Arch Dis Child 95:898-902 doi:10.1136/adc.2009.179648
  • Original article

Reported care giver strategies for improving drinking water for young children

  1. Ashley Farrelly2
  1. 1University of Calgary, Calgary, Canada
  2. 2London University of Tropical Medicine and Hygiene, London, UK
  1. Correspondence to Dr John D McLennan, TRW Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada; jmclenna{at}
  • Accepted 13 April 2010
  • Published Online First 22 June 2010


Objectives Care givers may engage in a variety of strategies to try and improve drinking water for children. However, the pattern of these efforts is not well known, particularly for young children in high-risk situations. The objective of this study was to determine care giver-reported strategies for young children with (1) undernutrition and (2) living in an unplanned poor peri-urban community in the Dominican Republic.

Methods Practices reported by care givers of young children from a community and clinic group were extracted from interviews conducted between 2004 and 2008 (n = 563). These results were compared to two previous similar samples interviewed in 1997 (n = 341).

Results Bottled water is currently the most prevalent reported strategy for improving drinking water for young children. Its use increased from 6% to 69% in the community samples over the last decade and from 13% to 79% in the clinic samples. Boiling water continues to be a common strategy, particularly for the youngest children, though its overall use has decreased over time. Household-level chlorination is infrequently used and has dropped over time.

Conclusions Care givers are increasingly turning to bottled water in an attempt to provide safe drinking water for their children. While this may represent a positive trend for protecting children from water-transmitted diseases, it may represent an inefficient approach to safe drinking water provision that may place a financial burden on low-income families.

Unsafe drinking water is an important risk factor for mortality and disease burden in developing regions.1 This is especially important for young children given their susceptibility to diarrhoeal mortality, due in part to unsafe drinking water.2 When the quality of drinking water is in doubt, care givers may engage in strategies to improve drinking water for their children. Understanding the pattern of practices may inform health promotion efforts for supporting care givers in optimising child health.

Child care givers, particularly mothers, may be key decision-makers for which, if any, household water treatment (HWT) strategy to employ to improve drinking water for young children, versus (1) older children where there may be less control over drinking water type intake, and/or (2) whether non-household strategies will be employed, such as the development of a piped water system. Although HWT strategies are not currently core indicators of progress towards meeting the Millennium Developmental Goal of reducing the proportion of the population who lack sustainable access to safe drinking water,3 4 these strategies are promoted by some groups as a viable option for improving drinking water,5 some of which are shown to reduce childhood diarrhoea.6 However, whether they are ready for “going-to-scale” is still under debate.7

What is already known on this topic

  • Quality drinking water is an important contributor to child health.

  • Household water treatment strategies are commonly employed in low- and middle-income countries to try and improve drinking water quality where water delivery systems may be inadequate.

What this study adds

  • This study identifies an increase in reliance on bottled water as a key drinking water improvement strategy for young at-risk children in the Dominican Republic.

  • This study identifies child age as an important factor that influenced the type of household-level drinking water improvement strategies, particularly use of boiling water.

In a recent analysis of 67 national surveys of HWT, guidelines of the WHO/UNICEF Joint Monitoring Program were used to categorise reported HWTs as “microbiologically effective” or “adequate” for boiled, bleached, filtered or solar disinfected and “inadequate” for strained or settled water.8 9 A total of 33% of households reported use of HWT, 29% of which used “adequate” strategies, with boiling being the most common (21%).8

National surveys may not always provide adequate detail on HWT or information on specific subgroups. For example, some surveys ask about practice at the household level, though practices may vary within households.8 For example, in the 2007 Demographic and Health Survey for the Dominican Republic, approximately one-quarter of households endorsing boiling or filtering drinking water indicated it was only done for children in the household.10 Furthermore, HWT may vary as a function of child age. In a study in a peri-urban community in the Dominican Republic, care givers were more likely to endorse boiling water for younger versus older children.11

Although not typically included in studies of HWT, use of bottled water can be a strategy employed by care givers as a perceived safer drinking water source (eg, ref 12). Little information is known, however, about the extent of use of bottled water in low- and middle-income countries (LMICs), though some reports suggest levels may be high in some countries.3 For example, 67% of urban and 35% of rural households in the Dominican Republic reported bottled water as their primary drinking water source, despite most having access to a public water distribution system.10 Use for children was not specified, however.

While nationally representative data are important, specific information is needed about high-risk subgroups, particularly those at greater risk for health problems. Two high-risk groups of children are considered in this study: (1) children with undernutrition and (2) children living in unplanned peri-urban communities. Undernutrition is a major underlying determinant of death in children, often in combination with infectious diseases.2 Malnutrition is also a risk factor for longer duration of diarrhoeal illness.13 Quality of drinking water for malnourished children is particularly important to prevent exposure or re-exposure to pathogens. Extent of HWT may vary for children with malnutrition.14

Rapidly growing, unplanned (ie, “squatter”), peri-urban communities in LMICs are important settings in which to determine use of improved drinking water, as children may be at higher risk for poor health. Although urban areas generally have better access to improved water than rural areas, there has been an increase in the absolute number of persons in urban areas without access to improved drinking water in LMICs.3 This is a particular problem in peri-urban communities where population expansion may outstrip infrastructure development. Although national data can help determine differential access to quality drinking water along economic lines in urban populations,8 15 unplanned neighbourhoods may not be specifically indexed, limiting the ability to determine differential access in these settings.

This study examines strategies employed by care givers of young children within two samples drawn from high-risk populations in the Dominican Republic: (1) children living in a poor, unplanned peri-urban community and (2) children attending a clinic for the treatment of undernutrition. The objectives were to determine (1) the extent of use of different strategies to improve drinking water by care givers of young children, (2) the variation in practice as a function of child age and (3) the changes in frequency of strategies used compared to a decade ago.



The setting was a district on the outskirts of the city of Santo Domingo, Dominican Republic, comprised of several planned and unplanned communities. The Recent Community Sample (RCS) was recruited from one unplanned neighbourhood. Squatters moved into the essentially uninhabited area approximately 20 years ago. Substantial improvements have been realised in this community, including paving some roads and a partially developed water delivery system.

The Past Community Sample (PCS) was recruited from six unplanned neighbourhoods in this district, including that used for the RCS. The five additional neighbourhoods are similar to that of the RCS. Additional details on this sample are reported elsewhere.11

Both the Recent Nutrition Clinical Sample (RNCS) and Past Nutrition Clinical Sample (PNCS) were recruited from a nutrition clinic based in a non-governmental hospital in this same district. Most attendees are from this district and most referrals came from the hospital's general paediatric clinic.


The RCS (n = 251) was recruited from a door-to-door inquiry for a care giver of a child 6 years of age or under in the residence between February 2007 and August 2008. If there was more than one young child per household, one was selected randomly. Recruitment visits occurred twice more if no one was home. The non-response rate was not collected, though refusals were rare.

The PCS (n = 266) was similarly recruited door-to-door; however, every 10th home on each road was visited to identify care givers of a child 5 years of age or under in the household between June 1997 and November 1997. Additional sample details are reported previously.11 Two eligible families declined participation (99% participation rate).

The RNCS (n = 312) is comprised of care givers recruited from consecutive admissions to the child nutrition program at the participating hospital between July 2004 and November 2009. Although the suggested admission criteria for the clinic was a weight for height Z score ≤ −2 using the 2000 growth parameters of the Centers for Disease Control,16 several children with lesser degrees of thinness were enrolled in the clinic and were still eligible for this study. Anthropometrics were available for 253 children (81.1%) in this sample. Weight for height Z scores were M = −2.57 (SD 1.44).

The PNCS (n = 75) is comprised of care givers recruited from consecutive admissions to the child nutrition program between April 1997 and December 1997. Only mid upper arm circumference values were available (M = 129 mm, SD = 15 mm).


The care giver of each eligible child was invited to participate in a structured interview, conducted by Dominican researchers. All participants signed informed consent forms. Each of RCS/RNCS and PCS/PNCS received the same interview schedule.


Questions on water use from the “Recent” Interview Schedule

Care givers were asked how frequently the index child drank boiled, chlorinated, bottled and untreated water. Frequency options were “never” (nunca), “almost never” (casi nunca), “sometimes” (algunas veces), “almost always” (casi siempre) and “always” (siempre). “Almost never” was collapsed into “never” and “almost always” into “always” as these “almost” responses were rarely endorsed.

Questions on water use from the “Past” Interview Schedule

The interview schedule used in 1997 had some important differences in key questions about drinking water use. For treated types, ie, bottled, boiled and chlorinated, care givers had a “yes”/”no” response option. For untreated water use, the response options were “almost always”, “sometimes” and “almost never”.

To compare recent and past groups, “always”, “almost always” and “sometimes” responses of recent cohorts were collapsed to compare with “yes” for the past cohorts.


Frequency distributions were generated to describe HWT strategies for improving drinking water. Pearson's χ2 and Student t tests were used to compare cross sample differences in water improvement strategies. χ2 Tests were used to compare use of strategy by child age group.


The study was approved by the Bioethics Committee of the University of Calgary for the studies of the two recent samples, and the institutional review board committee of the University of Pittsburgh for the data from the early comparison samples. The participating Dominican hospital did not have an ethics committee. Senior administration at the Dominican hospital accepted the ethics reviews by the above bodies and approved the study.


Characteristics of the samples are summarised in table 1. Mothers were the most common respondents across all samples. The recent groups had more education and fewer children, and the index children were slightly older and less likely to have had a recent diarrhoeal episode.

Table 1

Characteristics of study participants by sample typea

Frequency distributions of the water improvement strategies are summarised in table 2. Bottled water is the most frequent strategy reported by both recent samples, which occurred both at the “always/almost always” and “sometimes” levels, suggesting bottled water is a main approach, as well as a supplementary approach for drinking water improvement. Rates of bottled water consumption reported in recent samples are much higher than those from the 1997 samples. A reduction in use of chlorination and non-treated water over time was also observed. Within the clinic population, there was a dramatic reduction in use of boiling, which has been replaced by bottled water given that the overall rates of “any” strategy not significantly changing from its early high rate. Finally, the recent community sample reported a higher use of “any” strategy, mainly driven by bottled water.

Table 2

Frequency of different water improvement strategies by sample typea

The relationship between water improvement strategies and child age are summarised in table 3. Boiling is the most common strategy for children under 1 year of age, which markedly decreases over time. By contrast, bottled water use increases with age. Untreated water use is rare in the youngest children and increases with age. These patterns are evident in both recent samples.

Table 3

Water improvement strategy by child age for recent samples

Bottled water is typically purchased in recyclable 5-gallon bottles. These are obtained at corner stores and the empty bottles returned for exchange with a full bottle. Reported costs typically ranged from 20 to 45 Dominican pesos/refill. Estimated weekly expenditures on water ranged from 0 to 400 pesos, with 78% reporting >0 pesos expenditures. Mean weekly expenditure was 59 (SD 55) pesos, representing a mean of 5.2 (SD 6.9) percent of income for a subgroup that reported typical household income (47% of recent samples).


HWT strategies were commonly employed for young children. Bottled water use has dramatically increased and now represents the most commonly employed strategy. Water purification, especially boiling, decreases with increasing child age as reported previously.11 Bottled water use increases with age, indicating a degree of replacement of practice over time. Adult consumption was not considered in this study; however, given high rates of bottled water use reported in a Dominican Republic national survey,10 it may be that bottled water use is the preferred approach for the whole household. In contrast, boiling water may be used predominately for particular family members at a particular time, in this case, for the earliest years of a child's life.

Lack of confidence in the piped water system was raised informally. Some community members occasionally noticed a strong smell or taste of chlorine from piped water sources. This might deter care givers from adding chlorine at the household level. Issues such as dissatisfaction with tap water, as reported elsewhere,17 may also play a role in the rise of bottled water use. Another concern is that piped water periodically stops without warning in the participating neighbourhoods.

Limitations to this study include reliance on care giver report. There may be a social desirability bias to report higher rates of HWT strategies than actually occurs. Systematic observations would be one approach to verify practices; however, it may alter typical practice. Despite potential social desirability bias, many care givers endorsed the use of non-treated water. Additionally, although social desirability may generally over-estimate frequencies of HWT use, it may not impact on the relative ordering of strategies reported or the pattern by child age.

A second limitation is the change in response options between the past and current samples. It is not obvious what direction any bias would take. However, some of the differences identified across time points are substantial, and the use of other cut points would have also resulted in significant differences across time. The findings are strengthened by replication within two sample types. Another factor limiting the cross-time analysis for the community group is that not all the same neighbourhoods participated in the recent sample. However, there are no obvious differences between these neighbourhoods.

A third limitation is the representativeness of the samples. Typically, the participation rate from the nutrition clinic is over 90%, and hence, this group is likely representative of the clinic. Whether this group represents children with malnutrition in the community is not known. High rates of community recruitment were realised for the past sample. However, it is unknown whether the participating neighbourhoods are representative of other unplanned peri-urban communities, as this was not a representative or random sample of unplanned urban neighbourhoods in the Dominican Republic.

A fourth limitation was the failure to collect information on advertisements of bottled water. The extent and impact of bottled water advertisements are important areas to examine to inform understanding of this rapid rise in use; bottled water represents a substantial global business with complex underpinnings.18

Finally, we did not ask about other potentially important water improvement strategies. For example, biosand filters have been piloted in the Dominican Republic in one rural district,19 although we are not aware of their use in the participating communities. We also did not ask about obtaining water from small water trucks, although the recent national survey reported this as a primary drinking water source for 12% and 6% of urban and rural households, respectively.

Despite these limitations, this study provides detailed information about current practices and changes in practices over the last decade for at-risk children and offers a partial delineation of household level approaches for improving drinking water for young children. Furthermore, the breakdown by child age informs a more nuanced understanding of current practice. This information may inform health education efforts, although first, there is a need to determine what is optimal for these communities and what should be promoted.


Direct funding sources included a starter grant from the University of Calgary, a Petro Canada Young Innovator Award in Community Health and a grant from the Center for Latin American Studies, University of Pittsburgh for JDM. JDM also received research salary award support from the Alberta Heritage Foundation for Medical Research and the Canadian Institutes of Health Research.


  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Bioethics Committee of the University of Calgary and IRB Committee of the University of Pittsburgh.

  • Provenance and peer review Not commissioned; externally peer reviewed.


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