bacteria that cause diseases and we don t get diarrhea. I feel more secure than the tap water Source: Current users, no free containers I have more time to do household chores and other things (due to not having to boil water). Source: Current users, no free containers But it s cheaper if you use this tablet (Aquatab). Water with tank is 30,000 VND, only water is 8,000 VND. People in rural are poor, so they don t have enough money. Source: Current users, no free container It (the Aquatab) is more convenient and cost efficient. If I boil the water, it costs 5 10 thousand VND per week. With Aquatabs, I use 3 4 pills a week. This costs 3 4 thousand VND. I save 5 6 thousand VND and I don t need to boil the water. Source: FGD, Current users, no free container 6.4. The Effects of the Free Water Storage Containers Although one of the key objectives of the evaluation was to assess the added effects of the free water containers on the product uptake and consistent use, the small number of uptake and consistent users made it impossible to perform statistical tests of such potential effects. The descriptive data presented in Table 12 hence sought to answer the evaluation question in a ABT ASSOCIATES INC. 28

34 more qualitative way. As revealed, already nearly 100 percent of the surveyed respondents reported having a water storage device of some kind. Of these, nearly 50 percent had a device that looked rather similar compared with the 20L containers distributed by the pilot. In the whole sample, only 16 households reported having received the containers from the pilot and six of them reported currently still using Aquatabs. All six indicated that they would still be using Aquatabs even if they had not received the container. These facts revealed that the 20L water containers were introduced to a market where shortage of storage device was not a problem. No hard evidence was found to support the enhanced effects of the containers on uptake and consistent use of Aquatabs. Table 12. The Effects of the 20L Containers Number of households having drinking water storage device 1011 Number of storage devices looking similar to 20L containers distributed by the pilot 511 Number of households reported receiving 20L containers from the pilot 16 Number of households still using pilot s containers 10 Number of households currently using Aquatabs among those having received containers Number of households indicating that they would still be using Aquatabs even if not having received free containers 6 6 The qualitative assessment did not find overwhelming evidence indicating the effects of the free containers one way or another, especially from the user s point of view. The CHS staff interviewed in the basic commune appeared to think that not having the containers was a barrier to Aquatabs uptake in his or her commune. When talking about prices and benefit, they understand. But the container and smell prevent them to use Source: CHS staff, No free containers In general, it s very suitable (price). But there is one challenge. My commune doesn t have containers. Hence when we implemented the program, some households said that they didn t have the 20L container. They want to use but they don t have any container to store water Source: CHS staff, No free containers The Role of the Health Staff ABT ASSOCIATES INC. 29

35 The Vietnam pilot chose to promote Aquatabs through CHS and commune health collaborators under the assumption that people s trust in health staff will encourage product uptake. This premise was supported by the endline survey data: 31 of 33 current and past users of Aquatabs stated that they trust the information from the supply source predominantly the CHS and collaborators. In addition, the qualitative assessment clearly showed that users had nearly absolute faith in the CHS, health collaborators, and the local authority. In fact, other than the doubts on the long term health effects of Aquatabs mentioned above, people seemed to have no question about the effectiveness of Aquatabs because the product was promoted by people who typically care about health of the community. Yes I believe because this (event) was organized by the People s Committee. There s no reason why the local authority would do anything harmful to the people. They must care about people s health. That s why I think I can trust, I came and brought some home to try. Source: lapsed user, free container I don t know why but my kids had diarrhea all the time, they complained about headache, and vomited. Then I met the lady organizing the event. She said there re those tablets the antibacterial, anti diarrhea ones. Then I bought some to use for my family and my kids. Now my kids do not have diarrhea anymore, both of them are now fine, no disease. Source: current user, no free container Regarding payments to CHS collaborators, the fixed monthly travel stipend appeared to be a stronger motivator than was the mark up from sales. Regardless of the sales revenue they generated, each health collaborator received a monthly travel allowance of VND 450,000 (approximately US$22.5), much more than the monthly allowance the collaborators received from projects run by the government or sponsored by other agencies. 2 In contrast, the mark up per tablet of Aquatabs was only VND 2,500 (US$0.125), too small to motivate the collaborators to expend the effort to increase sales. Each month they give us VND 450 thousand for travel. That s for 4.5 days, VND 100 thousand a day. That is the main motivation for collaborators to sell Aquatabs. Otherwise, with the purchase price of VND 7 8 thousand and the sale price of VND 10 thousand, I don t think they have the motivation to go. Also before they said the project would stop in October November, now they say stipend will stop in June. If there s stipend, the collaborators will spend time to do the work; if the stipend ends I don t know what will happen. Source: health collaborator, no free container Aside from the product s strong smell being a deterrent to Aquatabs sales, the main challenge for the collaborators was the large and unfamiliar catchment sales area. Vietnam has a widespread network of collaborators, each in charge of general health promotion in his or her own village. (Collaborators do not usually work across villages.) As explained above, the 2 For example, the Population and Family Planning Program pays CHS collaborators VND 100,000 per month. ABT ASSOCIATES INC. 30