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Bottled water quality and associated health outcomes: a systematic review and meta-analysis of 20 years of published data from China

Alasdair Cohen 7,1,2 , Jingyi Cui 3 , Qingyang Song 3 , Qiwen Xia 3,4 , Jiexuan Huang 3 , Xinjia Yan 3,4 , Yalu Guo 5 , Yixin Sun 5 , John M Colford Jr 6 and Isha Ray 2,4

Published 20 January 2022 • © 2022 The Author(s). Published by IOP Publishing Ltd Environmental Research Letters , Volume 17 , Number 1 Citation Alasdair Cohen et al 2022 Environ. Res. Lett. 17 013003 DOI 10.1088/1748-9326/ac2f65

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1 Department of Population Health Sciences, Virginia Polytechnic Institute and State University, 205 Duck Pond Dr Blacksburg, VA, 24061, United States of America

2 Berkeley Water Center, University of California, Berkeley, CA, United States of America

3 College of Letters and Science, University of California, Berkeley, CA, United States of America

4 Rausser College of Natural Resources, University of California, Berkeley, CA, United States of America

5 College of Engineering, University of California, Berkeley, CA, United States of America

6 School of Public Health, University of California, Berkeley, CA, United States of America

Author notes

7 Author to whom any correspondence should be addressed.

• Received 11 August 2021
• Accepted 13 October 2021
• Published 20 January 2022

Peer review information

Method : Double-anonymous Revisions: 1 Screened for originality? Yes

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Bottled water is a rapidly growing yet relatively understudied source of drinking water globally. In addition to concerns about the safety of bottled water, the adverse environmental health and social impacts associated with bottled water production, distribution, consumption, and reliance are considerable. Our objective was to comprehensively review, analyze, and synthesize ∼20 years of publicly available data on bottled water quality and associated health outcomes in China. We conducted a systematic review and meta-analysis of publicly available studies of bottled water quality and associated health outcomes in China published between 1995 and early 2016 (in Chinese and English). We pre-specified and registered our study protocol, independently replicated key analyses, and followed standardized reporting guidelines. Our search identified 7059 potentially eligible records. Following screening, after full-text review of 476 publications, 216 (reporting results from 625 studies) met our eligibility criteria. Among many findings, 93.7% (SD = 10.1) of 24 585 samples tested for total coliforms ( n = 241 studies), and 92.6% (SD = 12.7) of 7261 samples tested for nitrites ( n = 85 studies), were in compliance with China's relevant bottled water standards. Of the studies reporting concentration data for lead ( n = 8), arsenic ( n = 5), cadmium ( n = 3), and mercury ( n = 3), median concentrations were within China's standards for all but one study of cadmium. Only nine publications reported health outcome data, eight of which were outbreak investigations. Overall, we observed evidence of stable or increasing trends in the proportions of samples in compliance over the ∼20 year period; after controlling for other variables via meta-regression, the association was significant for microbiological but not chemical outcomes ( p = 0.017 and p = 0.115, respectively). Bottled water is typically marketed as being safe, yet in most countries it is less well-regulated than utility-supplied drinking water. Given the trend of increasing bottled water use in China and globally—and the associated environmental health impacts—we hope this work will help to inform policies and regulations for improving bottled water safety, while further highlighting the need for substantially expanding the provision of safe and affordable utility-supplied drinking water globally.

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1. Background and justification

From the 1990s on, global consumption of bottled water has grown rapidly as it has expanded from markets primarily centered in high-income countries (HICs) to those in low- and middle-income countries (LMICs). The majority of the world's bottled water is now consumed in LMICs [ 1 ]. Global growth in bottled water consumption is attributed to consumer demand—driven by perceptions that it is safe and convenient—and is fueled by widespread marketing [ 2 ]. Studies on consumer preferences in HICs find that perceived safety and convenience are the primary reasons for bottled water use [ 3 , 4 ]. While utility-provided safe water access has expanded over the last few decades in most large LMICs, consumption of bottled water has increased far more rapidly [ 5 ].

Compared with water utilities that supply piped drinking water (municipal water), regulations for bottled water production in LMICs and HICs are typically less rigorous, and water quality testing and monitoring are required far less frequently. One of the few relatively extensive and publicly available studies on bottled water in the USA concluded that bottled water was not necessarily safer than tap water overall, and ∼20% of the brands tested were contaminated at levels above California's standards [ 6 ].

Beyond concerns about the safety of bottled water, the negative social and environmental health impacts associated with bottled water production, distribution, consumption, and reliance are considerable. Bottled water costs hundreds to thousands of times more per liter than treated piped water [ 2 , 6 ], and the negative environmental impacts associated with single-use plastic bottle production and disposal have become a global concern [ 7 ]. Life cycle assessments of bottled water production, transportation, and associated waste help quantify the scope of adverse environmental impacts and demonstrate that contributions to greenhouse gas emissions are orders of magnitude higher than those associated with utility water supply [ 8 , 9 ]. In recent years, multiple studies have found microplastic contamination to be near-ubiquitous in surface waters, and frequently detected in bottled water samples as well [ 10 , 11 ].

At this writing, we are aware of only two published bottled water focused systematic reviews. Williams et al [ 12 ] conducted a relatively comprehensive review focused on fecal contamination in packaged and bottled water in LMICs; however, as the authors noted in their review, they did not include results from China due to the language barrier. The other systematic review focused only on fluoride concentrations in bottled water [ 13 ], but likewise did not review Chinese-language results. In addition, in a recently published non-systematic review [ 14 ] focused on emerging contaminants (including microplastics), as well as contamination attributed to the types of plastic used for water bottles, the authors did not appear to include results from Chinese-language publications. This is noteworthy when one considers that in 2013, China surpassed the USA to become the world's largest market for bottled water by volume [ 15 ]. Furthermore, limited available data indicate that even in rural China more and more households are turning to bottled water (19 l bottles) as their primary source of drinking water [ 16 , 17 ].

Thus, there appears to be a substantial 'China gap' in the bottled water research literature. China's population is large, its consumption of bottled water is increasing, and it has a relative wealth of publicly available data from published studies on bottled water quality—in contrast to the relatively limited bottled water focused research literature from the USA or Europe. To address this research gap, we conducted a systematic review and meta-analyses focused on bottled water contamination and associated health outcomes in China. The objective of this work was to synthesize publicly available data on bottled water contamination in China published over a period of approximately two decades, analyze data and trends, and attempt to shed light on the underlying causes of reported bottled water contamination.

We conducted a systematic review of published and publicly accessible studies on bottled water contamination and associated health outcomes in China. We registered our study protocol with the International Prospective Register of Systematic Reviews (PROSPERO, 2016:CRD42016048863, www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016048863 ) and on Open Science Framework (OSF; including our search terms, sets, code, and relevant Chinese/English translations: https://osf.io/yqbdy ). All statistical analyses were conducted using Stata (v.15), and our primary analyses were independently replicated using R (v.4.0.3). This manuscript was prepared in accordance with the PRISMA reporting guidelines [ 18 ], and a completed checklist is provided in the last section of the supplementary material (SM).

2.1. Eligibility criteria

We wished to collect and analyze data from any study or investigation of bottled water quality in China. Studies were considered eligible if they measured, quantified, evaluated, assessed, or otherwise tested bottled water samples in China for microbiological and/or chemical contaminants (including heavy metals and radionuclides, but not microplastics), reported original analyses and results, were conducted during or after 1990, and were published between 1995 and early 2016. We did not limit our eligibility based on who evaluated the water quality (universities, government agencies, private companies, other) or based on the type of study design, use of comparison groups, controls, or specific water sampling methods. For the purposes of this review, bottled water was defined as any type of packaged drinking water.

For our key outcome measures, we considered any microbiological contaminants with known links to health to be eligible (whether reported as presence/absence, percentage of samples meeting national/local standards, or mean or median concentrations), provided that such outcomes were directly assessed/measured. Studies based on qualitative descriptions of bottled water quality were not considered eligible. We used these same criteria for chemical contaminants with known or suspected links to health (organic, inorganic, radionucleic, disinfection byproducts). Similarly, we considered any health outcomes with direct or hypothesized links to the consumption of bottled water to be eligible, provided the study also assessed at least one indicator of bottled water contamination. Additional details on our inclusion and exclusion criteria are provided in our PROSPERO protocol (2016:CRD42016048863).

2.2. Search strategy

To identify potentially eligible studies, we searched the primary Chinese-language databases, CNKI ( www.cnki.net/ ) and Wanfang ( http://librarian.wanfangdata.com.cn ), as well as the online databases PubMed/MEDLINE, EMBASE, and Web of Science. We limited our searches to all records (English or Chinese) published from 1995 to April 2016, when the searches were conducted.

For CNKI, we searched titles and abstracts in six separate databases; for Wanfang we searched titles, keywords and abstracts in nine separate databases. For the Chinese-language databases we used three sets of search terms to identify all records related to: bottled water, microbiological contaminants , and/or chemical contaminants . For water contaminants (microbiological, chemical, etc) we included all parameters listed across China's official Drinking Water Standards at the time of the search, as well as any additional parameters listed in drinking water standards of the World Health Organization and US Environmental Protection Agency.

For the databases PubMed/MEDLINE, EMBASE, and Web of Science, early piloting of our search terms and sets showed that there were very few records related to bottled water in China. Therefore, to ensure that we identified all potentially eligible records in these three databases, we used search sets and search terms for bottled water and China (all variants of the country name), and did not use search sets and terms to specify individual microbiological and chemical parameters. To ensure that we did not inadvertently overlook non-Chinese language records using the term 'packaged water' (rather than 'bottled water'), a search for 'packaged water' and the variants of 'China' (e.g. 'PR China') was also conducted via a hand-search using Google Scholar.

All search sets and terms, as well as English translations of Chinese search terms, the search code used for database searches, as well as additional notes, are available online on OSF (at https://osf.io/yqbdy ).

2.3. Record screening, data extraction, and derivation protocols

Three reviewers (XY, QX, QS) screened all available titles and abstracts to identify potentially eligible records for full-text review. For the initial record screening step, to avoid inadvertent bias from viewing author name/s, publication type, journal names, etc, only the record titles and abstracts were reviewed. Any records that, based on the content in the title and/or abstract, could have possibly discussed bottled water related analyses in China were retained. To assess inter-rater reliability and evaluate the potential need for full duplicate title/abstract screening, 100 records were selected at random and independently screened by all three reviewers (XY, QX, QS).

Five researchers (QS, QX, JC, PD, JT) reviewed all the potentially eligible full-text records to determine eligibility for data extraction. For each eligible study with extractable data, data was entered into a pre-specified data extraction template (using Google Sheets). To assess the accuracy of the data extraction, data from a random selection of ∼10% of eligible full text records were extracted independently by pairs of reviewers. Following initial data review, to facilitate data cleaning three researchers (QS, QX, JC) reviewed the extracted data for all full-text records assessed to be eligible for inclusion. Given the number of parameters for which we sought to extract data, following these steps we conducted extensive quality control and data cleaning over a period of multiple years.

2.4. Data analyses

Assuming sufficient data was available, our pre-specified objective was to conduct meta-analyses for all primary contaminant classes as well as for specific contaminants, indicators of contamination, and testing methods. For our analyses of health outcomes, we anticipated that inter-study variability (resulting from differences in study designs, bottled water types, sample collection methods, analytic protocols, etc), as well as random error, would be best addressed by using meta-analysis with a random-effects based weighting. If the data structure permitted, we also pre-specified to conduct a meta-regression analysis (with random effects).

We pre-specified subgroup analyses in our protocol (and also as a means of evaluating expected heterogeneity, using standard methods such as the I-squared statistic). To assess studies by climatic region, we binned studies based on province into four categories [ 19 ]: cold and mild temperate, warm temperate, mild subtropical, and subtropical/tropical (see table S1 available online at stacks.iop.org/ERL/17/013003/mmedia ).

We conducted meta-regression analyses to assess heterogeneity and potential confounders, using a generalized linear model with a logit link, binomial distribution, and cluster-robust standard errors (treating included eligible papers as clusters to adjust for outcomes from multiple sub-studies). For our meta-regression analyses, our outcome variable was the reported passing rate (expressed as a proportion) for all microbiological and chemical parameters for which we extracted data, and we analyzed the following covariates: the year of study publication, the study setting (rural, urban, other), the study setting climate, an indicator of provincial level economic consumption (low, medium, and high levels), the type/source of the bottled water (mineral, spring, purified, other), and the number of bottled water samples analyzed. Because many publications reported multiple results for the same parameters from different sub-studies, standard errors were adjusted to control for the clustered nature of the data.

2.5. Assessment of bias

We anticipated significant heterogeneity in study methods and reporting among those records eligible for data extraction. To assess risk of bias (ROB), we adapted approaches from previously published systematic reviews [ 20 – 22 ] and created a composite index based on six variables (assessing sampling methods and how study methods and protocols were reported), each of which was scored on a three-point scale (see table S2 for details). To assess potential publication bias, we used standard methods (Egger's test, funnel plots).

3.1. Search and screening results

Our search resulted in the identification of 7059 potentially eligible records (after duplicate removal) (figure 1 ). Through title and abstract screening, we identified 476 potentially eligible records. For the randomly selected sub-sample of 100 records the kappa statistic for three reviewers (XY, QX, QS) with two possible outcomes (yes, no) was 0.83 ( z = 14.3, p < 0.001), indicating a very high degree of inter-rater agreement [ 23 ]; therefore, we did not conduct additional duplicate review for the title/abstract screening stage. Of the 476 records identified for full-text review, we were unable to find the full text for 39, and a further 221 were excluded for various reasons, as outlined in figure 1 (additional details in table S3).

Figure 1.  Study screening and selection flow chart.

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3.2. Characteristics of eligible studies with extractable data

All 216 of the eligible records with extractable data were journal publications; 110 reported results for microbiological parameters only [ 24 – 133 ], 67 reported results for microbiological and chemical parameters [ 134 – 200 ], 30 reported results for chemical parameters only [ 201 – 230 ], and nine reported results for health outcomes and microbiological parameters [ 231 – 239 ].

As shown in table 1 , of the publicly available records which were eligible for inclusion in our review, 84% ( n = 182) were authored by employees from Chinese government agencies. Among these 182 records, 43% ( n = 78) were published by authors from various Center for Disease Control and Prevention (CDC) agencies, 29% ( n = 53) by authors working at government Sanitation and Anti-Epidemic Stations, and 15% ( n = 27) by authors from Institutes for Health Inspection. Sanitation and Anti-Epidemic Stations were the predecessors for today's China CDC agencies, and Institutes for Health Inspection are affiliated with the China CDC, meaning the vast majority of studies that were eligible for inclusion in our review were conducted and published by authors from China CDC and affiliated agencies.

Table 1.  Overview of eligible records with extractable data.

Notes: Gov. = government; Uni. = university; BW = bottled water; nfs = not further specified.

Across the 216 eligible papers, results from 625 studies were reported (i.e. multiple results reported for parameters based on the analysis of samples collected from different sources and locations). Most studies reported results for water quality parameters in terms of the 'passing rate'; that is, the proportion of samples with test results that were in compliance with the relevant Chinese bottled water standards at the time of the study (the passing rate, '合格率', is a commonly-used metric in China).

Of the papers that reported one or more microbiological outcomes ( n = 186), only 10% ( n = 18) provided specific concentrations (e.g. coliform forming units/100 ml). Of the papers that reported one or more chemical outcomes ( n = 97), 28% ( n = 27) reported results in terms of specific concentrations (e.g. mg l −1 ). In addition to extracting reported data, in cases where sufficient data for passing rates and/or concentrations were reported, we also calculated concentrations and passing rates ourselves (equations for such calculations, along with notes describing where data were found, are embedded in the relevant cells in our SM excel data file available online at stacks.iop.org/ERL/17/013003/mmedia ). Summary tables for China's primary bottled water, and drinking water, standards are provided in tables S4 and S5.

We extracted data on the location of the study by province (figure 2 ) and setting where study samples were collected: rural, urban or peri-urban, or a combination thereof (table 1 ). The majority of studies—overall and by paper type (microbiological, chemical, microbiological and chemical, health outcomes)—were conducted in the relatively higher-income provinces along China's coast (figure 3 ). We also sought to extract data on the brands of water tested, but this information was provided for only a few studies. Similarly, we attempted to extract data on the method(s) of bottled water treatment used, but only 16 eligible papers provided such information. A histogram of eligible papers by year of publication and paper type is provided in figure S1.

Figure 2.  Map of China with number of eligible publications with extractable data by province: all study types. Note: three publications (Wu Q 2009, Xu B 2001, and Zhang Z 2009) reported data from multiple provinces.

Figure 3.  Eligible publications with extractable data by province: microbiological outcomes (a), microbiological and chemical outcomes (b), chemical (c), health outcomes (d). Note: three publications (Wu Q 2009, Xu B 2001, and Zhang Z 2009) reported data from multiple provinces.

3.3. Microbiological outcomes

Studies that reported results for only microbiological parameters are summarized in table 2 , and those that reported results for microbiological and chemical parameters are summarized in table 4 . As shown in figure 4 , for those studies reporting data for specific pathogens such as Salmonella, Shigella, and Staphylococcus, in almost all cases the samples were reported to be in compliance with China's relevant bottled water standards at the time the studies were conducted (boxplots are shown in figure S2). However, for several indicators of microbiological contamination, such as total bacteria and total coliforms, many bottles water samples were assessed to exceed the relevant standards (i.e. were not in compliance).

Figure 4.  Passing rate means and 95% confidence intervals (CI) for selected microbiological parameters.

Table 2.  Overview of eligible records with microbiological outcomes ( n = 110).

Notes: nfs = not further specified; MD = missing data.

Table 4.  Overview of eligible records with microbiological and chemical outcomes ( n = 67).

Across microbiological parameters, most studies reported data for total bacteria and total coliforms. As shown in table 3 , the mean passing rate from 297 studies of total bacteria was 71.1% (SD = 18.5), and 93.7% (SD = 10.1) for the 241 studies of total coliforms, and 88.9% (SD = 5.8) for the 17 studies of P. aeruginosa (see table S6 for unweighted data).

Table 3.  Summary statistics for reported passing rates for selected microbiological parameters.

Notes: nfs = not further specified. Statistics weighted by study sample sizes. Excludes results from eight publications reporting results from outbreak investigations. a Study authors reported aggregated results using this classification, with insufficient available data to extract 'passing rate' results for specific organisms.

As shown in figure 5 , looking at passing rate results by year of study publication, from the late 1990s to late 2000s the mean proportion of samples in compliance increased (improved) slightly for total bacteria. We did not observe evidence of strong temporal trends for total coliforms (publication-specific boxplots for both parameters in figures S3 and S4).

Figure 5.  Samples in compliance for total bacteria and total coliforms by publication years.

3.4. Chemical outcomes

Studies that reported results for chemical parameters are summarized in tables 4 and 5 . Among chemical parameters analyzed, results for lead, arsenic, and nitrite were most commonly reported. Mean passing rates for most parameters were >95% (figure 6 and table 6 ) though this was not the case for nitrites (mean = 92.6%) or for disinfection byproducts (mean = 71.2%) (boxplots in figure S5 and unweighted data in table S7).

Figure 6.  Passing rate means and 95% confidence intervals (CI) for selected chemical parameters.

Table 5.  Overview of eligible records with chemical and related outcomes ( n = 30).

Note: MD = missing data.

Table 6.  Summary statistics for reported passing rates for selected chemical parameters.

Notes: nfs = not further specified. Statistics weighted by study sample sizes. a Study authors reported aggregated results using this classification, with insufficient available data to extract 'passing rate' results for specific organisms or indicators.

Looking at the results from studies that measured nitrite and nitrate by year of study publication (figure 7 ), there is evidence of a positive trend over most of the time span covered in our review (i.e. studies reported higher average passing rates); the trend is more pronounced for nitrites than for nitrates (publication-specific boxplots in figures S6 and S7).

Figure 7.  Samples in compliance for nitrate and nitrite by publication year.

As discussed previously, relatively few studies reported results in terms of specific concentrations. Across the papers that did report specific concentrations for lead ( n = 8), cadmium ( n = 3), arsenic ( n = 5), and mercury ( n = 3), aside from one study reporting results for cadmium (Zhou 2016) median concentrations for these heavy metals were all in compliance with China's national bottled water standards (figure 8 ) (additional details in table S4).

Figure 8.  Boxplots of reported concentrations by study for lead (a), cadmium (b), arsenic (c), and mercury (d), with references to China's national maximum contaminant standards for bottled water (GB19298-2003) (red dashed lines) (additional details in table S4).

3.5. Health outcomes

Studies that reported results for health outcomes and microbiological parameters are summarized in table 7 . Eight of the nine studies which reported data for health outcomes were outbreak investigations, and of those, only four (case-control study designs) reported sufficient data for comparative analysis. As shown in figure 9 , across these four case-control outbreak investigations, consumption of bottled water was significantly associated with an increase in the pooled odds of reported gastrointestinal illness (logged OR = 1.90, p < 0.001). However, because these investigations were conducted in response to disease outbreaks, and focused on student populations, the results are not generalizable to more typical situations and settings.

Figure 9.  Forest plot—case-control studies of bottled water consumption and gastroenteritis.

Table 7.  Overview of eligible records with health and microbiological outcomes ( n = 9).

Note: nfs = not further specified.

Funnel plot asymmetry indicated some evidence of potential publication bias (see figure S8). It is reasonable to assume that similar case-control studies with null findings may have been conducted over this time period, but were perhaps not submitted for publication. More broadly, the nature of these studies limits our ability to generalize beyond outbreak settings.

3.6. Meta-regression

As shown in table 8 , results from meta-regression analyses indicated that, after controlling for other variables in the models, reported passing rates for microbiological and chemical outcomes were positively associated with the year of study publication, though the association was only statistically significant for microbiological outcomes, and not for chemical outcomes ( p = 0.017 and p = 0.115, respectively) (model-predicted passing rates for both outcomes in figures S9 and S10). Reported passing rates were significantly lower (i.e. worse) for studies conducted in rural regions compared with urban and other settings, for both microbiological and chemical outcomes ( p = 0.041 and p = 0.002, respectively); however, relatively few studies ( n = 13 and n = 2, respectively) were conducted in primarily rural settings (table S8).

Table 8.  Meta-regression results for proportion of microbiological and chemical samples in compliance.

Note: Excludes results from eight publications reporting results from outbreak investigations; BW = bottled water. a Cluster-robust standard errors (to adjust for publications reporting results from multiple studies).

4. Discussion

4.1. results in context: climate and economic indicators.

We observed some evidence of differences in mean passing rates for microbiological outcomes, but not for chemical outcomes, by climatic region (table 9 and figure S11). This observation of higher overall passing rates in warmer and wetter regions (i.e. more samples found to be in compliance compared with cold/mild and warm regions) is potentially at odds with previous drinking-water focused research which found higher overall prevalence of fecal indicator organisms in wetter and warmer conditions [ 240 ]; though this would likely depend, among other factors, on bottled water storage durations prior to testing (and we lacked the data needed to evaluate this potential association).

Table 9.  Passing rates for microbiological and chemical outcomes by study climatic region.

Notes: Means and standard deviations adjusted using sample size based weights. Excludes results from eight publications reporting results from outbreak investigations.

To evaluate the potential impacts of broader economic indicators and socioeconomic status by study setting, we used 2012 Household Consumption Expenditure data from China's National Bureau of Statistics [ 241 ] as a comparative indicator of economic status by province. After sorting provinces into thirds based on this expenditure data, we observe that for microbiological outcomes the mean passing rate from studies conducted in provinces with lower annual consumption expenditures (RMB 8–15 × 10 7 ) was significantly lower compared with the mean from provinces with higher (RMB > 20 × 10 7 ) consumption expenditures (80.1% and 86.8%, respectively; ANOVA, using analytic weights based on sample size, Scheffe's test, p < 0.001). No significant differences in passing rates by levels of consumption expenditures were observed for chemical outcome data (table S9). However, after controlling for other covariates in our meta-regression models (table 8 ), we did not observe any significant associations between these economic indicators and overall passing rates.

4.2. Results in context: bottled water characteristics

Compared with mineral, spring, and other types of bottled water, results from the meta-regression show that passing rates were higher for samples from 'purified' bottled water, and the associations were statistically significant for both microbiological and chemical outcomes ( p = 0.021 and p = 0.014, respectively). However, bivariate analysis of passing rates and bottled water type did not indicate substantive differences in this regard (see table S10).

With regard to the size of the water bottles sampled, we did not observe any significant differences in mean passing rates for chemical outcomes and bottle size (table 10 ). However, for studies reporting microbiological outcomes based on samples from smaller water bottles (<2 l), the mean passing rate (72.1%) was more than 10% points lower than the mean passing rate (83.4%) from studies of larger water bottles (>10 l) (Analysis of variance [ANOVA], using analytic weights based on sample size, Scheffe's test, p < 0.001 for comparison between small and large categories).

Table 10.  Passing rates for microbiological and chemical outcomes by bottled water size.

Notes: Means and standard deviations adjusted using sample size based weights. Excludes results from eight publications reporting results from outbreak investigations. a Study authors reported combined results from analysis of small and large bottles.

Looking at only those studies that reported results for total coliforms (table 10 ), we see that the mean passing rate is also significantly lower for small bottles compared with larger ones (ANOVA, using analytic weights based on sample size, Scheffe's test, p < 0.001 for comparison between small and large categories). These findings with regard to small versus large bottles and microbiological passing rates are somewhat at odds with previous research (outside of China) which found more evidence of microbiological contamination in larger water bottles [ 12 ]. Whereas 131 papers reported the size of the water bottles sampled in qualitative terms (e.g. 'small', 'large'), only 21 papers reported the specific size of the bottles in number of liters. For those papers ( n = 21), the data are suggestive of higher levels of microbiological contamination (i.e. lower passing rates) in larger bottles, but the differences between smaller bottles (<1 l) and large (∼19 l) was not significant (see figure S12). With regard to contamination and risks of exposure associated with the use of small- or large-sized bottles, most Chinese households who use large water bottles heat or boil the water before consuming it, a practice that would be expected to reduce pathogen exposure [ 22 , 242 ]; this is not typically the case with small, single-use, water bottles. That said, because larger bottles are not typically consumed immediately after being opened, consumption over a period of days or weeks could provide more time for organism growth if the bottled water was already contaminated when purchased, or became so after the bottle was opened. Overall then, we cannot draw clear conclusions from these data with respect to relationships between bottled water size and reported passing rates.

4.3. Methodological rigor and risk of bias analysis

Studies were assigned an ROB score based on six items (table S2) and were then divided into thirds and assigned to groups for low, medium, and high ROB (table S11 and figure S13). Looking at passing rate trends by publication year, for studies assessed to have a higher ROB (i.e. a higher likelihood of methodological shortcomings or other limitations) the average reported passing rates were lower overall (i.e. worse) compared with studies assessed to have a medium or low ROB for microbiological and chemical outcomes (figures S14 and S15).

One of the components used to estimate ROB was study sample size. As shown in table 8 (and table S12), we did not observe significant differences in mean passing rates for microbiological outcomes based on the number of bottled water samples used in the underlying studies. However, for studies reporting chemicals outcomes based on relatively large sample sizes (i.e. ⩾61 bottled water samples) the mean passing rate (91%) was significantly lower than for the smaller sample size categories (table S12; ANOVA with Scheffe's test, p < 0.05 for all three comparisons).

4.4. Author-provided hypotheses for observed contamination

The primary objectives of this review were to better understand the nature of bottled water quality in China and to elucidate some of the reasons for observed contamination, with the larger goal of potentially identifying management or policy approaches that could prevent or mitigate contamination. Based on the nature of the available reported data, we cannot responsibly make inferences with regard to reasons for the microbiological and chemical contamination observed. However, in most cases the authors of the individual papers did provide hypothesized explanations for their findings. To examine some common themes across studies, we extracted and synthesized author-provided explanations for observed contaminations (these author-provided explanations should be treated as informed opinions rather than as evidence).

Explanations for observed microbiological contaminants are summarized in figure 10 by climatic region. The hypothesized reasons varied, but in all climatic zones most authors postulated that contamination was due to insufficiently sanitary bottled water production, insufficient source water treatment, insufficient sanitation of reused bottles (typically the large ∼19 l bottles) and insufficient regulations or oversight. Slightly more authors of studies published in subtropical regions hypothesized that the source water was microbiologically contaminated, but this observation may be driven by other factors (e.g. more of China's less economically developed provinces are situated in subtropical regions).

Figure 10.  Hypothesized reasons study authors provided for observed microbiological contamination.

Looking at author-provided explanations for observed chemical contamination over levels of annual consumption expenditures (figure 11 ), we see that most authors mention the same reasons as those offered for microbiological outcomes. However, more authors hypothesized that contaminated source water was an important factor, particularly in provinces with higher indicators of economic development. The confluence of industrialization, economic production, and higher province-level household consumption expenditures might partially explain this association, but as with the would-be explanations associated with microbiological outcomes, other factors are likely relevant as well.

Figure 11.  Hypothesized reasons study authors provided for observed chemical contamination.

4.5. Study limitations

Findings from our review summarize only publicly available data from eligible published studies and are unlikely to be representative of the situation across China with respect to bottled water quality for the approximately 20 year period from 1995 to the beginning of 2016. In addition, because the majority of the reviewed papers came from relatively more economically developed provinces (figure 2 ), our findings are likely not representative of less-developed provinces in China. Only a few studies reported which brands of bottled water were tested, or provided information specific to the source-water location; therefore, we were unable to analyze results based on where bottled water was sourced geographically, or where production facilities were located. We tentatively assumed that in most cases the bottled water sampled was from companies that sourced and produced the bottled water within the province where the study was conducted, or within the region surrounding the province. However, some studies may have focused their testing efforts on nationally available brands (e.g. Nongfu, Wahaha) that are sold across China and that are produced in multiple regional bottled water facilities.

As noted above, most of the eligible studies with extractable data in our review did not provide specific average concentrations and associated measures of variance (e.g. mean and SD) when reporting the results of analyses of microbiological and chemical parameters. Rather, most studies presented results only in terms of the passing rate, and we assumed that study authors were making these determinations (i.e. the proportion of samples in compliance) based on the relevant bottled water standards at the time of sample collection and/or study publication. Consequently, we were not able to assess the degree to which samples were not in compliance (i.e. for non-compliant samples we could not discern whether they fell just below, or markedly below, the standards). The lack of specific concentration data also limited our ability to compare results to specific standards, or conduct many of the subgroup analyses we pre-specified in our protocol. Likewise, for our meta-regression analyses, we were unable to include some variables hypothesized to be relevant because relatively few studies reported such data.

The limited number of eligible health outcome studies, and the nature of the data reported, prevented meaningful interpretation of results with regard to health impacts associated with bottled water consumption. Relatedly, we were unable to adequately quantify the extent of potential publication bias generally—i.e. we do not know how many studies with results on bottled water contamination may not have been published due to the nature and direction of their findings.

Finally, in our protocol we pre-specified that we would use the Grading of Recommendations Assessment, Development and Evaluation approach to assess and compare the degree of bias in eligible studies. However, because we found relatively few health-focused studies, and due in part to limitations based on the nature and extent of the available reported data, we chose to instead use an index-based approach for ROB.

More broadly, due to the extensive nature of this review it was beyond the scope of this paper to report summary findings for all the microbiological and chemical parameters for which we extracted data. We encourage interested readers to consult the SM excel data file should they wish to view or analyze results for less-commonly-reported parameters or otherwise explore the data we extracted for this study (available online at stacks.iop.org/ERL/17/013003/mmedia ).

5. Conclusions

Included in the United Nation's 2030 Agenda for Sustainable Development is Sustainable Development Goal 6.1: ' By 2030, achieve universal and equitable access to safe and affordable drinking water for all ' [ 243 ]. Increasing consumption of bottled water and bottled water contamination are not issues unique to China, but China is unique in that, unlike most other countries, there exists a large body of published research on bottled water quality.

Overall, we observed that the vast majority of bottled water samples tested across the 625 reported studies from the 216 eligible publications for which we were able to extract data were in compliance with China's relevant bottled water standards. Over the period from 2005 to 2015, we also observed evidence of relatively stable or increasing (positive) overall trends in the proportions of samples reported to be in compliance with relevant bottled water standards. After controlling for other variables via meta-regression analysis, however, these associations were only statistically significant for microbiological outcomes overall, and not for chemical outcomes. We found only nine eligible studies that reported on health outcomes associated with bottled water consumption. Overall, due to the nature of the underlying available data and associated limitations, as well as geographic variation in the number of eligible studies, our findings should not be considered as representative of the general situation in China with respect to bottled water quality over this period.

Increasing reliance on bottled water in China and in other LMICs may serve to further exacerbate disparities in safe water access both directly—via the potential consumption of contaminated bottled water—and indirectly, via its normalization as a primary form of drinking water access. This normalization of bottled water for everyday drinking may in turn undercut efforts to expand and improve public water supply [ 5 ]. Of course, there are settings in China and in other LMICs in which centralized drinking water treatment and piped distribution are not feasible. In many such settings in China, government-run mini-utilities provide filling stations where people pay for and collect treated drinking water in large 19 l reusable bottles at costs much closer to those of piped drinking water than retail bottled water [ 244 ]. This type of kiosk-model for decentralized drinking water provision offers a relatively affordable and sustainable means of providing access to safe drinking water in regions with low population densities or challenging topography or hydrogeology. As noted in this review, one of the key challenges inherent in such an approach is ensuring sufficient disinfection of the reusable bottles between consumption and refill. In settings in China and other LMICs where centralized drinking water treatment and piped distribution is not feasible, efforts should be made to further expand well-regulated decentralized approaches for safe drinking water supply.

Across the world, bottled and packaged water is often accompanied by branding and marketing, promoting the notion that it is healthier and safer than alternative drinking water sources. In China, as well as in other LMICs and HICs, this trust may not always be warranted. The extent of, and impacts from, contaminated bottled water consumption remain poorly understood in both LMIC and HIC contexts—more research is needed on this issue. Given that bottled water will be part of the global waterscape for the foreseeable future, we hope that this work will stimulate more discussion and action on how to better regulate and improve bottled water production and quality. At the same time though, we hope this work will serve to further reinforce the need for LMICs—and HICs—to increase investments in the expansion and improvement of drinking water utilities as a far more equitable and sustainable pathway for providing reliable access to safe and affordable drinking water for all.

Acknowledgments

We are grateful to Li Hongxing at the National Center for Rural Water Supply Technical Guidance (Chinese Center for Disease Control and Prevention, Beijing) for his assistance with results interpretation, replication of primary statistical analyses, and suggestions on earlier drafts of this article. We thank Keith Gilles (UC Berkeley) for his steadfast support of this and other research projects. We also thank Pu Da and Jia Tang (UC Berkeley) for their assistance during one of the semesters of our multi-year work on this project, as well as Stefanie Ebeling and UC Berkeley's Undergraduate Apprenticeship Research Program (URAP). Funding and support for this research was provided by URAP and by UC Berkeley's College of Natural Resources (under Dean Gilles). These funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability statement

All data that support the findings of this study are included within the article (and any supplementary files).

Author contributions

A C designed the study, managed the data extraction, data cleaning, and quality assurance and control, conducted the statistical analyses, created the tables and figures, wrote the first draft of the manuscript, incorporated co-author feedback, and prepared the final manuscript and supplementary material files. Q X, Q S, and X Y assisted with the search strategy design and piloting. J C, Q S, Q X, Y S, X Y, Y G, and J H conducted the search screening, full text identification, review, and data extraction. J C, Q S, and J H conducted extensive data cleaning, quality assurance, and control. J H created the map figures. J M C provided guidance on study design and contributed to results interpretation and the final manuscript. I R oversaw research assistant recruitment, provided guidance on study design, assisted with results interpretation, contributed to drafts, and helped write the final manuscript.

Conflict of interests

The authors declare they have no actual or potential competing financial interest.

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• Published: 29 July 2011

Packaged water: optimizing local processes for sustainable water delivery in developing nations

• Ayokunle C Dada 1  

Globalization and Health volume  7 , Article number:  24 ( 2011 ) Cite this article

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With so much global attention and commitment towards making the Water and Sanitation targets of the Millennium Development Goals (MDGs) a reality, available figures seem to speak on the contrary as they reveal a large disparity between the expected and what currently obtains especially in developing countries. As studies have shown that the standard industrialized world model for delivery of safe drinking water technology may not be affordable in much of the developing world, packaged water is suggested as a low cost, readily available alternative water provision that could help bridge the gap. Despite the established roles that this drinking water source plays in developing nations, its importance is however significantly underestimated, and the source considered unimproved going by 'international standards'. Rather than simply disqualifying water from this source, focus should be on identifying means of improvement. The need for intervening global communities and developmental organizations to learn from and build on the local processes that already operate in the developing world is also emphasized. Identifying packaged water case studies of some developing nations, the implication of a tenacious focus on imported policies, standards and regulatory approaches on drinking water access for residents of the developing world is also discussed.

The development and use of water portends wide-ranging implications for global survival, security, health and economic development [ 1 ]. This demands the need for water issues to be tackled at the highest political level. Consequently, enshrined in international covenants and attested to by world nation's heads are the MDGs, one of which is to halve the proportion of people without sustainable access to portable water and basic sanitation. Today, more than halfway into the deadlines, available figures reveal a large disparity between the expected and the achieved [ 2 ]. Following a general paraphrase of the paper in the first section, the gruesome challenges that make achievement of the Millennium Development Goals daunting task in the developing world is described in the second section of this paper. Given the prevailing social and technical cost needed to revitalize or put in place functional public institutions, associated technologies and political will power, it is much undoubted that the standard industrialized world model for delivery of safe drinking water technology may not be affordable in much of the developing world in the foreseeable future [ 3 ], the third section suggests packaged water as one of the low cost alternative water provision that could help bridge the gap. As presented in the fourth section of this paper, despite the established role that this drinking water source plays in developing economies and populations, its importance is significantly underestimated. The fifth section highlights a view point that promotes identification of means of improvement rather than disqualification of local provisions and processes in a bid to safeguard public health. Using relevant case studies, it also suggests possible implication of irrational adoption of global policies on water supply access for residents of the developing world. The sixth section concludes.

The Daunting Challenge of Meeting the MDG targets

Global attention and efforts have been committed towards making the MDG target for water and Sanitation a reality. It is more than halfway into the deadline, yet available figures seem to speak on the contrary especially in the developing world [ 2 ]. In most regions of the world, this target is far off-track [ 2 , 4 , 5 ]. Reports have shown that going by current trend, the global MDG sanitation target will be missed by more than half a billion people if the trend 1990-2004 continues up to 2015 [ 2 ]. A recent report asserts that the potential challenges to actualizing the MDGs are basically: maintaining the gains already made, coping with a rapid pace of urbanization, and a huge backlog of unserved rural people [ 6 ]. Although, some regions will reach the drinking water and sanitation target, places like sub-Saharan Africa remain an area of greatest concern. For example, in sub-Saharan Africa, with an 85% increase in urban population from 1990 to 2004, the number of urban dwellers unserved with either safe drinking water or basic sanitation doubled from 1990 to 2004 [ 6 ]. Recent studies suggest that in addition to rapid urbanization [ 7 ], ineffective governance ([ 8 , 9 ]) and persistent poverty [ 10 ] remain the root cause of water infrastructure associated problems that might make the goal far from being realistic in developing nations.

A recent article [ 11 ] presents thought provoking insights to the debate on the achievement of the MDGs. Optimistic as the millennium development targets may sound, some debates are however evident. It may be argued that there are fundamental problems associated with the statement of these goals and the means of measuring progress towards meeting them. There are wide definitional variations of what constitutes "safe drinking water" and "basic sanitation". These variables are difficult to measure and each has widely different cost and effort implications [ 11 ]. Thus, indicators chosen for monitoring the MDGs are often confusing, misrepresenting and many a times missing. Examples abound to attest to this. In India, a household is considered to have access if there is a water source within one mile (1.6 km) and in many cases; it is not the individual or the household access that is measured but the village as a whole. In Lagos, the newest major mega city in Africa with so many slums and shanty towns [ 12 ], the case could be different. What a kilometre distance means to urban dwellers in Lagos would differ significantly to the structures and population densities that are available in the rural settlements, yet they apparently have the same indicator yardstick. Currently based on existing data sources access is often taken to be a facility such as a standpipe, well, or public toilet within reasonable distance [ 11 ]. Again, masking effects of richer populations being served over unserved on the overall figures presented might be evident. This could stand as potent demodulators for aggressive and timely interventions for deprived residents in deficient locations.

Even where there is a water source it may not necessarily be accessible to all owing to other associated physical, economic or social complexities [ 11 ]. Apart from distance, the cost, level of sharing and queuing are decisive factors that determine actual water availability, accessibility and use [ 13 , 14 ]. Again, in practical terms, it is not clear what providing "basic" amenities will actually mean, and this will most likely vary in different contexts and countries [ 11 ]. Furthermore, access to the 'improved access' might not necessarily infer adequacy for a healthy life as access to water within a kilometre's reach may not be convenient or sufficient to protect health. Optimally, water should be made available at home [ 15 ] or at least within a hundred meters or five minutes total collection time, which has been observed to make a difference with regard to actual water use [ 16 , 17 ].

Packaged Water: A Local Drinking Water Initiative

Several water supply models are already established, tested and proven effective in the developed world. Given the prevailing social and technical cost needed to revitalize or put in place functional public institutions, associated technologies and political will power, it is much undoubted that the standard industrialized world model for delivery of safe drinking water technology may not be affordable in much of the developing world in the foreseeable future [ 3 ], Subsequently, with the renewed global commitments towards the MDGs marked for 2015, the importance of locally sourced, low-cost alternative drinking water schemes in contributing to increased sustainable access in rural and peri-urban settings of developing nations cannot be over-emphasized [ 18 ]. One of such local interventions in Nigeria, where public drinking water supply is endemic is packaged drinking water [ 19 ]. This form of packaged water is usually distributed and sold in sachets (Figure 1 ). Packaged water refers to water that is packaged generally for consumption in a range of vessels including cans, laminated boxes, glass, plastic sachets and pouches, and as ice prepared for consumption [ 20 , 21 ].

Roadside vendors hawking chilled water in sachets .

Scattered around the breadth of developing nations are small, medium and large scale industries that manufacture packaged water sold as sachets (commonly referred to as pure water). The package water industry started initially as a cottage business to meet the demand of the thirsty population not adequately catered for by the available municipals. Today, the packaged water industry has become part of the unofficial economy as the sales of thousands of brands of thermoelectrically sealed nylon sachets containing about 0.5 L water have increased tremendously in many developing nations. Sold by the poor and patronised by members of the low and middle socio-economic class, this form of water started out as 'iced water' which was simply hand-tied nylon pouches containing treated or untreated cold water. Treatment then was simply with the use of absorbent pads (referred to as 'foam'), although it was thought to trap the all dirt and germs, it was largely effective for removal of suspended solids. Recent studies [ 3 , 22 ] confirmed the persistence of this drinking water source in some parts of Ghana owing to its affordability.

In urban Tanzania, a similar experience prevails based on the result from a recent survey that showed a significantly higher proportion of the population depend on packaged water owing to its perceived safety as compared to water from public pipes [ 23 ]. The hierarchical order of perception of safety in Nigerian water supply model is presented in Figure 2 . The public perception safety in favour of packaged water in Nigeria stems out partly from the inadequate attempts of previous governments to provide potable piped water. The second contributing factor to this perception is the prevalent doubt on the quality of 'piped water' supplied at a reasonable charge by many informal vendors at the community level. The lack of trust in the quality of water supplied by these informal vendors is attributable to the subjectivity in the construction of wells from which the water is outsourced. There is currently no formal abstraction management or regulatory scheme in place in the entire nation. The effect of rapid urbanization in cities like Lagos has seen the sprawling city extending far beyond its original lagoon setting to encompass a vast expanse of mostly low-rise developments including as many as 200 different slums where living conditions are extremely crowded and dismal [ 12 ]. The resultant effect is a continuous reduction in the spacing between inter- and intra-building septic tanks and water wells, thus increasing the vulnerability of available sources to pollution from anthropogenic influence. Yet, anyone at any point in time with the necessary financial wherewithal could employ the service of cheap local labour to dig wells of subjective depths and specifications for water vending purposes. In most instances, as a cost saving measure, only a few concrete well rings are fixed to support the dug well (Figure 3 ).

Water for drinking and domestic purposes: Nigerian Water Supply Model .

Water treatment process in a typical sachet water factory .

Water pumped from these 'upgraded' wells into elevated storage tanks are widely referred o as 'borehole water' or 'tap water' among the nation's populace. It costs about N100,000 (about USD800) to put this system in place. On the other hand, to install a deep drilling system using heavy duty boring machines require a minimum of N400,000 (about USD3,200). In most instances, only a restricted proportion of the citizenry, precisely the wealthy, can afford the expensive deep drilling that conventional borehole technologies offer. In most instances, when this is the case, the water is strictly for owner usage and is not available for commercial purposes. Despite the debates associated with the quality of water provided by these upgraded wells of informal vendors, water from such sources is cheap (costs about 20-50 cents for 50 Litres), readily available but usage is only restricted for domestic uses alone - washing, bathing and cleaning. Sachet water, costing 50 cents for 3 Litres (one bag containing 20 sachets each of 150 ml volume), is thus often relied upon for drinking purposes. Although restively more expensive than water for domestic uses sourced from upgraded wells of informal vendors at the community level, a public perception of safety prevails - at least it must have gone through one form of treatment or the other, even if they were gotten from questionable sources [ 24 ].

Realistically sachet water produced in recent years by small-scale industries has experienced drastic improvement as the raw water is now treated by aeration, double or single filtration using porcelain molecular candle filters or membrane filters (Figure 3 ) and in some instances, disinfection is applied. The level of treatment generally depends on the source of water [ 3 ]. Although there are still inherent quality and regulatory challenges associated with this form of drinking water [ 25 ], the importance of this form of drinking water is well acknowledged by civil societies and nation governments of the developing world [ 26 ].

Seeking Solutions For Local Problems: Local Processes Or Global Policies?

Despite the established role that this drinking water source plays in developing economies and populations, its importance is however significantly underestimated or not appreciated as presented by currently available 'guidelines' and 'policies' of internationally respected organizations - most of which are irrationally copied and adopted by the developing world [ 27 ]. The denial process stems from the equalisation of reasons attached to people's patronage of packaged water for the developing and the developed world. For example, a report by NDRC [ 28 ] asserts that given the explosion in bottled water use in the United States, driven in large measure by marketing designed to convince the public of bottled water's purity and safety, and capitalizing on public concern about tap water quality, people are willing to spend from 240 to over 10,000 times more per gallon for packaged water than they typically do for tap water [ 28 ]. As analysed by Riemann and Bank [ 29 ] in their study on regulatory standards for the developed and developing world, this is characteristic of a typical 'risk-averse' western world. Factors that stimulate demand in the developing nations are apparently different. In many developing nations, contamination of municipal water supply systems by faecal bacterial pathogens has become a public health hazard, because often there are not enough resources (cost, capital or commitment) to install or to operate functional municipal water systems leaving the civil society to resort to alternatives, one of which is packaged water.

In a similar vein, a World Health Organization (WHO) report [ 30 ] also itemizes the reasons for global consumption of packaged water. However, not elucidated in this report is the fact that packaged drinking water is an alternative source and its patronage, more of a survival strategy for many residents of the developing world rather than the reasons mentioned. This typifies the international community's partial or non-recognition given to this drinking water initiative which of course is a social adaptation to failed public municipals in the developing world. England felt a similar wave of the heat when the 2007 summer floods hit Gloucestershire leaving thousands of people to survive on packaged water which was generously distributed by the government and intervening organizations as relief aid [ 31 ]. It is much undoubted that what classifies patronage of packaged water as a survival strategy, psycho-satisfaction or a mere show of socio-economic status is more or less subjective differing with the particular prevailing situation.

In addition to the wrongly perceived cause and effect hypothesis, another conflicting view point is the definitional classification using certain 'exclusion criteria'. This is typified in the WHO report [ 30 ] that refers to 'bottled water' and 'packaged water' interchangeably without making concrete distinction between the two terms (for instance, Section 6.5.2: p114). In the report, households that relied on packaged water along with other vended sources are classified using the 'exclusion criteria' as not having 'reasonable access' to improved water supply along with those who get theirs from unimproved wells or surface water sources (Additional file 1 , Table S1). It should however be noted that water obtained from these recommended 'improved sources' can also have a significant increase in contamination between the source and storage. A report [ 16 ] suggested possible contamination arising from two distinct physical domains- the public (outside the household) and the domestic (inside the household). Thus it may be realistic to suggest that the proportion of the world's population actually using safe drinking water is likely to be lower than that using the globally recognized 'improved' drinking water sources.

Going by the 'exclusion criteria' and the 'official indicators', progress towards the water target of the MDGs is achieved as people switch to piped water connections, or to free public stand pipes, boreholes, or rainwater cisterns within a kilometre of their home [ 10 , 32 , 33 ]. But the daunting challenge is the time frame for which this could become a reality for residents of the developing. Apparently, it appears not to be too realistic a goal in the near future given the insufficiency of capital, cost (operation and maintenance) and commitment evident in most rural and urban settlements of low and medium income countries where municipal water supply functions are sub-optimal. As presented by the WHO report and other available literature, bottled water is considered unimproved and sachet water or other forms of packaged water are nowhere to be found either in the identified classes. By oppressing packaged water in a bid to protecting public health in developing nations, there is a danger that authorities could be making it still more difficult for deprived residents to obtain water which again could lead to more grievous conditions as people may revert to poorer sources (Figure 4 ). Agreeably, proffered recommendation to improving drinking water access in developing nations may not simply be about disregarding packaged water or other local initiative as unimproved. Instead, questions need be raised about what could be done to increase the effectiveness of the treatment and distribution system and how it could ultimately make a positive contribution to the widely publicised MDGs. It is therefore logical to conclude that there may be cases where improving services from so-called 'unacceptable options' (local provisions) can make much more significant difference to the well-being of the most deprived populations than striving for ideal solutions such as universal piped water connections [ 33 ].

Fate of the Public with irrational regulatory policies .

Implication for Policy and Way Forward

The developing world is masked with challenges of coping with failing infrastructures, inadequate finance, poor legislation, lack of appropriate institutional capacity for regulation and control and often the political will to enforce control measures. The position is complicated by the fact that many of these developing nations are at a loss on how to set standards [ 27 ]. Consequently, they resort to dependence on adopted standards, policies and guidelines as presented by international organizations based on scenarios and context in the developed world. These are only moderately modified and ultimately imbibed into national regulatory structures of developing nations without the means of attainment. There could be possible serious implication of a tenacious focus on such policies, standards and regulatory approaches imported from developed countries on drinking water access for residents of the developing world (Figure 1 .1) as each situation differs in its own respect and has to be treated as such. For example, the WHO bacteriological water guidelines are widely accepted in industrialized as well as developing countries but they are not always achieved in practice [ 34 ].

Solving the water-related problems in the unserved regions of the developing world will demand acknowledgement, and attendant support of local processes that already exist in such locations. This will ultimately enable the local entrepreneurs to positively contribute their little yet significant quota to the achievement of international goals. Arguably, as a DFID report [ 35 ] portrays it, the best way to meet the people's demand for clean water and sanitation is to work with civil societies and government to help enable the voices of those without access to be heard and then for the governments to act on what they hear. In the past, many attempts by service providers and intervening non-governmental agencies have one way or the other failed because they allegedly did not involve the local community and already existent local processes in their action plans. Case studies are presented shortly of some on-going success stories in the packaged water industry. In the cited locations, various levels of stakeholder participation led to the birth of solutions that found a right balancing in between safeguarding public health through enactment of regulatory standards and improving social welfare through sustained access to packaged drinking water.

Lagos, Nigeria

An alternative to erratic pipe borne drinking water supplies in Nigeria is Sachet water, popularly referred to as 'pure water'. A high demand drinking water alternative, it is sold by the poor and finds patronage from members of low and middle socio-economic class [ 36 ]. With concerns of questionable quality of packaged drinking water, the national regulator, NAFDAC, declared a 'gradual' nationwide ban on sachet waters to allow the manufacturers of sachet water to start winding-up or change to bottle packaging [ 26 ] which is more expensive but perceived safer than water in sachets. Successful implementation of this ban on sachet water has remained far from reality as a vast majority of its population depends on it. Today, the sachet water market is witnessing tremendous growth. In a recent survey [ 24 ] of thirty-four households in the location, 86.5% of respondents claim that they cannot cope if the proposed ban were to hold given the unavailability of other affordable drinking water options. A total of 73.5% claim increased price associated with the bottled form of packaged water will ultimately deny them access to the suggested option by the regulator. It became obvious that the most probable outcome of such a ban of sachet form of packaged water is a reversion to poorer sources. Again, the federal government did assert that sachet water industry has remained one of the most successful poverty alleviation programs it embarked upon since independence. The proposed ban was consequently suspended. Focus was redirected to other means of improving the sachet water industry to produce the desired results and ultimately safeguard public health.

The late nineties marked the commencement of packaged drinking water regulation in India. Solely handled by the Bureau of Indian Standards in collaboration with the Health Ministry, the rules on its safety were drafted into a Prevention of Food Adulteration Act. The original plan was to come up with a standard that matches with international standards. Given the complexities and the technologies involved in the implementation, the PFA Act however remained vague on the issue of allowable levels of pesticides in packaged drinking water. With growing health concerns, a stakeholder meeting between the BIS and the Health Ministry officials marked the declaration of specific allowable limit - no pesticide should exceed 0.0001 mg/litre and total content of pesticide not exceeding 0.005 mg/litre. It was agreed that testing methods and support are to be provided by the BIS. Again, consensus was reached that it will take some time before the necessary changes take effect in the packaged water industry [ 37 ].

Accra, Ghana

A rapidly emerging water vending business in Ghana has been that of vending sachet water or bagged water, which is a cheaper alternative to bottled water [ 22 ]. Given the unreliable supply of drinking water by the municipals, a large proportion of the people depend on this bagged form of drinking. To ensure that Ghanaians have access to cheap clean water, sachets approved by the Ghanaian government that meet the Ghana Standards Boards sanitation requirements, are being sold all over the country [ 38 ]. These sachets are one of the main contributors to the trash that blankets the streets and gutters. The Accra Metropolitan Assembly (AMA) declared a possible ban on the use of sachet and polythene bags for drinking water, if manufacturers of such products refused to immediately negotiate with the AMA on concrete proposals as to how to deal with the menace of plastic waste [ 39 ]. This led to the birth of several stakeholder forums that heralded the emergence of a recycling taskforce - people picked from the government, plastic manufacturers, water sachet producers and city authorities to encourage and facilitate the recycling of the sachets, creation of new recycling plants as well as working with existing recyclers to expand their facilities [ 40 ]. Sponsored by some sachet bag manufacturers, several campaigns on plastic waste disposal and management were launched at Primary and Junior Secondary Schools in the nation to educate the school children on the proper disposal of plastic waste and how to manage such waste. In addition to this, an Accra based NGO, focusing on sustainability and the environment has taken on the task of cleaning up the streets of Accra. They employ staffs which does not include the local Ghanaians that are compensated for collecting the sachets. To date, this NGO has taken over 10 million sachets off the streets of Accra [ 38 ], the proposed ban on sachet water was suspended and residents still have access to drinking water in sachets.

As presented by the examined case studies, it is evident that rather than simply disqualifying packaged water as portrayed in respected international literature, focus should be on identifying means of improvement. For instance, more research could be conducted with focus placed on determinants of the final quality of produced sachet water - treatment, handling and distribution practices. Furthermore, international and local organizations and national health agencies could help facilitate research targeted at the identification, substantiation and incorporation of Hazard Analysis Critical Control Points (HACCP) and limits. This would address hazard analysis of the treatment and distribution processes and ultimately herald the emergence of a workable water safety plan that applies specifically to the packaged water industry. Intensified efforts on local and international research that major on the production of readily accessible and adaptable in-house water testing kits could also play a significant role in fortifying daily in-house bacteriological monitoring of the finished products. International organizations could also partner with regulatory agencies and civil societies to facilitate intensive hygiene and sanitation awareness training programs for vendors, manufacturers and other relevant stakeholders in the packaged water industry. Predictably, the implementation of these will yield desired results that would warrant a better packaged water industry, an improved social welfare through sustained access to drinking water and ultimately, a safer public at large in the developing world.

Packaged water made available in sachets, like other local initiatives offer substantial hope in contributing to increased sustainable access in rural and urban settings of developing nations if acknowledged and improved upon. The call is therefore made to intervening global communities and developmental organizations for the need for to learn from and build on the local processes that already operate in the developing world. Room for optimum improvement, via collaborative efforts with relevant stakeholders will demand striking a suitable balance between two preferred options: promoting public health (through improved regulation of the packaged water industry) while concurrently improving social welfare (encouraging access through support of these initiatives that cover for institutional inadequacies in public water supply coverage).

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Standards and Consumers - A Case Study of Packaged Drinking Water

14 Pages Posted: 14 Aug 2015

Central University of Gujarat

Date Written: July 29, 2015

Consumer bodies across the world, especially amongst developed countries have been performing prominent role in the process of standardization of products of mass consumption. Food sector, is an important area within which, packaged drinking water has emerged as a great market potential in recent times. Late 1990s saw a revolution of sorts when a handful of consumer organizations in India took it upon themselves to highlight the deficiencies in the system that led to interest of the consumer being sidelined as the regulations for bottled water were not as stringent as needed. Through effective use of science & technology in terms of conducting comparative product testing of various brands of packaged drinking water available in the market in independent laboratories and also comparing the Indian standards vis-à-vis the international ones, these organizations tried to open the eyes of public at large and Government bodies in particular. How this movement, a continuous one, has played a significant part in development and up gradation of standards for packaged drinking water is one of most important findings of the study. The study also tries to explore various facets of standardization — its definition, the process of standardization, major categories and its benefits. The study attempts to capture the involvement of different interest groups, especially, the consumer organizations and how it helps in shaping the standards. It is pertinent to mention here that the standards need not become the tools of power for the government or prerogative of big business houses; rather they should empower the people in asserting their rights as a consumer. Therefore the role of consumer organizations in standardization process not only needs to be recognized but also enhanced in terms of support from Government bodies. The commercial establishments or manufacturers on the other hand need to be sensitized to the issue of need for standards for food products. Strengthening the consumer movement by capacity building would encourage more and more people coming together for effective and greater contribution in the field of standardization and beneficial to the society on the whole. Standards have accordingly been a site of struggle between citizens and experts — or, more precisely, among social movement groups, academic scientists, regulators, and industries. The activism of health-based social movement organizations, for example, has often involved challenges to standardized procedures; the environmental justice movement in particular contests standards for statistical significance in epidemiological studies that systematically thwart fence line communities’ efforts to prove that disease rates are elevated in residential areas near hazardous facilities. Finally, the findings of this study throw light upon the potential benefits of associations likely to take place between Governmental organizations and consumer bodies involved in standard setting process in terms of collaborative studies or any other research efforts that are required and that must be inclusive of the end users.

Keywords: Standardization, interest groups, consumers, comparative study, water.

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Bacteriological Assessment of Bottled Drinking Water Available at Major Transit Places in Mangalore City of South India

Nitin joseph.

1 Post Graduate Diploma in Family Medicine, Associate Professor, Department of Community Medicine, Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India

Sevitha Bhat

2 Associate Professor, Department of Microbiology, Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India

Subhani Mahapatra

3 MBBS Student, Kasturba Medical College, Light House Hill Road, Manipal Academy of Higher Education, Mangalore, India

Ayush Singh

Ahamed unissa, namritha janardhanan, associated data.

The data used to support the findings of this study are available from the corresponding author upon request.

Introduction

Safe drinking water is essential for human life. It is generally considered that bottled water is safe for usage by people. For long-distance travelers, it serves as the only source of reliable drinking water. But, several studies have reported that bottled water does not always meet the acceptability standards.

To assess the bacteriological and physical quality of bottled water marketed in major transit areas and to check its compliance with national standards.

The investigating team visited retail shops at three main transit sites for long-distance travelers in Mangalore city. A total of 24 water bottles of 12 brands were randomly selected. The analysis of total viable count (TVC) was done to assess the bacteriological quality of samples.

In 3(12.5%) samples, all of which were of local brands, batch number, the period of manufacture, and the period of expiry were not mentioned. Odor and floating bodies were present in one sample each. Five (20.8%) water bottles had been enriched with minerals. Ozone treatment was the most commonly 22(91.7%) used method for disinfection of water. In only 15(62.5%) samples, the bacterial contamination was within acceptable limits certified for drinking purposes. Water samples manufactured by multinational companies ( p =0.018), those with batch number mentioned ( p =0.042), the best period of manufacture ( p =0.036), and long expiry dates ( p =0.028) were acceptable for usage.

Surveillance of bottled water manufacturing industries in the settings on a regular basis needs to be done by regulatory agencies. These measures will ensure safe and wholesome bottled water for public usage.

1. Introduction

Bottled water is generally regarded safe for usage by people. It serves as the only reliable source of drinking water accessible for long-distance travelers. Its usage rate in parts of Asia is estimated to be around 27% [ 1 ]. With respect to bottled water consumption, India is rated among the top ten countries in the world. Bottled water production companies are one of the fastest growing industrial sectors in this part of the world. Presently, there are more than 3400 bottling plants in India. Half of these are concentrated in the southern regions of India [ 2 ].

Demand for bottled water has resulted in springing up of several small-scale entrepreneurs involved in its production and distribution. However, with increasing demand, serious concerns about its quality and safety have arisen subsequently. The chemical and microbiological qualities of packaged water of some manufacturers have been found to be in violation of national standards [ 3 ]. Studies done in India and other parts of the world have reported that bottled water was contaminated with harmful disease-causing microorganisms at various stages of its production [ 4 – 6 ]. Consumption of contaminated water in India has led to frequent outbreaks of waterborne diseases such as cholera, typhoid, and hepatitis A and E [ 7 ].

The manufacturing plants of most companies of bottled water in India are situated in unhygienic locations like agricultural fields or estates. Most companies use bore wells as source of water. Here, water is pumped out from depths varying from 80 to 500 feet below the ground [ 8 , 9 ]. The less likely sources of packaged water are from public drinking water systems such as Municipality supply water [ 10 ].

Ground water has quality problems due to salinity (particularly in coastal areas) and contaminants like agrochemicals, nitrates, fluoride, iron, and arsenic [ 11 , 12 ]. The ground water available in about one-third of India's districts was found to be unfit for drinking. This was because of the presence of contaminants exceeding the tolerance levels [ 12 ].

Significant levels of pesticides like organochloride compounds (lindane, DDT, and endosulfan) and organophosphorus compounds (malathion and chlorpyrifos) have been reported in fresh water systems and in the bottled water samples collected from some major cities in India [ 8 , 9 ]. These observations imply that the technology currently being used for treating raw water is insufficient to have safe water for consumption [ 9 ].

Hence, periodic surveillance of packaged drinking water like bottled water is very much essential. This will serve the dual purpose of monitoring the standards of bottled water production industries as well as help in giving reassurance of quality to users.

This study was therefore done to assess the bacteriological and physical quality of bottled water marketed in major transit areas within a city and check its compliance with national standards.

2. Materials and Methods

This cross-sectional study was done in April 2016 in Mangalore city of Karnataka state situated in south India. The ethical approval was obtained from the institutional ethics committee.

It was conducted at three main transit sites for long-distance travelers in Mangalore namely Karnataka State Road Transport Corporation bus stand, Mangalore central railway station, and Mangalore junction railway station.

The sample size was calculated using the formula Z α 2 pq / d 2 . Based on the findings of a previous study, which reported 94% of the bottled water samples within acceptable standard for usage [ 13 ], and at 95% confidence intervals and 90% power, the sample size of a total of 24 bottled water was calculated.

Two bottles each of twelve different brands available at various retail outlets at these sites were randomly purchased using a simple random sampling method.

The selected bottles before purchase were inspected for good condition of the cap and the protective seal. The brand name, dates of manufacture and expiry, batch number, Indian Standard Items (ISI) symbol, mineral contents, the process of water purification employed, and place of manufacture were documented in a pro forma.

It is mandatory for all the manufacturers of bottled water to obtain the ISI certification from Bureau of Indian Standards (BIS) as per the Government notification issued in the year 2000 by Ministry of Health and Family Welfare [ 9 ]. The BIS staff does a check of the water samples from these plants in an independent laboratory. Only if the samples are reported safe for consumption, official confirmation and license number are given by them to the plant for commencing commercial production [ 14 ]. They also assess the infrastructure facilities of the manufacturing plants by surprise inspections and periodic testing of samples available at the manufacturing and marketing sites [ 9 ]. The BIS standard for bottled drinking water follows IS 14543 : 1998 guidelines covered under the relevant Prevention of Food Adulteration Act of the Government [ 9 , 10 ].

The type of physical, chemical, and microbiological tests to be done for the water samples to be tested is prescribed under IS: 3025 guidelines [ 14 ]. The various treatment procedures done for packaged drinking water at the factory constitute decantation, filtration by sand, carbon and micron cartridge filter (to remove suspended and colloidal impurities), filtration with ultramembrane filter (to remove fine suspended solids, protozoa, bacteria, and viruses), depth filter, cartridge filter, activated carbon filtration (to remove organic impurities), ozonization (to eliminate bacteria), ultraviolet treatment (to inactivate bacteria), silver ionization, ion exchange and reverse osmosis (to remove dissolved solids, heavy metals, fluoride, and pesticides/fertilizer residues), and procedures like demineralization and remineralization to meet the prescribed standard of the packed item [ 8 , 10 ]. Among the chemical disinfectants, free chlorine is most commonly used to treat water [ 9 ]. Water is then filled in cleaned and rinsed containers. Containers are visually inspected for any suspended matter and for leakage against an illuminated screen [ 10 ]. The manufacturer needs to do periodic in-house testing of packaged water as stated in the BIS document. The various tests done at their quality control laboratories include examination of total dissolved solids, turbidity, pH, color, and conductivity in addition to routine bacteriological analysis [ 9 ]. The standard also prescribes that the shelf life of the product shall be declared and marked on the product by the manufacturer based on their in-house studies [ 10 ]. The source water should also be tested once in three months for physical, chemical, and bacteriological parameters by the manufacturers and the records to be maintained by them [ 10 ].

However, in spite of all these protective measures, presence of contaminants in bottled water implies that the treatment process at the plants is not effective [ 8 ]. Hence, it was necessary to check the quality of packaged water available at this setting.

The plastic bottles that were purchased from various outlets for analysis in this study had a capacity of 500–1000 ml. All the bottles were transported to the laboratory of the Department of Microbiology of this institution. Each bottle was vigorously shaken and observed for turbidity, odor, and floating bodies. The analysis of total viable count (TVC) was done using the standard plate count method. TVCs are good indicators of general contamination and of the overall quality of production of the product [ 15 – 17 ]. It gives a quantitative estimate of the concentration of microorganisms in a water sample to be tested. The count represents the number of colony-forming units (CFUs) per ml of the sample. The reported count is the number of colonies counted multiplied by the dilution used for the counted plate. A high TVC count indicates a high concentration of microorganisms, which may indicate poor quality for drinking water or foodstuff [ 18 ].

The microbiological test was done within 2 hours of purchase of the bottles from the point of sale [ 19 ]. The determination of total heterotrophic bacteria was done using serial dilution and pour plate technique. For this, tenfold serial dilutions in sterile water were carried out for each water sample brought for testing. One ml from the 10 th test tube was aseptically taken on two occasions and placed in two different sterile 4-inch diameter Petri dishes. Then, 20 ml of molten plate count agar cooled to 50°C was added to each plate and mixed thoroughly. The mixtures were allowed to solidify. One plate was incubated at 22°C and the other at 37°C for 48 hours. After incubation, the number of bacterial colonies in both the plates was counted, and the average was reported as CFUs per milliliter of the tested sample [ 20 ].

The recommendations of BIS for acceptability of packaged natural mineral water was used for comparison of physical and bacterial quality [ 10 ]. According to this, the viable count limit should not exceed 100 CFU per ml of the sample at room temperature. It should also be devoid of any turbidity, odor, or floating bodies.

Data were entered in Microsoft windows excel and were exported to SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) for analysis.

Chi-square test, Fisher's exact test, and binary logistic regression analysis were done to test the association between variables with the status of acceptability of water samples. All statistical significance was assessed at the 5% level.

Out of the total, 20 bottles were collected from the central bus stand area and two each from the two railway stations situated within the city limits. All these collected samples were found to have a sealed cap and were labeled with ISI certification.

Majority of the bottles (10; 41.7%) were manufactured by multinational companies. In 3 (12.5%) bottles, batch number, period of manufacture, and period of expiry were not mentioned. ( Table 1 ). These were of brands manufactured by local (regional) companies. There was also a significant association between non mention of these parameters with bottled water manufactured by local companies using Fisher's exact test ( p =0.0277).

Characteristics of the packaged drinking water bottles.

Most common methods used for purification of water was by ozone treatment 22 (91.7%) followed by ultraviolet irradiation 19 (79.2%) and with reverse osmosis technique 16 (66.7%). ( Table 2 ). In 16 (66.7%) samples, more than one purification technique was used by the manufacturers.

Purification techniques used for packaged drinking water bottles ( n =24).

There was no sample with turbidity. One sample was found to have odor while another contained floating bodies. The number of CFU per ml was <100 in 15 samples, 101–200 in 3 samples, 201–400 in 4 samples, and 401–500 in 2 samples. The mean CFU count was 123.4 ± 161.9, and the median count was 30 with the interquartile range (4, 275). The CFU count ranged from 1 to 500 ( Figure 1 ). Therefore, in only 15 (62.5%) samples, the bacterial growth was within acceptable limits certified by BIS for drinking purposes. The nine unacceptable samples belonged to six brands, two each of three brands and one each of three different brands.

Determination of colony-forming units of total heterotrophic bacteria using serial dilution and pour plate technique.

Five (20.8%) water bottles had been enriched with minerals. Three of these bottles were manufactured by multinational companies and two by local companies. The minerals comprised of magnesium sulphate in all 5 bottles, potassium carbonate in 3 bottles, and sodium chloride in two bottles.

Water samples manufactured by multinational companies ( p =0.018), samples from bottles with the batch number mentioned ( p =0.042), the best period of manufacture in the current month ( p =0.036), and expiry date beyond six months ( p =0.028) were found to be significantly acceptable for drinking purposes. ( Table 3 ).

Association between various characteristics with bacteriological acceptability status of water samples.

Multivariable analysis showed no association of any of the factors with acceptability of bottled water analyzed in this study. For the calculation of odds ratio for the characteristics introduced in this model, water bottles manufactured by regional companies, bottles manufactured in the previous month or without mention of manufacture date, and bottles due for expiry within the next 6 months or without mention of expiry date were taken as the reference ( Table 4 ).

Multivariable analysis of characteristics influencing acceptability of water samples ( n = 24).

4. Discussion

Provision of safe drinking water is one of the most essential amenities to be made available for citizens in the modern world. Particularly, for long-distance travelers who need to be extra careful of their health but do not have other options, depend on these packaged water sources. Therefore, it is a matter of concern that only about two-thirds of the bottled water tested was suitable for drinking in the present study. This was similar to the findings of another study done in Mangalore in 2002 which reported 66.7% of the sampled bottled water safe for consumption [ 21 ]. This meant that the situation of hygienic status of bottled water available in this city has not shown any improvement with time. It could be because of the reason that, this issue was not given priority as much as other public health issues concerning this city. In other studies done in India, the acceptability of bottled water ranged from 60% [ 4 , 22 , 23 ], 83% [ 24 ], 90% [ 25 ], and even 100% [ 26 – 28 ]. In studies done in other parts of Asia, the acceptability of bottled mineral water samples ranged from 50% [ 29 ], 64.2% [ 19 ], 97.1% [ 30 ] and a study done in Iran even reporting 100% [ 31 ]. In studies done in Africa, it was 67.4% [ 20 ], 70% [ 32 ], 71.4% [ 17 ], 75% [ 33 ], 85% [ 16 ], 88.9% [ 34 ], 90% [ 35 ], 94% [ 13 ] and a study done in Uganda [ 36 ] and Nigeria [ 37 ] reporting 100%.

In a study done in Pakistan, the TVC in CFU/ml was <1 in 40%, 15–20 in 24%, 20–200 in 10%, 200–300 in 13%, and >300 in 13% [ 19 ]. In a study done in different parts of North India, around 2% of the samples tested had bacterial counts of more than 1000 CFU/ml [ 24 ]. The contamination level of water samples reported in these above-mentioned studies was therefore much more than our observations. However, another study done in Chennai, India, reported that bacterial counts ranged from 0 to 41 CFU/ml among all the water samples tested, which was much lesser than that observed in the present study [ 28 ]. The presence of heterotrophic bacteria in the bottled water causes significant health risk particularly for children, elderly, and immunocompromised individuals [ 38 ]. Its presence in bottled water is also an indicator of poor practices involved in the manufacturing processes.

The kind of bacteria found in the bottled water has previously been reported to have multiple drug resistance in samples collected from different parts of India [ 23 ]. Safety of bottled drinking water can be ensured with sealed caps on bottles, hygienic filling systems, the minimal time between production and sale, and use of nonreturnable plastic containers [ 4 , 6 , 34 ]. It was observed in a Nigerian study that contamination of packaged water aggravates as the product moves down the distribution chain [ 39 ]. Assessment of water quality is therefore required not only at various stages of production but also in postproduction stage [ 28 ]. This will ensure improvement in transportation and storage practices in the supply chain. Government and other stakeholders need to intensify surveillance activities of water treatment processes at packaged water industries. This will ensure that strict hygienic measures are followed, resulting in safe and quality bottled water being available at various retail outlets for public use.

Among the physical parameters, turbidity was absent in all the water samples tested in this study. This was comparable to the observations of a study done in Ghana [ 16 ]. Turbidity of water depends on the amount of particulate matter present in it. This interferes with the disinfection process of water [ 40 ]. It also affects the taste, odor, and the color of the water [ 41 ].

Odor and floating bodies were present in one sample each in this study, which again is an indicator of poor manufacturing and storage practices. In a study done in Nigeria, total suspended solids (particulate matter) was absent in all bottled water samples under investigation [ 33 ]. Similarly, in another study done in Telangana, India, all the bottled water samples were colorless and had no objectionable odor and taste [ 26 ].

The batch number, period of manufacture, and period of expiry were not mentioned on three bottles, all of which were manufactured by local companies. A Nigerian study also reported that none of the bottled water brands had mentioned the batch number [ 33 ]. Batch number is very essential for any manufactured product. In the event of discovery of any abnormality, with the help of the batch number, the entire lot the product can be identified and recalled from the market by the company [ 33 ].

In this study, five water bottles had been enriched with minerals and were labeled with these specifications. The mineral composition was not stated in any of the sampled water bottles in the Nigerian study. However, all the bottled water samples in the latter study had mentioned manufacturing and expiry dates, unlike our observations [ 33 ]. All the samples without batch number, manufacture date, and expiry date were found unacceptable for drinking in the present study. Therefore, public enlightenment on particulars which they need to look out for on the package label before purchasing bottled water is essential. The local companies that manufacture products without complete label need to be questioned on these issues.

Moreover, three-fourth samples of locally manufactured bottled water were found unfit for consumption in this study. Springing up of several small-scale entrepreneurs engaging in the production of mineral water, without due regard to hygienic practices, has resulted in Mangalore. This might be due to the high demand of water as a consequence of the hot and humid weather seen mostly at this place. Packaged water manufactured by these regional companies may lack the guarantee to meet the set standards for drinking water quality. Therefore, identification of all local companies involved in its production, licensing, and renewal of licensing of these companies, by concerned authorities, is required in order to safeguard the health of the consumers [ 27 ].

On the other hand, bottled water manufactured by multinational companies was mostly of acceptable standards, as observed in this study. These companies have better infrastructure and a wide variety of sophisticated equipment for quality production of items. The production processes by these companies are done by qualified personnel who are closely supervised by trained professionals. The licensing of these companies is also periodically renewed [ 20 ].

5. Conclusion

More than one-third of bottled water available at major transit sites in Mangalore was found to be not suitable for usage. The absence of essential labeling items like batch number, date of manufacture and expiry on the containers, and unacceptability of water for drinking was seen significantly among local brands of bottled water. This infers toward noncompliance with stipulated guidelines in the production process by local manufacturers. Therefore, surveillance of packaged water manufacturing industries by regulatory agencies at this setting needs to be stepped up. ISI certification authorities also need to do a random sample check of all their licensee products. Imposition of sanctions should also be done on defaulting industries to ensure effective compliance with BIS standards. The distributors, retailers, and consumers also need to be made aware of the identification, reporting, and removal of problematic bottled water available at points of sale. These measures will ensure that safe and wholesome bottled water is available for public usage.

Acknowledgments

The authors thank the Departments of Community Medicine and Microbiology of Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, for providing us the facilities for conducting this research work.

Data Availability

Conflicts of interest.

The authors declare that they have no conflicts of interest.

Authors' Contributions

NJ was the guarantor of this research work and was involved in study design, literature search, and manuscript preparation. SB was involved in the bacteriological evaluation and manuscript editing. SM was responsible for collection of samples, manuscript review, and language editing of the manuscript. AS was involved in concept of the study, collection of samples, and data analysis. SJ and NJ were responsible for collection of samples, data analysis, statistical analysis, and interpretation of data; AU was involved in collection of samples, literature search, and manuscript editing. This manuscript has been read and approved by all the authors.

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Customer's Perception and Preference towards Packaged Drinking Water

Affiliations.

• 1 Department of Animal Production and Technology, Wolkite University, Wolkite, Ethiopia.
• 2 Department of Management, College of Business and Economics, Arba Minch University, Arba Minch, Ethiopia.
• PMID: 32180686
• PMCID: PMC7066422
• DOI: 10.1155/2020/6353928

Two hundred customers were purposively selected from two study areas (market, residence) in Addis Ababa to assess customer's behavior and perception towards packaged water. The sampling and data collection process of the study followed systematic analysis of Theory Planned Behavior. The average monthly income of respondents of this study lay between 5000 ($175) and 10000 ($350) Eth Birr. The primary customer information sources were television and radio. Residence place customers were more concerned about health as compared to market place customers. Market place customers primarily gave emphasis to the price of packaged water. Almost all (97%) customers were not sentient to packaged water standards. However, only few, 86 (43%), customers checked labeled chemical composition, of which 74 (85%) did not understand it. Customer's sex, education level, and health status showed significant relationship with choice of packaged water quality, -1.42 ( p < 0.05); price, -2.45 ( p < 0.01); and health status, -1.80 ( p < 0.05) in market place and residence place, respectively. Customers were not well aware of what they were purchasing and even customer's ability to read was not related to customer's ability to understand what was written in the labels. Customers' choice of packaged drinking water has been challenged by their health status. Customers are becoming more concerned about prices while they are out of their residence place.

Copyright © 2020 Minyahel Tilahun and Melaku Beshaw.

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Conflict of interest statement

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Ajzen TPB model.

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INTRODUCTION

Materials and methods, acknowledgements, data availability statement, conflict of interest, analysis of packaged drinking water use in indonesia in the last decades: trends, socio-economic determinants, and safety aspect.

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Arman Nur Ikhsan , Morrin Choirunnisa Thohira , D. Daniel; Analysis of packaged drinking water use in Indonesia in the last decades: trends, socio-economic determinants, and safety aspect. Water Policy 1 August 2022; 24 (8): 1287–1305. doi: https://doi.org/10.2166/wp.2022.048

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This study combines multiple data and analyses to gain insights into the trend of the use of packaged drinking water (PDW) in Indonesia, including the national survey to analyze the trends of PDW consumption, the Demographic Health Survey data to discover the socio-economic determinants of PDW consumption, and the systematic literature review to assess the quality and safety of PDW. The increasing rate of PDW consumption per year in Indonesia was 1.24% from 2000 to 2020 annually, and 50% of the Indonesian population is predicted to consume PDW in 2026. The increasing use of PDW in Indonesia was significantly associated with the economic growth of the country, i.e., proxied by the gross domestic product and urban population. Moreover, the use of PDW by households was significantly associated with the age of the household head, mother's educational level, father's educational level, wealth index, types of residence, regions, and types of toilet facility. The findings suggest that young people in urban areas would dominate the PDW consumer in Indonesia. Additionally, previous studies indicated that PDW in Indonesia is often contaminated. Thus, this study underlines the need to improve the quality and safety aspects of PDW to minimize its negative health effects.

This study estimates that 50% of Indonesia's population would use commercial drinking water (CDW) in 2026.

It is estimated that half of CDW in Indonesia is contaminated.

The increasing use of CDW was associated with the economic growth of the country.

Newly married couples in urban areas may dominate the CDW user in the future.

Household water treatment and hygienic conditions of water dispensers are suggested.

Graphical Abstract

Access to reliable, affordable, and safe drinking water is a human right and is essential to maintaining human health ( Andualem et al. , 2021 ; WHO & UNICEF, 2021 ). According to a report by the World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) ( WHO & UNICEF, 2021 ), the world is not on track to achieve the Sustainable Development Goal (SDG) 6 by 2030. Globally, there were still two billion people who did not have access to safely managed water services in 2020. Achieving universal coverage by 2030 in targets SDG 6.1 requires a quadrupling of current progress rates in safely managed drinking water services.

Globally, drinking water is obtained from various sources, including surface water, unprotected dug well or springs, piped water, boreholes or tube wells, protected dug wells or springs, rainwater, and packaged or delivered water ( Rauf et al. , 2015 ). Packaged drinking water (PDW) is one of the available drinking water options that is packaged in plastic, bottles, sachets, or bags in a range of sizes, and may be sold in shops, on the street, or delivered to homes ( Fisher et al. , 2015 ). PDW is rapidly growing in recent years worldwide. Global PDW consumption was predicted to increase by approximately 54% in 2017, i.e., approximately 391 billion liters, compared to 2007 ( Statista, 2014 ). Global PDW consumption is estimated to increase by 513 billion liters in 2025 ( Aslani et al. , 2021 ). Factors such as health and cleanliness, the bottle, convenience, taste, and self-image trigger people to consume PDW ( Ballantine et al ., 2019 ). Furthermore, the safety aspect of PDW was another attractive aspect of PDW ( Johnstone & Serret, 2012 ). A recent study in Cimahi, Indonesia, found that PDW, generally, has a good quality. The majority of the respondents consume PDW because they perceive better quality than other drinking water options and affordability for all income levels ( Prayoga et al. , 2021 ).

Studies found that PDW is not always safe although many people consider the safety of PDW. A previous study found that only 5% of bottled water purchased in Cleveland, USA, met the recommended concentration of fluoride, as recommended by Environmental Protection Agency (0.8–1.3 mg/L). Almost all tested bottled water samples met the fecal contamination standard (>1 of the colony-forming unit [CFU]/mL), whereas six samples contained 6–4.900 CFU/mL ( Lalumandier & Ayers, 2000 ). A study in Nepal revealed that 6 of 24 samples of bottled water were fecally contaminated ( Pant et al ., 2016 ), while another study in one province in Indonesia revealed that approximately half of the sampled PDWs were fecally contaminated ( Cronin et al. , 2017 ). Unsafe PDW leads to waterborne illnesses and causes various health issues, e.g., diarrhea, malnutrition, and impaired physical and cognitive development ( Cameron et al ., 2021 ).

Photos of PDW in Indonesia from authors: (a) un-refilled drinking water and (b) depot refilled drinking water.

The use of PDW is increasing in Indonesia, but no study has further analyzed the trends and current status of PDW consumption in Indonesia. The current study aims to fill that gap. Furthermore, this study analyzes the socio-economic determinants of PDW consumption to determine the characteristics of PDW consumers in Indonesia. We complemented the analysis with a review of PDW quality from previous drinking water quality studies in Indonesia. These analyses are expected to provide a holistic view of PDW consumption in Indonesia and enable stakeholders to design relevant policies and strategies on this topic, especially in Indonesia. Thus, this study contributes to the analysis of drinking water-related practices in developing countries.

This study conducted three analyses, including (1) trends of PDW in the last two decades, (2) socio-economic determinants of PDW consumption, and (3) a systematic literature review (SLR) of PDW in Indonesia that focuses on the water quality. Further information about the step of analysis is provided in each section.

Trends of PDW in Indonesia

The trends in the use of PDW in Indonesia were obtained from the website of the Indonesian Statistics (BPS; https://www.bps.go.id ). The collection of statistical data in the Indonesian National Socio-Economic Survey (SUSENAS) was conducted from selected households through face-to-face interviews. This survey is conducted twice a year, in March at the district/city level, and in September at the provincial level. The main results are then presented on the BPS website, i.e., percentages for national and provincial levels. The yearly data on PDW consumption from 2000 to 2020 was extracted and used in this study to see the trends of PDW consumers in Indonesia in the last two decades. Linear regression in Microsoft Excel was conducted to estimate the future PDW consumption in Indonesia.

Moreover, we were interested to confirm the hypothesis that PDW consumption in Indonesia is correlated with economic growth. In this study, the economic growth is represented by the urban population and gross domestic product (GDP) per capita. Bulut & Seçer (2019) found that population growth and urbanization influenced PDW consumption. Moreover, GDP annual growth rate has a significant positive correlation to PDW demand ( Zhang et al. , 2017 ). The urban population and GDP data were obtained from the World Bank data ( https://data.worldbank.org/country/indonesia ). The bivariate Pearson correlation in IBM Statistical Package for the Social Sciences (SPSS) version 26 was conducted to assess the correlation between them ( IBM SPSS Statistics, 2021 ).

Socio-economic determinants of the use of PDW in Indonesia

Data sources.

We used the Indonesian Demographic Health Survey (IDHS) data ( https://dhsprogram.com/ ) from three periods, including 2007, 2012, and 2017. IDHS was a cross-sectional survey that collects data from a representative sample of the population in the countries that participate in The DHS Program. IDHS was conducted by Indonesian Statistics in collaboration with the National Population and Family Planning Board (BKKBN) and the Ministry of Health ( National Population and Family Planning Board et al. , 2018 ). These three periods were used to determine the pattern of socio-economic determinants of PDW consumption in Indonesia, i.e., whether or not there is a variation or change of determinants over time.

We combined information from household-level and women's individual-level data from the IDHS datasets to perform a statistical analysis of socio-economic determinants of the PDW consumption in Indonesia because some variables were located in household-level data only, and vice versa. Data on the source of drinking water, sex and age of the household head, type of residence, region, and type of toilet facilities are available at the household-level data. Meanwhile, data on the mother's educational level, father's educational level, and mass media exposure are available at the individual-level data. After combining these datasets, 29,840 respondents in DHS 2007, 31,173 respondents in DHS 2012, and 31,253 respondents in DHS 2017 were used in the statistical analysis.

PDW variable

The PDW variable was obtained from the drinking water source information at household-level surveys. It was coded as a binary variable, wherein households who used non-PDW were assigned as ‘0’ and those who used PDW as ‘1’. This study defined PDW as refilled and un-refilled water, which has been treated before being distributed or sold to the consumer.

Socio-economic determinant variables

The selection and classification of variables.

The variable exposure to mass media was created from three variables, namely, the frequency of reading newspapers or magazines, listening to the radio, and watching television. Each of these three variables was coded as a frequency value between 0 and 3 (0=not at all, 1=less than once a week, 2=at least once a week, 3=almost every day). These values were then summed to get a score that measures the exposure to mass media, with a minimum score of 0 and a maximum score of 9.

Percentage of PDW consumers in Indonesia by the province according to IDHS 2007, IDHS 2012, and IDHS 2017. The map was created using ArcGIS 10.8.1 ( Esri, 2020 ).

Other variables were directly obtained from the datasets and used without any significant modification. We used the wealth index categorization and the mother's educational level, which are available in the datasets.

Statistical analysis

The three IDHS datasets were collected and entered into Microsoft Excel for data cleaning and merging of an individual- and household-level data based on case identification. The merging of an individual- and household-level data was used because some variables were located in household-level data only, and vice versa ( Table 1 ). Afterward, the data from Microsoft Excel were entered into SPSS version 26 for statistical analyses. Logistic regression was used to find significant socio-economic determinants of PDW consumption in the three IDHS datasets, i.e., three regressions were separately conducted for each dataset. The independent variables include the socio-economic variables and the dependent variable includes PDW consumption.

Systematic literature review

The SLR aims to unveil the water quality of PDW in Indonesia. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) were followed. PRISMA is a guideline to assist the researcher in conducting systematic reviews and meta-analyses by preparing the high standard protocol ( Moher et al. , 2015 ).

Studies collected for SLR were extracted from three indexed databases, including ScienceDirect, Scopus, and PubMed. Keywords used were as follows: ‘water quality’ and ‘commercial drinking water’ or ‘packaged drinking water’ or ‘potable drinking water’ or ‘refilled drinking water’ or ‘bottled drinking water’ and ‘fecal contamination’ or ‘ Escherichia coli ’ and ‘Indonesia’. The elimination of duplicated articles was also conducted in this phase.

The screening process is conducted by scanning the article by title and abstract to select and ensure the relevance of the article to the research topic. Furthermore, we selected articles that contain information on the water quality of PDW, either physical, chemical, or biological aspects.

This study denoted microbial concentration as fecal contamination which includes coliform, fecal coliform, and E. coli . The microbial concentration unit was measured in either CFU or myeloproliferative neoplasms (MPN). Furthermore, the physical and chemical aspects also followed the standard used in the WHO guidelines of drinking water ( WHO, 2017 ).

Trend PDW in Indonesia

Percentage of PDW consumers in Indonesia in the last two decades (Source: Indonesian Statistics).

Socio-economic determinants

Descriptive analysis.

Descriptive analyses of variables.

a Values of mean±standard deviation.

b Categorization of provinces into regions can be seen in Figure 2 .

The highest percentage of the educational levels of parents from three datasets were at the secondary education level. Based on the place of residence, more than half of the respondents lived in rural areas in IDHS 2007 data, whereas more than half of the respondents lived in urban areas in IDHS 2012 and 2017. The use of mass media respondents from IDHS 2017 had the highest average score of 4.25±2.84, IDHS 2007 was 4.10±2.14, and IDHS 2012 was 3.06±1.41 (range 0–9). The majority of people in Indonesia used private toilet facilities for sanitation.

The trends of PDW in each province in Indonesia according to the three datasets are shown in Figure 2 . DKI Jakarta and Riau Islands are the provinces in Indonesia that have the highest percentage of PDW consumers. East Nusa Tenggara province consistently has the lowest PDW consumer in three IDHS datasets. Generally, there is an increased PDW usage across all provinces in Indonesia from 2007 to 2017. However, some provinces, such as Aceh, West Papua, Jambi, Bengkulu, and East Nusa Tenggara, have declined, especially from 2012 to 2017.

Logistic regression analysis

Binary logistic regression result of independent variables for the source of drinking water.

B, beta values; SEB, standard errors beta; β , odds ratio.

R 2 (Nagelkerke R square) in IDHS 2007=0.330; R 2 in IDHS 2012=0.284; R 2 in IDHS 2017=0.296. Region=reference is Eastern Indonesia, Region (1): Celebes, Region (2): Borneo, Region (3): Sumatra, Region (4): Java and Bali.

*Significant at p <0.05.

The type of residence, wealth index, and regions were considered to have the largest influence on PDW consumption, i.e., highest β values, in all three dataset comparisons. Based on IDHS 2007, respondents who lived in urban areas were 2.3 times more likely to utilize PDW compared to rural areas, and the value increased to 2.8 in IDHS 2012 and 2.6 in IDHS 2017. The results also indicate that wealthier households tend to consume PDW. A variation of PDW usage was found between regions in Indonesia, in which other regions ( Figure 3 ) were more likely to consume PDW compared to Eastern Indonesia.

Furthermore, the age of the household head was significant to PDW usage. The mother's educational level had a positive relationship with the PDW consumption, as well as the father's educational level. The type of toilet facility was significantly associated with PDW consumption. The variable of mass media exposure had no significant effect on the PDW usage in the three datasets. Moreover, a significant association was found between PDW and diarrhea cases in children using DHS datasets in 2007 ( X 2 [1]=31.901, p ≤0.05), 2012 ( X 2 [1]=22.184, p ≤0.05), and 2017 ( X 2 [1]=3.985, p ≤0.05), in which PDW is associated with lower diarrhea cases in children.

Systematic review

Summary of PDW quality from previous studies in Indonesia.

Notes: ‘–’ no average data available in these studies.

a Risk level of fecally contaminated PDW as seen in Figure 5 .

Flowchart of the PRISMA process.

If we combined PDW samples from all studies ( n =425), approximately 48% of the total samples ( n =214) were fecally contaminated and 25% ( n =36) exceeded the pH threshold. These nine studies used either coliform, fecal coliform, or E. coli as microbiological water quality indicators. All studies found fecally contaminated PDW in their samples and samples in two studies were found to exceed the pH standard, i.e., outside the range of acceptable pH values of 6.5–8.5.

Cronin et al. (2017 ) included most samples ( n =183), in which 50.8% were fecally contaminated. Irda Sari et al. (2018 ) was the second study with most samples ( n =126) and revealed that 50% of their refilled water samples were fecally contaminated. Baharuddin & Ichsan (2020) revealed that 100% of their PDW samples ( n =6) were fecally contaminated and also exceeded the standard pH. Moreover, Baharuddin et al. (2018 ) revealed that 80% of their PDW samples ( n =30) were fecally contaminated and approximately 10% exceeded the standard pH.

Percentage of fecally contaminated PDW by risk level (according to the WHO classification).

Our results found that PDW consumption in Indonesia continues to increase and is predicted to reach 50% of consumers by 2026. According to SUSENAS 2020 data, refilled drinking water was the most widely used source of drinking water in Indonesia (29.1%). Meanwhile, 10.23% of households used un-refilled water as the main source of drinking water. The increasing use of PDW in Indonesia follows the global situation, e.g., in China, the USA, or European countries. The sales of un-refilled or bottled water reached over 200 billion liters globally in 2007. Europe and North America were the biggest markets, but the sales are expanding in many developing countries ( Gleick & Cooley, 2009 ; Qian, 2018 ). Contrastingly, a slowing consumption trend of PDW consumers was found in Indonesia from 2012 to 2017 compared to 2007–2012. This may cause a decreased average rate of population growth in Indonesia from 1.9% per year in 2000–2010 to 1.25% per year in 2010–2020 ( Statistics Indonesia, 2021 ).

The analysis revealed that the trend of PDW consumption in Indonesia is strongly correlated with the economic growth level of the country, i.e., proxied by urbanization and GDP levels. We argue that the economic growth of a country indirectly influences one's working time, i.e., increased working time, limits the spare time, and makes them choose a time- and cost-efficient drinking water option, i.e., PDW ( Komarulzaman et al ., 2017 ). Additionally, the regression analyses revealed that wealthier households positively correlated with PDW consumption. Households who have higher incomes can afford the PDW cost ( Irianti et al ., 2016 ; Adil et al ., 2021 ). We argue that the PDW cost is relatively affordable for the majority of the Indonesian population. The average expenditure on drinking water is IDR 119.850 (USD 8.3) with the assumption that the total water demand per month is 115 L per capita for four people in a household. Based on income, water expenditure for low-income households is 77.556 (USD 5.34), middle-income is 134.375 (USD 9.25), and high-income is IDR 182.391 (USD 12.56) ( Prayoga et al. , 2021 ).

Urban households were more likely to consume PDW compared to rural households. Firstly, because the urbanization level increased the accessibility of PDW producers or markets while accessing PDW in rural areas is more difficult due to limited infrastructure ( Irianti et al ., 2016 ). Moreover, there is a tendency of the urban population to consume ready-to-use drinking water, i.e., PDW ( Baharuddin & Ichsan, 2020 ; Saimin et al. , 2020 ).

Our study revealed that the educational levels of parents were associated with the likelihood of choosing PDW as the main drinking water source. Similar findings were found in other studies from Ethiopia, Pakistan, and Indonesia ( Nastiti et al. , 2017 ; Adil et al ., 2021 ; Gebremichael et al. , 2021 ). The increased educational levels of parents may lead to increased beneficial awareness of PDW as the main source of drinking water, e.g., quality, convenience, and affordability.

Region or location is significantly related to PDW consumption. In the IDHS 2007 and 2012, respondents who lived in Java and Bali relatively consume PDW more than other regions, probably because Java and Bali are more developed and urbanized than other regions in Indonesia. However, there was a remarkable increase in PDW consumption in the Borneo region, from 7% in IDHS 2007 to 47.2% in IDHS 2017, possibly because of a quite significantly increased economic growth in this region ( Afkarina et al ., 2019 ). Meanwhile, the peat swamp areas are commonly found on the Borneo island, which are characterized by a low pH, high turbidity, and high organic content ( Oktiani et al. , 2020 ). People on this island may see that PDW is the best option for their drinking water source. PDW consumption in some provinces declined, e.g., Aceh, West Papua, etc., especially in 2012–2017. We assumed that the fall was caused by the fluctuating GDP in those provinces from 2012 to 2017. Furthermore, the global economic crisis in 2015 may affect the GDP in some provinces in Indonesia, thereby decreasing the PDW consumption. However, further investigation is necessary to ensure the reason for the decreased PDW consumption in these provinces.

Exposure to mass media does not significantly relate to PDW consumption. Particularly, advertising PDW in newspapers, television, and radio may be of no influence or have a small correlation to choosing PDW. The findings support the study of Doria (2010) that impersonal information, e.g., mass media, does not have a direct influence on PDW consumption compared to social-economic status and interpersonal information from family or friends. The increased PDW consumption in the neighborhood may create a norm, i.e., social pressure, of using PDW, which will create a ‘reinforcing effect’ and rapidly increase the PDW consumption, as discussed in the context of household water treatment (HWT) behavior in developing countries ( Daniel et al ., 2022 ).

Another significant variable is the household head's age. A negative coefficient indicates that younger household head tends to consume PDW, probably because the young household head does not want to bother themselves with the time to do HWT, so they can focus more on their job. Income, educational level, and urban area positively influence PDW consumption in combination with this finding with other study findings, we then argue that young people in urban areas may dominate the PDW consumer in the future. These young people can then be a potential object of intervention in improving PDW safety in Indonesia, e.g., by educating them to always keep their PDW dispensers clean.

The SLR revealed that approximately half of the analyzed samples were fecally contaminated. However, the Ministry of Health of Indonesia ( Ministry of Health, 2021 ) revealed that 67% of the refill water was contaminated. Some studies imply that PDW has relatively better water quality than other types of drinking water sources, e.g., tap, protected well, spring, etc., although PDW is not fully safe ( Cronin et al. , 2017 ; Irda Sari et al. , 2018 ). First, the treatment process is not effective. A previous study found that a combination of water treatment in refilled PDW depot, e.g., reverse osmosis, ultraviolet, and ozone, decreases the total coliform by 92.6%, suggesting that the treatment process is not fully effective. Secondly, there is a high possibility of recontamination after treatment, e.g., during packaging or consumption at the house ( Sari et al. , 2020 ). Other factors that influence the water quality are hygienic processes during production, improper storage, high temperature, lack of protection after treatment, and the quality of raw water sources, which may be caused by open defecation, underground damaged sewerage lines, and drainage system seepage ( Halage et al. , 2015 ).

Photo examples of PDW dispensers from authors in the house in Indonesia.

The systematic review revealed that PDW is not always safe although people often perceive that PDW has a good quality. Therefore, boiling water treatment is recommended to ensure the safety of PDW. Waterborne pathogen exposure will be significantly reduced and be safer if a household boils its drinking water ( Cohen et al. , 2020 ). Another strategy is to make sure that the water dispenser, the area surrounding the dispenser, and the water cup are hygienic, e.g., by not putting the bottle or dispenser on the floor, as shown by the rightmost picture in Figure 6 .

Furthermore, issues of microplastic contamination in PDW are rising in recent years. Microplastics have been identified in bottled water. The presence of microplastics in PDW has been highly detected in reusable plastic bottles ( Eerkes-Medrano et al ., 2019 ). The contamination of microplastic in PDW could also occur in Indonesia due to increased PDW consumption. A study (including Indonesia) reported that 93% of samples ( n =259) of bottled water from across 11 different brands showed some sign of microplastics. The average density of microplastics from all samples is 325 MPP/L for (size: >100 μm) and 315 MPP/L (size: 6.5–100 μm) ( Mason et al ., 2018 ).

The safety aspect of PDW cannot be underestimated. Unsafe drinking water threatens human health and can lead to morbidity and in some cases, death. Diarrhea was the most common disease that occurred through water transmission, especially among children, who are the most vulnerable group. Approximately 11% of child deaths in the world are linked to diarrhea from unsafe drinking water ( Pal et al. , 2018 ). Our statistical analyses confirm that PDW is associated with lower diarrhea cases in children although PDW is not always safe, which could be because other types of water sources have worse water quality than PDW and are not treated. However, improving the quality of PDW and minimizing recontamination to reduce the risk of getting diarrhea in children is important because children who consume PDW suffer from diarrhea.

HWT, especially boiling, is practiced by the majority of Indonesian households. However, HWT consumption has decreased in the past decade. The IDHS reports show a decreased HWT, i.e., 91% in 2007 compared to 70% in 2017 ( National Population and Family Planning Board et al. , 2018 ). Boiling is considered a time-consuming HWT ( Clasen et al. , 2008 ). The decreasing consumption of HWT is due to the increasing PDW consumption. However, this needs more investigation.

This study has some limitations. We realize that other variables may affect the household decision to consume PDW but are not included in this study, especially perceptions regarding PDW ( Gebremichael et al. , 2021 ). Perceptions or psychological factors are considered to have higher explanatory power to explain water-related behavior compared to socio-economic characteristics ( Lilje & Mosler, 2017 ). Future studies should investigate the household's perceptions regarding PDW to provide a better understanding of PDW consumption in Indonesia. Furthermore, future studies need to confirm our argument that the decreased HWT is due to the increasing PDW consumption. We could not confirm this argument because of the limited annual data on HWT in Indonesia, unlike PDW. One can use data from other countries to confirm this argument. Moreover, we need more studies to find the reason for many contaminated PDWs. The water quality analysis combined with the sanitary inspection at the water producer, depot, and house, is expected to reveal this issue in more detail. We need to investigate where (e.g., depot or house) and when (e.g., during treatment, production, or consumption at the house) contamination or recontamination occurs. Future studies also need to discover the role of mass media or other communication channels to influence the household decision in consuming PDW. This can help us to understand how people change their main drinking water source to PDW.

Finally, this study is limited due to the use of secondary data. We have relied on other studies or data sources and have no control over the data collection or reporting. Particularly, there is an anomaly in the data of PDW consumers in Indonesia in 2012, i.e., the percentage significantly increased from 22.29% in 2011 to 38.85% in 2012, but then decreased to 27.66% in 2013 ( Figure 3 ). This raises a question in either data collection, validation, or reporting by the related agencies. Another example is PDW water sampling. Information on sample collection and testing is limited in previous studies, either directly from the sealed bottle, from the water dispenser (directly to the sampling bag), or the cup. This may moderate (or confirm) our conclusion that one out of two PDW in Indonesia is fecally contaminated.

This study reveals the trends of PDW consumption in Indonesia in the past decades. There is a fast-increasing PDW consumption in Indonesia and 50% of people in Indonesia are expected to consume PDW in 2026. The increasing PDW consumption in Indonesia was strongly associated with the economic growth of the country, which is represented by the GDP and urban population. Regression analysis revealed that socio-economic characteristics, including the age of the household head, mother's educational level, father's educational level, wealth index, type of residence, and type of toilet facility, significantly predict the PDW consumption. Our findings indicate that young people in urban areas may dominate the PDW consumer in the future. Moreover, past studies revealed a high chance of fecal contamination in the PDW, suggesting the need to better regulate and implement the hygienic procedure of PDW production, distribution, and storage, i.e., before reaching the consumer, in Indonesia. Finally, people can perform HWT and make sure that the water dispenser and the surrounding area are hygienic to prevent recontamination at the household level.

The first author receives a master's study funding from Indonesia Endowment Fund for Education (LPDP). The second author receives master's study funding from the Balikpapan Stimulan Scholarship.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.

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Examining the prospects of residential water demand management policy regulations in ethiopia: implications for sustainable water resource management, 1. introduction, 2. study area description, 3. data and methodology, 3.2. methodology, 3.3. method of data analysis, 4. results and discussion, 4.1. policy framework for residential water demand management, 4.1.1. overview of existing policy, 4.1.2. implication of the policies, 4.2. assessment of policy effectiveness, 4.2.1. evaluation of implementation, 4.2.2. impact on water consumption, 4.3. prospects and opportunities, 4.3.1. identification of gaps, 4.3.2. best practices, 4.3.3. stakeholder engagement, 4.4. strategies for enhancing sustainable water resource management, 4.4.1. policy recommendations, 4.4.2. community engagement, 4.4.3. integration with water resource planning, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Timotewos, M.T.; Barjenbruch, M. Examining the Prospects of Residential Water Demand Management Policy Regulations in Ethiopia: Implications for Sustainable Water Resource Management. Sustainability 2024 , 16 , 5625. https://doi.org/10.3390/su16135625

Timotewos MT, Barjenbruch M. Examining the Prospects of Residential Water Demand Management Policy Regulations in Ethiopia: Implications for Sustainable Water Resource Management. Sustainability . 2024; 16(13):5625. https://doi.org/10.3390/su16135625

Timotewos, Mosisa Teferi, and Matthias Barjenbruch. 2024. "Examining the Prospects of Residential Water Demand Management Policy Regulations in Ethiopia: Implications for Sustainable Water Resource Management" Sustainability 16, no. 13: 5625. https://doi.org/10.3390/su16135625

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Ryan Cronk , Jamie Bartram

Background Packaged water products provide an increasingly important source of water for consumption. However, recent studies raise concerns over their safety. Objectives To assess the microbial safety of packaged water, examine differences between regions, country incomes, packaged water types, and compare packaged water with other water sources. Methods We performed a systematic review and meta-analysis. Articles published in English, French, Portuguese, Spanish and Turkish, with no date restrictions were identified from online databases and two previous reviews. Studies published before April 2014 that assessed packaged water for the presence of Escherichia coli, thermotolerant or total coliforms were included provided they tested at least ten samples or brands. Results A total of 170 studies were included in the review. The majority of studies did not detect fecal indicator bacteria in packaged water (78/141). Compared to packaged water from upper-middle and high-income countries, packaged water from low and lower-middle-income countries was 4.6 (95% CI: 2.6–8.1) and 13.6 (95% CI: 6.9–26.7) times more likely to contain fecal indicator bacteria and total coliforms, respectively. Compared to all other packaged water types, water from small bottles was less likely to be contaminated with fecal indicator bacteria (OR = 0.32, 95%CI: 0.17–0.58) and total coliforms (OR = 0.10, 95%CI: 0.05, 0.22). Packaged water was less likely to contain fecal indicator bacteria (OR = 0.35, 95%CI: 0.20, 0.62) compared to other water sources used for consumption. Conclusions Policymakers and regulators should recognize the potential benefits of packaged water in providing safer water for consumption at and away from home, especially for those who are otherwise unlikely to gain access to a reliable, safe water supply in the near future. To improve the quality of packaged water products they should be integrated into regulatory and monitoring frameworks.

Rishi Patel

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Iheanyi Okonko

charles ssemugabo , Ali Halage

Objective. To assess the bacteriological and physical quality of locally packaged drinking water sold for public consumption. Methods. This was cross-sectional study where a total of 60 samples of bottled water from 10 brands and 30 samples of sachet water from 15 brands purchased randomly were analyzed for bacteriological contamination (total coliform and faecal coliform per 100 mL) usingmembrane filtrate method and reported in terms of cfu/100 mL. Results. Both bottled water and sachet water were not contaminated with faecal coliform.Majority (70%, 21/30) of the sachetwater analyzed exceeded acceptable limits of 0 total coliforms per 100mL set byWHOand the national drinking water standards.The physical quality (turbidity and pH) of all the packaged water brands analyzed was within the acceptable limits.There was statistically significant difference between the median count of total coliform in both sachet water and bottled water brands (𝑈(24) = 37.0, 𝑝 = 0.027). Conclusion. Both bottled water and sachet water were not contaminated with faecal coliforms; majority of sachet waterwas contaminated with total coliformabove acceptable limits. Government and other stakeholders should consider intensifying surveillance activities and enforcing strict hygienic measures in this rapidly expanding industry to improve packaged water quality.

Journal ijmr.net.in(UGC Approved)

In this study, physical, chemical and bacteriological qualities of bottled and plastic-bagged drinking water sold and/or produced in Kumasi, Ghana, were examined to compare their compliance with World Health Organisation (WHO) and Ghana Standard Authority (GSA) standards. One hundred and ninety-eight (198) samples representing 22 brands from 5 bottled water and 17 plastic-bagged water were collected randomly from street vendors, local markets and shops and analysed for physical, chemical and bacteriological water quality parameters using WHO analytical methods. Temperatures of all the samples analysed were higher than the WHO/GSA standard. Forty percent (40%) of the bottled water and 5.88% of plastic-bagged water had pH values lower than WHO/GSA standard. All other physical and chemical parameters analysed were within the WHO/GSA acceptable standards. Total coliforms, faecal coliforms and enterococci bacteria were not present in any of the water brands. The results of this study indicate that bottled and sachet drinking water produced and/or sold in Kumasi, Ghana, are of good quality for consumption.

JollyBabe Acala

ready to survey, and outline defense for these chapters..

Ayokunle Christopher Dada

Jamie Bartram

Packaged drinking water (PW) sold in bottles and plastic bags/sachets is widely consumed in low- and middle-income countries (LMICs), and many urban users in sub-Saharan Africa (SSA) rely on packaged sachet water (PSW) as their primary source of water for consumption. However, few rigorous studies have investigated PSW quality in SSA, and none have compared PSW to stored household water for consumption (HWC). A clearer understanding of PSW quality in the context of alternative sources is needed to inform policy and regulation. As elsewhere in SSA, PSW is widely consumed in Sierra Leone, but government oversight is nearly nonexistent. This study examined the microbiological and chemical quality of a representative sample of PSW products in Freetown, Sierra Leone at packaged water manufacturing facilities (PWMFs) and at points of sale (POSs). Samples of HWC were also analyzed for comparison. The study did not find evidence of serious chemical contamination among the parameters studied...

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Known colloquially as “purewater”, sachet water has outcompeted all alternatives to Ghana’s unreliable government water infrastructure and serves as the cheap, portable, omnipresent solution for narrowing the safe water access gap. Each single-use sachet holds 500 ml of filtered potable water and is heat-sealed in a high-density polyethylene bag. Insufficient and often skeptical scholarship exists surrounding the state of sachet water in Ghana, and almost no research incorporates qualitative data into analysis and future recommendations. In the face of incomplete and decontextualized research on sachet water, this study aims to use qualitative data concerning Ghanaian viewpoints to showcase the recent positive developments in the lifecycle of sachet water. Data was gathered through semi-structured interviews with dozens of sachet water producers, regulatory parties, consumers from all over the country with diverse backgrounds, and members of the formal and informal waste management sectors over the summer months of 2013 and 2014. Although viewed as a problematic water alternative from a number of health and environmental viewpoints, this thesis demonstrates that sachet water is becoming more potable and better recycled. Results suggest that registered sachet water producers continue to raise water quality, private market waste management solutions are starting to curb the number of inappropriately discarded sachets, and Ghanaians generally are satisfied with sachet water’s role in increasing reliable potable water coverage.

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