Evaluating a Water Safety Plan Intervention in Ghana

The objective of this study is to evaluate the effects of water safety plans (WSPs) in rural Ghana. The investigators aim to evaluate the effects of WSPs on water supply system infrastructure, water availability and reliability, water quality, consumer perceptions, water service provider management and financial sustainability, climate resilience, equity, and consumer health.

Study Overview

• Status: Enrolling by invitation
• Conditions: Diarrhea; Water Quality; Water Treatment
• Intervention / Treatment: Other: Water Safety Plans

Detailed Description

Much of the global population is exposed to contaminated drinking water. In piped systems, it is often easier to mitigate at the water supplier level where it can be centrally managed. A water safety plan (WSP) is a holistic tool for proactively ensuring the safety of drinking water supplies from source to tap, and the World Health Organization (WHO) recommends this systematic risk assessment and preventive management approach for water systems.

While application of WSPs has spread, systematic evidence for their implementation and effectiveness in improving water quality and health is limited, particularly in low-resource settings.

The objective of this study is to evaluate the impact of WSPs on water supply system infrastructure, water availability and reliability, water quality, consumer perceptions, water service provider management and financial sustainability, climate resilience, equity, and consumer health. The investigators will use a randomized controlled trial across 92 piped water supply systems serving small towns and rural areas in Ghana to test the effectiveness of WSPs. The investigators will collect data at baseline before the intervention is implemented, and at endline approximately 2 years after implementation begins. The investigators will also conduct a process evaluation of the WSP implementation quality.

• Study Type: Interventional
• Enrollment (Estimated): 4500
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Ghana
  • Accra, Ghana
    • The Aquaya Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Eligibility to receive the intervention was determined by water system criteria:

Inclusion Criteria:

• Water systems must be operated by a partnering private, non-profit water supplier.
• Water systems must be functional during baseline data collection.

To be eligible to participate in household surveys or focus group discussions, participants need to be at least 18 years of age and a customer of a eligible water system. To be eligible to participate in health care facility interviews, participants must be at least 18 years of age and work at a health care facility that serves community members using the included water system.

Exclusion Criteria:

• Water systems did not meet both of the above inclusion criteria.
• Water systems had already implemented a water safety plan.
• Water systems were involved in another ongoing research trial with similar expected outcomes.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Water Safety Plan Intervention Arm; Water Safety Plans	Other: Water Safety Plans; Water safety plans will be implemented at the water system level as a holistic tool for ensuring the safety of drinking water supplies from source to tap. World Health Organization guidance will be followed for implementation and recommended water safety planning steps will be followed such as assembling a WSP Team, describing the water supply, hazard identification and risk assessment, developing and implementing an incremental improvement plan, monitoring control measures to verify the effectiveness of the WSP, and continuously documenting, reviewing, and improving WSP implementation.
No Intervention: Control Arm; No Water Safety Plans: Water systems will continue to manage their water supplies without the introduction of water safety plans.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Free chlorine residue in water at point of collection (water quality impacts)	Free chlorine residue in water at point of collection (public standpipes and private taps) at or above target level of 0.2 mg/L, and at or above detectable level of 0.1 mg/L	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
E. coli in water at point of collection (water quality impacts)	E. coli in water at point of collection (binary and categorical)	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Total coliform in water at point of collection (water quality impacts)	Total coliform in water at point of collection (binary)	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Turbidity of water at point of collection (water quality impacts)	Turbidity measured in NTU in water at point of collection	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Reliability/availability of water (water supply impacts)	Reliability/availability of water based on (1) service provider documented interruptions, and (2) consumer reported service interruptions	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Consumer satisfaction (consumer perception impacts)	Household respondent satisfaction with water supplier. They will be considered satisfied if they report they are either satisfied or very satisfied with the water supplier. They will be considered dissatisfied if they report they are either dissatisfied or very dissatisfied with the water supplier.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Household use of enrolled piped water system for drinking (consumer perception impacts)	Household use of enrolled piped water system for drinking (binary).	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Households perceive water quality issues with piped water system (consumer perception impacts)	Household respondents report water quality issues with the taste, odor, or appearance of supplied water.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Number of complaints (consumer perception impacts)	Number of complaints regarding the service or quality of water. This will be measured based on (1) household self-reporting, and (2) water system reports or records.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Prevalence of diarrhea (health impacts)	Prevalence of reported diarrhea in the past two weeks. Diarrhea is defined as 3 or more loose or watery stools within 24 hours. Measured for a household's youngest child <5 years old, and any household member showing symptoms.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Blood in stool (health impacts)	Prevalence of reported blood in stool in the past two weeks. Measured for a household's youngest child <5 years old, and any household member showing symptoms.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Prevalence of severe diarrhea (health impacts)	Prevalence of reported severe diarrhea in the past two weeks. Defined as having a fever and either diarrhea or blood in stool. Measured for a household's youngest child <5 years old.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Prevalence of acute respiratory infection (health impacts)	Prevalence of reported severe or non-severe acute respiratory infection (ARI) in the past two weeks. A severe ARI is defined as having a fever and either a cough or difficulty breathing. A non-severe ARI is defined as having a cough or difficulty breathing. Measured for a household's youngest child <5 years old.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Number of clinic visits for water-related illness (health impacts)	Clinical visits will be assessed based on (1) the number of clinic visits reported by households for diarrhea-related illness, and (2) records for the number of cases of water-related illness in patients who visited healthcare facilities serving the included communities.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
E. coli in stored water at point of consumption (water quality impacts)	E. coli in stored household water at point of consumption (binary and categorical)	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Total coliform in stored water at point of consumption (water quality impacts)	Total coliform in stored household water at point of consumption (binary)	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Free chlorine residue in stored water at point of consumption (water quality impacts)	Free chlorine residue in stored household water at point of consumption at or above target level of 0.2 mg/L, and at or above detectable level of 0.1 mg/L	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Total chlorine residue in stored water at point of consumption (water quality impacts)	Total chlorine residue in stored household water at point of consumption at or above target level of 0.2 mg/L, and at or above detectable level of 0.1 mg/L	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of risk factors identified by sanitary inspections (operational outcomes)	Number of risk factors identified by sanitary inspections of water system infrastructure including the water source, water tank, distribution system, and standpipes.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Quality and use of written documentation for water system management (operational outcomes)	Quality and use of written documentation for water system management including an operational monitoring plan, compliance monitoring plan, standard operating procedures, troubleshooting manual, maintenance schedule, and operator training program. It will be assessed whether written documentation exists, and if yes, whether it is detailed or incomplete and lacking detail. Water operators will also report if the written procedures are fully implemented in practice or not. This is intended to evaluate the professionalization and management of the water systems.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Cost recovery (financial outcomes)	Financial sustainability/cost recovery (ratio of revenue collected to operating costs) of the system	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Number of meetings (institutional outcomes)	(1) Number of internal and external water safety meetings, and (2) Number of consumer water safety training or awareness events	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Documentation of climate related risks and response (climate resilience outcomes)	Documentation of climate related risks and response including whether climate-related information for the water supply system has been identified and documented, climate-related hazards related to events like heavy rainfall, flooding, and drought have been identified and prioritized, and an emergency response plan has been prepared. It will be assessed whether each aspect has been completed, and if yes whether it has been partially undertaken, but not documented; or fully undertaken and documented.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)
Identification and prioritization of disadvantaged groups by the water supplier (equity outcomes)	Identification of disadvantaged groups in the water service area has been completed by the water supplier and they have been prioritized for participation or the service provider has made improvements to the water system to address inequalities between disadvantaged and non-disadvantaged groups. It will be assessed whether each aspect has been completed, and if yes whether it has been partially undertaken, but not documented; or fully undertaken and documented.	Baseline (before intervention), Endline (approximately 24-months after the start of the intervention)

Collaborators and Investigators

• Sponsor: The Aquaya Institute
• Collaborators: Conrad N. Hilton Foundation; Kwame Nkrumah University of Science and Technology (KNUST)
• Investigators: Principal Investigator: Valerie Bauza, The Aquaya Institute

Study record dates

Study Major Dates

• Study Start (Actual): March 13, 2023
• Primary Completion (Estimated): February 1, 2026
• Study Completion (Estimated): February 1, 2026

Study Registration Dates

• First Submitted: November 20, 2025
• First Submitted That Met QC Criteria: December 19, 2025
• First Posted (Actual): January 5, 2026

Study Record Updates

• Last Update Posted (Actual): January 5, 2026
• Last Update Submitted That Met QC Criteria: December 19, 2025
• Last Verified: November 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Signs and Symptoms, Digestive; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Diarrhea
• Other Study ID Numbers: WSP Evaluation

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: De-identified individual participant data will be made available.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No