Why do low-cost point-of-use water treatment technologies succeed or fail in combating waterborne diseases in the field? A systematic review

In a world where the consequences of inequalities in access to safe drinking water persist, Household Drinking Water Treatment Technologies (HDWT) remains the most readily available and promising alternative solution to prevent waterborne diseases. While successful cases of combating waterborne diseases with HDWT have been documented, there are also reports of failures in reducing water-related illnesses. Understanding the reasons behind these inconsistent results is crucial. This work aimed to identify and critically discuss barriers, enablers, and technology delivery strategies for HDWT-based interventions to improve drinking water safety. Data from 147 articles covering Solar Disinfection, Chlorination, Flocculation-Disinfection, BioSand Filter, and Ceramic Water Filter were extracted from a total of 11,982 systematically retrieved records. Among the identified factors, 77 barriers and 76 enablers were distributed across different domains: psychosocial (37.7, 47.4%), promotion (22.1, 26.3%), technology (28.6, 10.5%), economic (9.1, 14.5%), and environmental (2.6, 1.3%) for barriers and enablers, respectively. Technology delivery strategies primarily included water education and technology promotion, training for technology usage, provision of HDWT through donation or promotional sale, donation of safe water storage, technical assistance, and the use of a diarrhea control diary. All barriers and enablers affect the initial adoption, regular, and sustained use of HDWT and should be considered when planning and implementing interventions. The health impacts of interventions decreased over time since HDWT adoption. Adequate user training, HDWT donation, and high compliance are important predictors of success for HDWT-based interventions. In general, identifying and exploring the listed enablers can help overcome many of the reported limitations.