Process evaluation and assessment of use of a large scale water filter and cookstove program in Rwanda

Applying climate reparative finance toward water security

Water insecurity is increasing globally as one of the first perceivable effects of climate change. While water management is typically a local challenge, climate finance mechanisms offer the potential to switch climate-damaging capital toward climate reparative water infrastructure and create a sustainable, performance-based funding stream to incentivize safe water services globally.

Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: a cluster-randomized controlled trial in Rwamagana district

Unsafe drinking water remains a major cause of mortality and morbidity. While Rwanda's Community-Based Environmental Health Promotion Programme (CBEHPP) promotes boiling and safe storage, previous research found these efforts to be ineffective in reducing fecal contamination of drinking water. We conducted a cluster randomized control led trial to determine if adding a household water filter with safe storage to the CBEHPP would improve drinking water quality and reduce child diarrhea. We enrolled 1,199 households with a pregnant person or child under 5 across 60 randomly selected villages in Rwamagana district. CBEHPP implementers distributed and promoted water purifiers to a random half of villages. We conducted two unannounced follow-up visits over 13-16 months after the intervention delivery. The intervention reduced the proportions of households with detectable E. coli in drinking water samples (primary outcome) by 20% (PR 0.80, 95% CI 0.74-0.87, p < 0.001) and with moderate and higher fecal contamination (≥10 CFU/100 mL) by 35% (PR 0.65, 95% CI 0.57-0.74, p < 0.001). The proportion of children under 5 experiencing diarrhea in the last week was reduced by 49% (aPR 0.51, 95%CI 0.35-0.73, p < 0.001). Our findings identify an effective intervention for improving water quality and child health that can be added to the CBEHPP.

Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: A cluster-randomized controlled trial in Western Province, Rwanda

BACKGROUND

Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale.

METHODS AND FINDINGS

In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (β = -0.089, p = 0.486) or children (β = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes.

CONCLUSIONS

Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI.

TRIAL REGISTRATION

Clinical Trials.gov NCT02239250.

Early Adoption of an Improved Household Energy System in Urban Rwanda

Cooking with solid fuels and inefficient cookstoves has adverse consequences for health, environment, and human well-being. Despite the promise of improved cookstoves to reduce these impacts, adoption rates are relatively low. Using a 2-wave sample of 144 households from the baseline and first midline of an ongoing 4-year randomized controlled trial in Rwanda, we analyze the drivers and associations of early adoption of a household energy intervention marketed by a private sector firm. Households sign an annual contract to purchase sustainably produced biomass pellets and lease a fan micro-gasification cookstove with verified emissions reductions in laboratory settings. Using difference-in-differences and fixed effects estimation techniques, we examine the association between take-up of the improved cooking system and household fuel expenditures, health outcomes, and time use for primary cooks. Thirty percent of households adopted the pellet and improved cookstove system. Adopting households had more assets, lower per capita total expenditures and cooking fuel expenditures, and higher per capita hygiene expenditures. Households with married household heads and female cooks were significantly more likely to adopt. Adjusting for confounders, we find significant reduction in primary cooks' systolic blood pressure, self-reported prevalence of shortness of breath, an indicator of respiratory illness, time spent cooking, and household expenditures on charcoal. Our findings have implications for marketing of future clean fuel and improved cookstove programs in urban settings or where stoves and fuel are purchased. Analysis of follow-up surveys will allow for estimation of long-term impacts of adoption of interventions involving pellets and fan micro-gasification cookstoves.

Let the "A" in WASH Stand for Air: Integrating Research and Interventions to Improve Household Air Pollution (HAP) and Water, Sanitation and Hygiene (WaSH) in Low-Income Settings

BACKGROUND

Research often suffers from overspecialization, a practice nurtured in academia and reinforced by funders. Indeed, investigators in household air pollution (HAP) and water, sanitation and hygiene (WaSH), working in poor parts of the world, rarely interact despite having similar training and using similar methods to evaluate interventions in the same vulnerable populations. Disappointing results from recent trials of improved cookstoves and traditional approaches to WaSH suggest the need for alternative approaches.

OBJECTIVES

We argue that bringing these two areas together would improve the effectiveness and efficiency of interventions to reduce the massive disease burden associated with HAP and poor WaSH, including pneumonia and diarrhea, the leading killers of young children in low-income countries.

RESULTS

HAP and WaSH face similar challenges in designing, implementing, and securing the sustained and exclusive use of scalable interventions such as clean fuel and water.

DISCUSSION

Research can advance greater coordination of these areas by demonstrating their interactions and wider impacts on well-being as well as the potential for programmatic synergies. Integrated solutions to clean households and communities can benefit from the contribution in multiple disciplines, including economics and policy analysis; business and finance; engineering and technology; lab sciences, environmental health, and biomedical sciences; and behavioral and implementation sciences.

CONCLUSION

There are compelling reasons to overcome the artificial and unproductive segregation of HAP and WaSH. Researchers should encourage integration by expanding the scope of their collaborations and projects. Policy makers, funders, and implementers can help by supporting comprehensive solutions, encouraging innovation, and requiring rigorous evaluations of their effects. https://doi.org/10.1289/EHP4752.

Socio-Cultural Reasons and Community Perceptions Regarding Indoor Cooking Using Biomass Fuel and Traditional Stoves in Rural Ethiopia: A Qualitative Study

Around three billion people in the world and 90% of the rural households in low-and middle-income countries are exposed to wood smoke with varying exposure levels and resulting health risks. We aimed to explore perceptions of the community towards indoor cooking and the socio-cultural barriers to bring change in Butajira, rural Ethiopia. We conducted a qualitative study involving ten separate focus group discussions with purposively selected members of the community and two key informant interviews with health extension workers. Content analysis was carried out using ATLAS.ti software. Participants reported the use of fuel wood and traditional three-stone cook stove to cook food. Economic status, lack of commitment, cultural views and concern along with safety and security issues were found to be barriers to change from traditional to cleaner methods of cooking. The community perceived wood smoke to have effects on their eyes and respiratory health, though they culturally viewed it as beneficial for postpartum mothers and newborns, avoiding bad smell and insects and in order to strengthen the fabric of their houses. Health education at community level is essential in order to bring about change in the cultural views and cooking behaviors focusing on opening windows and keeping young children away during cooking.

Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda

Background

In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with biomass fuels on traditional stoves is a significant risk factor for pneumonia, while consumption of contaminated drinking water is a primary cause of diarrheal disease. To date, there have been no large-scale effectiveness trials of programmatic efforts to provide either improved cookstoves or household water filters at scale in a low-income country. In this paper we describe the design of a cluster-randomized trial to evaluate the impact of a national-level program to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households in Rwanda.

Methods/Design

We randomly allocated 72 sectors (administratively defined units) in Western Province to the intervention, with the remaining 24 sectors in the province serving as controls. In the intervention sectors, roughly 100,000 households received improved cookstoves and household water filters through a government-sponsored program targeting the poorest quarter of households nationally. The primary outcome measures are the incidence of acute respiratory infection (ARI) and diarrhea among children under five years of age. Over a one-year surveillance period, all cases of acute respiratory infection (ARI) and diarrhea identified by health workers in the study area will be extracted from records maintained at health facilities and by community health workers (CHW). In addition, we are conducting intensive, longitudinal data collection among a random sample of households in the study area for in-depth assessment of coverage, use, environmental exposures, and additional health measures.

Discussion

Although previous research has examined the impact of providing household water treatment and improved cookstoves on child health, there have been no studies of national-level programs to deliver these interventions at scale in a developing country. The results of this study, the first RCT of a large-scale programmatic cookstove or household water filter intervention, will inform global efforts to reduce childhood morbidity and mortality from diarrheal disease and pneumonia.

Trial registration

This trial is registered at Clinicaltrials.gov (NCT02239250).

Behavioral Reactivity Associated With Electronic Monitoring of Environmental Health Interventions--A Cluster Randomized Trial with Water Filters and Cookstoves

Subject reactivity--when research participants change their behavior in response to being observed--has been documented showing the effect of human observers. Electronics sensors are increasingly used to monitor environmental health interventions, but the effect of sensors on behavior has not been assessed. We conducted a cluster randomized controlled trial in Rwanda among 170 households (70 blinded to the presence of the sensor, 100 open) testing whether awareness of an electronic monitor would result in a difference in weekly use of household water filters and improved cookstoves over a four-week surveillance period. A 63% increase in number of uses of the water filter per week between the groups was observed in week 1, an average of 4.4 times in the open group and 2.83 times in the blind group, declining in week 4 to an insignificant 55% difference of 2.82 uses in the open, and 1.93 in the blind. There were no significant differences in the number of stove uses per week between the two groups. For both filters and stoves, use decreased in both groups over four-week installation periods. This study suggests behavioral monitoring should attempt to account for reactivity to awareness of electronic monitors that persists for weeks or more.