The results of this assessment from May of 2012 document the low access to safe water in rural Artibonite and resulting high risk for continued cholera transmission. Information about access to safe water in the Artibonite Department is critical; to date, more than 100,000 cases of cholera have been reported from Artibonite, and this department has had the greatest number of fatalities related to cholera.9
Based on our survey, use of improved water sources in this region is lower than the most recent estimate for both rural Haiti from JMP 2013 (48%)1
and the whole of Artibonite Department (not just rural) from the Demographic and Health Survey (DHS) 2012 (49%).11
Nearly one-half of this population reported collecting drinking water from unprotected springs, streams, canals, and rivers. Based on the estimated rural population of Artibonite Department, this result equates to over 450,000 people. With high rates of open defecation in rural Haiti,1
the risk of surface water being contaminated with Vibrio cholerae
and other waterborne pathogens is high. Furthermore, many of the improved water sources sampled were contaminated, suggesting that the proportion with access to microbiologically safe drinking water sources is lower than estimated by the JMP.
These findings contribute to an increasing body of evidence that shows that the classification of water sources as improved or unimproved is inadequate to measure access to safe water and that highlights the limitations of using this proxy alone.12–15
Furthermore, most of the improved water sources currently accessed in rural Artibonite were located off-plot, meaning that water has to be collected, transported, and subsequently, stored in the home. In the absence of safe storage, these steps introduce the possibility of secondary contamination.16,17
Finally, our results indicate that many of those individuals with access to an improved water source periodically consume river or canal water when outside the home. A recent article by Brown and Clasen18
suggests that the health gains that could be realized with HWTS are seriously limited if even periodic consumption of unsafe water occurs.
Similar to other recent surveys, our findings indicate that the national cholera response efforts increased knowledge of cholera and awareness and use of various household water treatment products, most notably NaDCC tablets.6–8,11
Although small-scale household water treatment projects and programs in Haiti have been operational for years,19
the reported use of household water treatment since the start of the cholera outbreak is considerably higher than before.20,21
However, important barriers for continuing HWTS promotion beyond emergency response were identified from this survey—namely, a lack of availability of water treatment products after emergency response activities had scaled back, a lack of understanding of correct use of products reportedly used, and a lack of understanding of the importance of consistent use of treated water.
At the time of this survey, only about one-third of respondents had a water treatment product in the home. Lack of affordability and lack of access to household water treatment products were cited as barriers to consistent use, although notably, one-half of those respondents using treatment products in the last 3 months had purchased them. The reported lack of access to products is unsurprising given that mass distributions were largely of imported disinfection products, and this large-scale response effort had scaled back after the first 1 year of the outbreak.5
Nevertheless, these barriers are clearly important barriers that need to be addressed as efforts shift to longer-term strategies.
Over two-thirds of the samples taken from reportedly treated and stored drinking water were negative for free chlorine residual. Our assessment revealed potential reasons for this finding. Extended storage time may have contributed to the loss of chlorine residual. However, lack of knowledge of correct use of the products was clearly a major contributing factor. Most respondents reportedly underdosed with the product that they used; this result was consistent across all types of products (liquid, tablet, and sachet). Incorrect dosage resulting from lack of sufficient education and training and confusion caused by use of multiple product types has been seen in other emergencies and may also apply to this situation.22
Although turbidity was not measured during the assessment, anecdotally, it was reported to be low in the majority of the water available to test and therefore, not considered a factor contributing to reduction in chlorine residual.
Finally, our results indicate that there are still gaps related to understanding the importance of consistent use of treated water, including use when outside of the home. At the time of the survey, more than one-half of respondents perceived their drinking water sources to be “safe as is” without treatment. The survey took place at the end of the dry season, when there were fewer cases of cholera23
and fewer response activities. Thus, there may have been a shift back to previous norms in terms of perceived risk regarding water source safety. Respondents who believed their water sources to be safe most commonly cited reasons of natural treatment, protection, and clarity. These beliefs are consistent with findings from other locations.24
Thus, as a longer-term strategy, there may be a need to separate drinking water treatment from cholera prevention action and promote consistent use of treated drinking water. This situation has been seen during cholera outbreaks in Madagascar and Mozambique, with the initial rise and then fall in sales of household water treatment products after the outbreak subsided.25,26
This assessment had several limitations. First, 3 of 40 clusters were not reached during the survey, and 2 of these clusters were among the most remote in the department. Thus, access to improved drinking water sources and household water treatment products in these areas may have been different than access in areas included in the survey. Second, we were not able to collect samples for microbiological analysis from all water sources used by surveyed households. This limited our ability to make inferences about the water safety of specific water source types in this region. Although an attempt was made to collect a representative sample, because of time restrictions, we slightly oversampled sources close to the homes of study participants, which may have been more likely to be improved sources, and likely undersampled sources that were farthest from the communities and may have been more likely to be unimproved. Third, reported treatment from boiling may have been underreported as a previous water treatment method, because interviewees were not specifically prompted about this method. Fourth, the results of this survey are representative of the rural population of Artibonite Department, and therefore, the results are not generalizable to all of Haiti.
In conclusion, this assessment documents the precarious situation facing households in rural Artibonite Department with respect to safe water supplies. It reinforces aspects of the newly published Government of Haiti National Plan for the Elimination of Cholera in Haiti 2013–2022 that calls for major investments in water and sanitation infrastructure as well as the importance of HWTS in rural Artibonite and presumably, other parts of Haiti to improve access to safe water in the near term.27
The national cholera response increased the awareness and acceptability of household water treatment and created an opportunity to continue and scale-up HWTS promotion. Various strategies are needed to transition from emergency response to a development model of HWTS promotion. Our findings suggest that these strategies should aim to increase product availability and affordability, knowledge of correct use, and understanding of the importance of consistent and routine use. Previous research suggests that a comprehensive understanding of context-specific social, cultural, and behavioral factors will be foundational for household water treatment programs to advance in rural Artibonite and elsewhere in Haiti.24
Finally, lessons learned in other settings indicate a combined approach involving partnerships between government, NGOs, and the private sector holds the most promise for scaling-up these necessary programs.26,28–30