Disparities in awareness and use of household water treatment in Madagascar

Background: Household chlorination solution has been manufactured and promoted in Madagascar by Population Services International (PSI) under the brand name Sūr'Eau since 2000. The purpose of this analysis was to identify disparities in Sūr'Eau awareness and use in Madagascar and to identify potential programmatic strategies for addressing these disparities.

Methods: Using PSI/Madagascar's 2006 nationally representative monitoring data, adjusted prevalence ratios for Sūr'Eau use and awareness were calculated according to key demographic characteristics associated with increased risk of diarrhea morbidity and mortality.

Results: Disparities in product awareness were associated with wealth quintile (PR: 0.46, p < 0.05), level of education (PR 0.50, p < 0.05), and distance to a health center (PR: 0.85, p < 0.05) when the most disadvantaged groups are compared with least disadvantaged groups. Significant disparities in product use were associated with wealth quintile (PR: 0.65, p<0.05) level of education (PR: 0.69, p < 0.05) and age of the respondent (PR: 0.70, p<0.05). Differences in level of awareness contributed significantly to overall population-level disparities in product use. Behavioral determinants of use, including perceived product availability; social norms; and self efficacy; differed significantly within the population and may contribute to overall disparities in use.

Conclusions: Findings suggest that targeted promotion among populations with low levels of awareness coupled with improved product availability in remote areas and product messaging and promotion that addresses key behavioral determinants of use (such as social norms and self efficacy) among at-risk groups may reduce disparities in adoption of point-of-use water treatment in Madagascar.