Consumer perceptions and purchasing of packaged water products in Sierra Leone

Introduction Access to improved sources of drinking water remains a complex challenge in Sierra Leone and other low and middle income countries. We aimed to qualitatively examine consumer perceptions and purchasing behaviors of packaged water products in Sierra Leone. Methods We conducted 25 focus groups with 178 consumers and petty traders of packaged water across the four geographic regions of Sierra Leone. Discussions were recorded, transcribed, and coded into themes. The Health Belief Model guided the thematic data analysis. Results Packaged water was broadly perceived as safe, accessible, and convenient. Participants who lived outside of the capital city, Freetown, were more likely to report cost as a barrier. Personal experiences with a brand moderated trust levels. Self-reported handling behaviors of PW products were generally unhygienic. There was widespread belief that packaged water keeps newborn babies healthy. Consumers desired a simple mechanism to better identify government approved PW products. Conclusion Perceived risks, benefits, barriers, self-efficacy, and reinforcing cues to action qualitatively influenced consumers’ purchasing behavior of packaged water. Government regulators should provide consumers with reliable means to identify approved packaged water products. Consumer education efforts should include hygienic handling of packaged water products in order to minimize post-production contamination.


Introduction
In Sierra Leone, like most of sub-Saharan Africa, access to improved sources of drinking water remains a complex challenge; with waterrelated illnesses being a leading cause of death [1]. Almost 40% of Sierra Leoneans cannot access improved sources of drinking water [2]. Despite government efforts, Sierra Leone did not meet its Millennium Development Goal target to reduce the proportion of its population without improved access to drinking water by half between 1990 and 2015 [3,4]. There has been a surge of packaged water (PW) businesses in the country, with an initial boom in the capital city of Freetown, and subsequent expansion in the provincial regions. The packaged water industry includes bottled water, machine-manufactured sachet water and handtied sachet water.
Sachet water products are typically 500mL of water packaged either by machine using heat seal technology or by hand tying a plastic bag. Bottles and machine-manufactured sachets are often bundled together for wholesale but may also be sold individually in the market and in stores, while handtied sachets are usually sold individually. In Sierra Leone, most PW businesses produce machine manufactured sachet products, although a few large bottled water manufacturers exist in Freetown.
Despite the ubiquity of PW, the government lacks effective regulation to ensure its safety. PW is marketed as safe and free of contamination using slogans such as "pure drinking water" [5].
Contrary to these safety claims, 18% of PW products sampled at 49 manufacturing facilities in Freetown contained detectable Escherichia coli [6]. However, a systematic review revealed that while there are quality problems with PW, in some contexts, it is safer than the available alternative sources [7]. Post-production quality of PW tend to deteriorate along the supply chain. In Sierra Leone, one study found that the exterior of sachet products sold by street vendors were significantly more likely to contain E.coli and total coliforms as compared to those sold by retailers [6]. Even in the presence of enacted regulation, effective surveillance of the industry remains a challenge for government authorities [8].
Likewise, discarded packaging from PW poses an environmental challenge [9]. Consumers' perceptions play a key role in their assessment of PW products and purchasing behaviors [10][11][12][13]. A study in Ghana revealed that sachet brands perceived to be of high quality were less likely to present detectable heterotrophic bacteria, after controlling for possible confounders, as compared to those perceived to be of low quality [12]. Another study in Nigeria found   that the availability of a National Agency for Food and Drug   Administration  registration  number  influenced  consumers' purchasing decision, but that other labeling information rarely had any effect [11]. While prior studies have provided valuable insights on consumer perceptions of PW in sub-Saharan Africa, none of them grounded the findings using a theoretical framework.
Health behavior theories and models have been extensively used to understand consumption behaviors [14][15][16][17]. The Health Belief Model (HBM) asserts that an individual's cognitive assessment of perceived risks, moderated by perceived benefits and barriers associated with a particular behavior, are reliable predictors of the behavior [14,17]. Applying the HBM to PW consumption behavior suggests that consumers' decisions could be influenced by their perceived susceptibility to waterborne contamination, perceived benefits and barriers of consuming PW, and cues to action such as labeling information, approval notices and branded messages. Using HBM as a guiding theoretical framework, the objective of this study was to qualitatively examine consumers' perceptions that influence their purchasing behaviors of PW products. To the best of our knowledge, this is the first study that has employed a health behavior theory in examining the relationship between consumer perceptions and purchasing behaviors of PW products in sub-Saharan Africa.

Results
Most participants generally perceived themselves to be susceptible to waterborne illness, citing annual cholera outbreaks and frequent diarrhea in newborns and under-five children. Trusted PW brands were viewed as less likely to cause waterborne contamination as compared to the alternatives. Brands that had been on the market longer were more likely to be trusted as compared to new or unfamiliar brands. Consumers' personal experiences with a brand also influenced their level of trust in that brand.
"Our well water used to be good but now it is no longer pure because children put harmful substances in the well. Rainwater is often polluted so I don't drink it. I prefer to drink packaged water because it is inside a plastic, which is protected from cholera." (Consumer, Makeni).

Perceived benefits
PW was perceived to be easily accessible.

Cues to action
Participants who could read were more likely to pay attention to expiration dates as compared to other labeling information. While most consumers did not pay close attention to certification/licensing information, they found them reassuring when provided on the packages. When probed further, most participants explained that they have no means of verifying the statement provided on the sachets and bottles. Participants would like to have the ability to easily verify producers that have been approved by the relevant authorities.

Self-efficacy
Most participants were not confident in their ability to properly objectively identify PW products that conformed to national quality standards. Across all FGDs, consumers expressed a desire for the government authorities to put mechanisms in place for the public to easily identify approved PW products. A common suggestion was for the government to publish a list of certified PW products in national newspapers and announce them on the radio. Participants would generally bite one of the edges and drink directly from the sachet or handtied sachet water. Few participants shared that they use a pair of scissors to cut the sachet and pour the water in a glass before drinking it. A majority of participants reported that they never wash their hands before handing PW products. However, they may use their hands or cloth to "wipe off" the sachet before biting into it.
Consumers who were also petty traders of PW products reported similar handling behaviors.

Discussion
The findings from the FGDs affirm the assertion of HBM that individuals are likely to engage in health related behaviors based on their weighing of perceived risks, benefits, barriers and self-efficacy to execute the behavior in the presence of reinforcing environmental cues [14]. Packaged water was viewed as more accessible than alternative sources of water for consumption -such as the municipal supply. Trust perceptions emerged as the factor that most frequently influenced consumers' PW purchasing decision.
Consumer perceptions of PW products tended to be comparative in nature such that a consumer would evaluate the decision to drink PW against an alternative source. Even though the perceived safety of PW products reinforced purchasing decisions, the narrative is not straightforward. Safety perceptions were formed through intermediary factors such as prior experiences with a particular product and overall brand popularity -leading consumers to perceive products as either trustworthy or untrustworthy. The Theory of Planned Behavior (TPB), a value-expectancy theory, would suggest that PW use is a function of consumers' intention to drink PW, with the attitudinal belief that it is safer than alternative sources, and normative belief that it is widely accepted by others in their social environment [15].
The HBM suggests that in order for an individual to engage in a desired behavior (e.g., purchase of only approved PW products), s/he would need to be confident in performing the promoted behavior [17]. The TBP supports this assertion as well by emphasizing that perceived behavioral control is often a reliable predictor of an individual's engagement in a promoted behavior.
Without a simplified means of verifying approved PW products, consumers would likely continue to make purchasing decisions based on their trust of PW products as opposed to objective safety measures -such as testing and approval by a sanctioned regulatory body.
The rapid urban expansion and deforestation in Sierra Leone [18,19]

Conclusion
Our findings highlight the need for effective government regulation of the PW industry in Sierra Leone to ensure consumer protection.
There is a need to provide consumers with simple means to identify approved PW products. Consumer and petty trader education should be an integral part of PW regulatory framework in Sierra Leone and other similar settings in the sub-Saharan region. A symbol linked to a government-generated list of approved PW products may be an effective way to communicate with consumers with no or low literacy. However, regulators would have to undertake rigorous surveillance to ensure that the approval symbol is not counterfeited or fraudulently used. Findings from the study further demonstrate the need to educate consumers and petty traders on hygienic handling of PW products in order to reduce the likelihood of postproduction contamination.
What is known about this topic  There has been a surge of packaged water businesses in sub-Saharan Africa, however, regulation of the industry continues to be a challenge.

What this study adds
 Widespread misconception that all packaged water products have been treated and are therefore safe for consumption;  Most participants cannot distinguished approved packaged water products from those that have not been approved by government authorities;  A recurring theme was for the government to institute simple means for consumers to verify approved PW products.
Development for their financial support of this project, through a grant administered by Adam Smith International.