design described in the united nation children s fund s end - decade multiple - indicator survey handbook ( 9 ) , which resulted in an equal - probability sample of 3,000 households in 30 enumeration areas throughout the country . data were analyzed with sas - callable sudaan 9.0.1 proc rlogist ( sas institute , inc . , colinearity and interactions between variables were assessed . to create an indicator of socioeconomic status , household asset factor scores , generated from a principal components analysis from the malawi 1992 demographic and health survey , were calculated by using the method described by gwatkin et al . ( 10 ) . among 3,000 households included in the survey , 1,787 mothers ( or maternal caretakers ) were identified , of whom 1,669 ( 93% ) were eligible , having at least 1 child < 5 years ; all completed the survey . this sample was representative of the population distribution for malawi , according to the malawi 2004 demographic and health survey ( table 1 ) . 1,075 ( 64% ; 95% confidence interval [ ci ] 5871 ) had heard of waterguard ; of these 726 ( 68% ) believed the product was  to make water safe ,  230 ( 21% ) believed the product was  to prevent diarrhea ,  and 108 ( 10% ) either did not know or gave another answer . among the mothers who had heard of waterguard , 556 ( 52% ) said they had used it  at some point in the past ,  and 124 ( 12% ) reported that they were currently using it . current users represented 7% ( 95% ci 411 ) of the total population . among these , 77 ( 62% ) said that waterguard caused  less diarrhea ,  or  less illness in the family . rates of awareness and use of the product were higher among those living in an urban area than a rural area . among 432 mothers who had used waterguard in the past , but were not using it at the time of the survey , 168 ( 39% ) indicated that they  can not afford it ,  145 ( 34% ) that it was  currently unavailable ,  12 ( 3% ) that they do nt like the taste ,  and 1 said she did nt  think it makes water safer . in all , 106 ( 25% ) gave no reason for no longer using waterguard . in a multivariate model , waterguard awareness was independently associated with living in an urban area ( adjusted odds ratio [ aor ] 3.92 , p<0.001 ) , being a mother who had attended school ( aor 2.84 , p<0.001 ) , having a husband who had attended school ( aor 1.90 , p<0.001 ) , and higher wealth quintile ( aor 1.97 p = 0.0003 ) ( table 2 ) . current use of waterguard was independently associated with living in an urban residence compared to a rural residence ( aor = 2.01 , p = 0.0342 ) ( table 2 ) . the program budget and national waterguard sales in malawi were substantially lower than comparable data from a similar sws program in zambia ( figure ) . * or , odds ratio ; ci , confidence interval ; ns or > 1 for region central or region south indicates a higher probability than the north region . or > 1 for higher quintile ( 4 and 5 ) indicates a higher probability than those in the lower quintile ( 1 , 2 , and 3 ) .   predictor variables with a p = 0.10 in univariate analysis were included in the multivariate model to adjust for these simultaneously . annual program budget and product sales of safe water system programs in malawi and zambia , 20022005 . year 2005 total population : zambia , 11,502,010 ; malawi , 13,013,926 ( www.cia.gov/cia/publications/factbook/geos/za.html ) . this national survey of malawian mothers found awareness of waterguard to be high in a very poor country with limited commercial penetration into rural areas . in addition , over half of mothers who had heard of waterguard had tried it , and 12% of these mothers reported currently using the product at the time of the survey . figures for awareness and past use in the present survey were consistent with an sws survey conducted in zambia ( 11 ) , a country that borders malawi and has a similar poverty and development ranking ( 12 ) . however , reported current use of sws in zambia was , at 42% , substantially higher than in malawi , reflecting substantially higher product sales in zambia . unlike the program in malawi , which has had inconsistent and relatively low levels of funding , the sws program in zambia has had stable funding at a higher level and substantially greater sales . if the malawi sws program were able to obtain stable funding at higher levels , similar utilization rates to those in zambia might be attainable . a substantial gap exists between the percentage of mothers aware of waterguard who had tried it and those who were current users at the time of the survey ( 52% vs. 12% , respectively ) , which can be considered a dropout rate of 78% . the goal of sws in malawi is to increase water quality in an area with limited access to clean water ; therefore , sustained use among mothers is as important for long - term health effects as is increasing the initial use of the intervention . the reasons given by mothers who stopped using waterguard suggest that cost was a primary barrier to sustained use , especially among rural mothers . more research is needed to better define these and other reasons for discontinuation of water treatment to better inform efforts to increase waterguard availability and affordability . the positive perception of waterguard among those currently using it , together with the product s proven ability to disinfect water and prevent diarrhea , justifies continued efforts to market and evaluate the cost effectiveness of waterguard in malawi ( 13 ) . overall , findings of this survey support a need to increase waterguard promotion and distribution among poorer , less educated , and rural populations . social marketing programs typically have difficulty reaching rural populations because of inadequate rural commercial infrastructure ( 11 ) . if commercial mechanisms are not sufficient to promote rural use , then alternative , nontraditional approaches should be considered . for example , a program that used trained nurses in a maternal and child health clinic to promote sws was associated with an increased rate of sws use in rural kenya ( 14 ) , and use of motivational interviewing has resulted in higher purchase and usage rates of water disinfectant in zambia ( 15 ) . using women s groups to market and sell products as income - generating activities , may also be efficacious ( www.who.int/household_water/resources/freeman.pdf ) . we recommend that such marketing efforts be targeted to mothers who are least aware of the product and who could benefit the most from safe drinking water , including those who have not attended school , live in a rural area , or are have a lower socioeconomic status .
a national household survey was conducted in malawi to determine awareness and use of a socially marketed water treatment product . in all , 64% of mothers were aware of the product , and 7% were using it . 
 both poor and rural mothers had lower awareness and use rates . 
 targeting promotion to rural populations could enhance program effectiveness .