Access to safe and affordable drinking water remains a major challenge worldwide, especially in rural areas. While passive in-line chlorination offers a promising approach for providing consistent treatment of water supplies in resource-limited settings, little is known about the factors influencing the uptake and use of these technologies. This study used a controlled pre-post intervention design to evaluate the technical performance and user acceptance of a low-cost and locally constructed chlorinator (the A’Jín) in four water distribution systems in rural Guatemala. Data sources included household surveys (N = 319) and operator interviews (N = 25), with regular monitoring of faecal contamination, pH, temperature and free residual chlorine (FRC) at reservoir tanks, taps and households. Faecal contamination was significantly reduced in water systems actively using the A’Jín device. In these systems, the share of tap and household drinking water samples with detectable E. coli decreased from 28% to 1% and 25% to 15%, respectively. Chlorine dosing consistency with the A’Jín was low, with only 24% of tap samples meeting the recommended minimal FRC threshold of 0.2 mg/L. Overall, the share of users expressing satisfaction with their water increased by 14% in the water distribution systems with the A’Jín and stayed constant for users of control systems. While the device’s low cost and simple design offered advantages over other chlorinators on the market, operators reported challenges with high maintenance needs and frequent clogging. To ensure the future success of passive in-line chlorination for small community supplies, we recommend prioritising ease of use combined with external support for addressing maintenance needs.

Previous research suggests that community-based participation, a process through which beneficiaries can actively influence and define the direction and execution of development programs, can promote long-term uptake, use, and management of shared resources, such as community-based safe water infrastructure. However, results are heterogeneous. Psychological ownership theory and initial evidence suggests that participation promotes positive outcomes for shared resources by fostering sense of ownership through three routes: having control, intimate knowledge, and investing the self. This study used community-based safe water infrastructure as an example to investigate how various forms of participation affect acceptance, use, and functionality of a shared resource and whether this effect is mediated by psychological ownership. We conducted a nonrandomized cluster-based controlled trial with pre–post intervention assessment (N = 369) in 33 villages in rural Nepal, where safe water infrastructure is shared. Participatory intervention activities (e.g., influence in decision-making, contributing materials and labour) favourably affected self-reported outcomes and use of the water supply infrastructure but not observed functionality or drinking water quality. In conclusion, this study supports the assumption that participation can foster psychological ownership, which in turn can support successful management of a shared resource.

Sanitation is a fundamental determinant of human health and well-being, and is essential for protecting the environment and enabling economic and social development. Ensuring universal, equitable and sustainable access to safe sanitation in all settings is a political priority in the pan-European region. This publication aims to support implementation of the provisions on sanitation under the Protocol on Water and Health, as well as national and international goals and targets on sanitation by providing an overview of the situation of sanitation and wastewater management in the region, describing current and emerging issues in ensuring access to safe and sustainable sanitation services, and proposing key action areas to strengthen sanitation governance. It is primarily targeted at national decision-makers and supports public health and environment authorities, surveillance agencies, sanitation service providers and other relevant stakeholder.

The consistent use of household water treatment and storage (HWTS) technologies is necessary for human health. However, most HWTS options are designed for typical household use as opposed to emergency contexts, where use is less consistent. To investigate ways to improve the consistency of HWTS use in emergencies, we conducted in-person surveys with 108 households in northern Kenya and comparatively analyzed factors that influenced the use of household filters during a protracted drought. Findings showed that about 50% of respondents used their filter consistently over the course of the study. The main limitation to usability was that none of the filters were well-suited for the indoor living environment of the survey respondents. The factors associated with consistency of use varied by filter design. For one-bucket filters, consistent use was associated with ease of assembly, reported availability of spare parts, and peer approval of HWTS use. For two-bucket filters, consistent use was best explained by the certainty regarding when the filter was functioning or not. We suggest that filter manufacturers should reduce the number of parts to mitigate assembly difficulties and should develop flexible filter designs to improve compatibility across households in terms of space and height requirements. Those disseminating filters during protracted emergencies should conduct user training on the assembly and disassembly of unfamiliar filters and ensure affordable access to necessary replacement parts. Finally, to improve consistency of use of new types of filters, implementers should assess the peer approval of these HTWS options among the target population.

Over 2 billion people globally lack access to safely managed drinking water. In contrast to the household-level, manually implemented treatment products that have been the dominant strategy for gaining low-cost access to safe drinking water, passive chlorination technologies have the potential to treat water and reduce reliance on individual behavior change. However, few studies exist that evaluate the performance and costs of these technologies over time, especially in small, rural systems. We conducted a nonrandomized evaluation of two passive chlorination technologies for system-level water treatment in six gravity-fed, piped water systems in small communities in the hilly region of western Nepal. We monitored water quality indicators upstream of the treatment, at shared taps, and at households, as well as user acceptability and maintenance costs, over 1 year. At baseline, over 80% of tap samples were contaminated with Escherichia coli. After 1 year of system-level chlorination, only 7% of those same taps had E. coli. However, 29% of household stored water was positive for E. coli. Per cubic meter of treated water, the cost of chlorine was 0.06-0.09 USD, similar to the cost of monitoring technology installations. Safe storage, service delivery models, and reliable supply chains are required, but passive chlorination technologies have the potential to radically improve how rural households gain access to safely managed water.

The water, sanitation, and solid waste sectors are closely related and have many interactions between their respective service chains in low-and middle-income countries. Currently, these interactions mostly lead to cross-contamination, and opportunities for co-benefits are seldom realized. This review presents the key advancements within each of these three development sectors in the past two decades. We identify numerous similarities such as decentralization, resource recovery, community involved planning, and digitalization. Despite the potential for synergies and the opportunities to maximize positive interactions, there have been few attempts to break the existing sectoral silos in order to integrate these three service chains. We argue that, with the right enabling environment, an integrated approach to holistically planning and implementing water supply, sanitation, and solid waste management can create positive interactions resulting in co-benefits among complementary development goals.

Antimicrobial resistance (AMR) is a growing public health challenge that is expected to disproportionately burden lower- and middle-income countries (LMICs) in the coming decades. Although the contributions of human and veterinary antibiotic misuse to this crisis are well-recognized, environmental transmission (via water, soil or food contaminated with human and animal faeces) has been given less attention as a global driver of AMR, especially in urban informal settlements in LMICs - commonly known as 'shanty towns' or 'slums'. These settlements may be unique hotspots for environmental AMR transmission given: (1) the high density of humans, livestock and vermin living in close proximity; (2) frequent antibiotic misuse; and (3) insufficient drinking water, drainage and sanitation infrastructure. Here, we highlight the need for strategies to disrupt environmental AMR transmission in urban informal settlements. We propose that water and waste infrastructure improvements tailored to these settings should be evaluated for their effectiveness in limiting environmental AMR dissemination, lowering the community-level burden of antimicrobial-resistant infections and preventing antibiotic misuse. We also suggest that additional research is directed towards developing economic and legal incentives for evaluating and implementing water and waste infrastructure in these settings. Given that almost 90% of urban population growth will occur in regions predicted to be most burdened by the AMR crisis, there is an urgent need to build effective, evidence-based policies that could influence massive investments in the built urban environment in LMICs over the next few decades.

Small towns lag behind cities in drinking water and sanitation access globally. Closing this gap requires developing service models for areas with both urban and rural characteristics. This study assessed Bushenyi-Ishaka, a municipality in Uganda situated at the rural-urban transition, with a focus on service ladder indictors. Data sources included household interviews (n = 500) and water quality samples from sources and storage containers. Households in more urban (as compared to rural) cells were more likely to use improved water sources (including piped water on-premises), make regular payments for water, rely on shared sanitation facilities, and make use of manual sludge emptying services. Most households (72%) used an unlined pit latrine not intended for emptying and reuse. These findings suggest that small town servicing models should prioritize non-sewered sanitation management, including incentives for safe excreta containment and disposal opportunities. This study also highlights a need for integrated services models to expand rural-urban water and sanitation coverage.