Recommendations

While much new information has been developed and CBT performance elucidated through the results of this research, additional research inquiries to assess the effectiveness, performance and acceptance of the CBT for E. coli are recommended to address issues that have arisen. Because different physical, chemical and biological parameters of environmental waters can influence water quality, it may be useful to test how specific conditions for these variables may influence the performance of the CBT in detection and quantification of E. coli in water. Due to the success of the pilot studies in incorporating the CBT within some regions of the DHS, it is recommended that a future study should look to using the CBT within all regions of the DHS or another national health survey such as the Multiple Indicator Cluster Survey at national scale. Other applications of water quality analysis for E. coli using the CBT besides drinking water should be evaluated. Such applications include the analysis of agriculture irrigation water, recreational waters, food safety aqueous solutions such as animal carcass and produce wash water, and hand rinse /hand washing samples, and other hygiene samples such as environmental surface swabs. Because these applications could potentially use a tool such as the CBT for E. coli analysis, the CBT should be evaluated for its feasibility performance and validation when

applied to these diverse samples and settings. The association between CBT results for E. coli concentrations in water and diarrheal disease risks from water could be explored in future research. The portability and ease of use of the CBT facilitates such epidemiological-

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health risks. Also, while this research shows that CBT results greatly influence user perception and attitudes about water safety, the associations between the CBT results for household water quality and its impact on health behavior actions should be further evaluated. Specifically, the use of the CBT as a health education tool in water management should be studied more systematically and extensively in different cultures and settings, as well as with diverse audiences.

7.5 Conclusions

A key step to ensuring better water quality around the world is having and using

convenient, accessible, and reliable water quality testing technology that provides actionable data to make management decisions, supports Water Safety Plans, informs water policies and

programs, and stimulates behavior change by people and communities through outreach and education. From the results of this study it is concluded that the Compartment Bag Test (CBT), with minimal training, enables practical, reliable, easy-to-use, actionable water quality testing for fecal microbes, such as E. coli, without the need for a lab, electricity, and supporting equipment.

This research confirms the previous results found by Stauber et al. and shows that the CBT can detect and quantify E. coli in water comparable to standard methods for E. coli detection and quantification, such as the Quanti-Tray Colilert MPN method and membrane filtration (Stauber et al., 2014). Though statistical differences was found between CBT and MF results in the Liberia pilot study, the are several issues concerning failure to follow proper protocol by the reference laboratory that may have contributed to differences. The effectiveness of the CBT for E. coli detection and quantification and its comparability to other E. coli methods,

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specifically membrane filtration methods, was demonstrated in both lab studies on ambient surface water and in field studies on drinking waters in diverse settings with different test users.

From the results of this research it is concluded that the CBT method is robust, easy to use by a variety of different users under different circumstances and in diverse settings. The visible results of the CBT were readily understood, accepted, and capable of influencing the perceptions and attitudes of people about the quality of their water. In this research, people from a variety of backgrounds were able to easily use the CBT to test drinking water for E. coli

presence and concentrations with only minimal training and no prior experience in or knowledge of water quality analysis. The CBT was utilized successfully in a variety of environments and settings, when applied to many different waters, including those in low resource settings and with no access to laboratories. The CBT was incorporated successfully within two national DHS programs on a pilot basis, one in Peru and the other in Liberia, and could be used by field survey staff in the field in the absence of a laboratory.

The CBT has the potential to reliably support widespread and expanded analysis of drinking water quality in a variety of settings for a variety of purposes, including large scale drinking water quality monitoring programs, such as those of the UN JMP. The successful evaluation of CBT for analysis of E. coli in drinking water samples from households and communities supports the JMP proposed water quality target for the post-2015 Sustainable Development Goals (SDGs). The post-2015 SDGs include a measurement of E. coli

concentrations as a fecal indicator of drinking water for monitoring basic and intermediate and safe water service levels, with the safe level defined as no E. coli per 100 mL of drinking water and the intermediate level defined as E. coli at levels no higher than 10 culturable bacteria/100 mL (Bain et al., 2014). The results of the pilot DHS studies in Peru and Liberia demonstrate the

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feasibility of CBT incorporation within national health surveys, which could lead to further evolution and expansion in microbial water quality monitoring, as well as facilitate monitoring efforts for a future drinking water target that includes a direct measure of microbial water quality in households and communities at national scale.

In conclusion, the CBT is an effective and potentially powerful tool to quantitatively evaluate microbial water quality, easily provide water quality analysis training, and positively influence knowledge, attitudes, perceptions and practices regarding water safety and quality. This conclusion is supported by the positive results of the household survey incorporating the use of the CBT to test household drinking water in Mwanza, Tanzania, As documented among household users for the CBT in Mwanza, Tanzania, the simplicity of the test allows anyone with brief training to test their own water, thereby empowering people with knowing if their water is safe or unsafe so that they can determine their own remedial actions. Improved access to simple, actionable water quality testing can drive behavior change and inform decision-making about steps to improve water quality, both in management policies and through on-the-ground water management practices of households and water providers. It is concluded that more accessible and convenient water quality testing could be a transformative catalyst for improving access to safe water and thereby diminish the severe health consequences of unsafe water. By simply making accessible and increasing water quality testing through use of the CBT, safer water for the future can be readily determined and potentially achieved on a more widespread, consistent and sustained basis.

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APPENDIX 1: CBT MPN ESTIMATE OF E. coli PER 100ML WATER SAMPLE