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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.

ABSTRACT: 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 (? = -0.089, p = 0.486) or children (? = -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.

SUBMITTER: Kirby MA

PROVIDER: S-EPMC6546207 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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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.

Kirby Miles A MA Nagel Corey L CL Rosa Ghislaine G Zambrano Laura D LD Musafiri Sanctus S Ngirabega Jean de Dieu JD Thomas Evan A EA Clasen Thomas T

PLoS medicine 20190603 6

<h4>Background</h4>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.<h4>Methods and findings</h4>In a large-scale program in Western Province, Rwanda, ...[more]

PMID: 31158266

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Project description:In environmental health interventions addressing water and indoor air quality, multiple determinants contribute to adoption. These may include technology selection, technology distribution and education methods, community engagement with behavior change, and duration and magnitude of implementer engagement. In Rwanda, while the country has the fastest annual reduction in child mortality in the world, the population is still exposed to a disease burden associated with environmental health challenges. Rwanda relies both on direct donor funding and coordination of programs managed by international non-profits and health sector businesses working on these challenges.This paper describes the design, implementation and outcomes of a pilot program in 1,943 households across 15 villages in the western province of Rwanda to distribute and monitor the use of household water filters and improved cookstoves. Three key program design criteria include a.) an investment in behavior change messaging and monitoring through community health workers, b.) free distributions to encourage community-wide engagement, and c.) a private-public partnership incentivized by a business model designed to encourage "pay for performance". Over a 5-month period of rigorous monitoring, reported uptake was maintained at greater than 90% for both technologies, although exclusive use of the stove was reported in only 28.5% of households and reported water volume was 1.27 liters per person per day. On-going qualitative monitoring suggest maintenance of comparable adoption rates through at least 16 months after the intervention.High uptake and sustained adoption of a water filter and improved cookstove was measured over a five-month period with indications of continued comparable adoption 16 months after the intervention. The design attributes applied by the implementers may be sufficient in a longer term. In particular, sustained and comprehensive engagement by the program implementer is enabled by a pay-for-performance business model that rewards sustained behavior change.

Project description: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).

Project description:Understanding microhabitat preferences of animals is critical for effective conservation, especially for temperate-zone bats, which receive fitness benefits from selecting optimal roost microhabitats. Artificial roost structures are increasingly being used in conservation efforts for at-risk bat species. To evaluate microhabitat differences in common artificial roost structures and determine if roost selection occurs based on structure type, we installed artificial roosts of three different styles (bat box, rocket box, and bark mimic) in six clusters. We compared size and measured temperature parameters (12 points/roost) while bats were excluded from one cluster. We simultaneously conducted census counts during the active season at five more clusters open to bats for 1-2 years. The rocket box style provided larger entrance area, surface area, and volume versus other roost types. Microclimate varied with roost design. More positions inside the bat box and rocket box stayed within critical temperature limits for bats (0-45°C)-i.e., were usable. The bark-mimic provided less usable space than the rocket box and, often, large proportions of the roost were > 45°C. The rocket box provided the widest temperature availability in a given hour (max range available 7°C) and was more stable than the bark mimic. A maternity colony of Indiana bats (Myotis sodalis) selected the rocket box style; four of five available rocket boxes became primary maternity roosts, with 2-210 bats emerging per night. Future work should aim to manipulate roost size, temperature availability, and temperature stability in isolation to identify which features drive roost microhabitat selection by bats. Comparative studies of artificial roosts account for some inherent irregularity in natural systems, allowing us to study the dynamics of roost microhabitats. We recommend season-long monitoring of microhabitat in novel artificial refuges and comparative studies of artificial and natural roosts, and urge managers to consider potential positive and negative effects when substituting artificial roosts for natural habitat.

Project description:BackgroundCommunity health clubs are multi-session village-level gatherings led by trained facilitators and designed to promote healthy behaviours mainly related to water, sanitation, and hygiene. They have been implemented in several African and Asian countries but have never been evaluated rigorously. We aimed to evaluate the effect of two versions of the community health club model on child health and nutrition outcomes.MethodsWe did a cluster-randomised trial in Rusizi district, western Rwanda. We defined villages as clusters. We assessed villages for eligibility then randomly selected 150 for the study using a simple random sampling routine in Stata. We stratified villages by wealth index and by the proportion of children younger than 2 years with caregiver-reported diarrhoea within the past 7 days. We randomly allocated these villages to three study groups: no intervention (control; n=50), eight community health club sessions (Lite intervention; n=50), or 20 community health club sessions (Classic intervention; n=50). Households in these villages were enrolled in 2013 for a baseline survey, then re-enrolled in 2015 for an endline survey. The primary outcome was caregiver-reported diarrhoea within the previous 7 days in children younger than 5 years. Analysis was by intention to treat and per protocol. This trial is registered with ClinicalTrials.gov, number NCT01836731.FindingsAt the baseline survey undertaken between May, 2013, and August, 2013, 8734 households with children younger than 5 years of age were enrolled. At the endline survey undertaken between Sept 21, 2015, and Dec 22, 2015, 7934 (91%) of the households were re-enrolled. Among children younger than 5 years, the prevalence of caregiver-reported diarrhoea in the previous 7 days was 514 (14%) of 3616 assigned the control, 453 (14%) of 3196 allocated the Lite intervention (prevalence ratio compared with control 0·97, 95% CI 0·81-1·16; p=0·74), and 495 (14%) of 3464 assigned the Classic intervention (prevalence ratio compared with control 0·99, 0·85-1·15; p=0·87).InterpretationCommunity health clubs, in this setting in western Rwanda, had no effect on caregiver-reported diarrhoea among children younger than 5 years. Our results question the value of implementing this intervention at scale for the aim of achieving health gains.FundingBill & Melinda Gates Foundation.

Project description:BackgroundThe environmental and health impacts of reliance on solid fuels and traditional cookstoves in low-income countries have motivated the promotion of household cooking energy systems that use cleaner burning fuels and cookstoves that lead to reduced exposure to harmful pollutants. Little is known about adoption and use of such systems from the users' perspective.MethodsWe explored the facilitators and barriers to adoption and use of a private sector marketed household cooking energy system that uses sustainably produced biomass pellets and the cleanest burning fan micro-gasification stove currently available. We conducted 48 in-depth qualitative interviews in Gisenyi, Rwanda with decision-makers and cooks in 16 households that adopted the improved cookstove system and 8 non-adopter households.ResultsReported facilitators and barriers to adoption and non-adoption, as well as use and non-use were complex, and in some cases, contradictory. Some adopters noted that cleanliness and low smoke production were major facilitators to adoption and use, while other adopters and non-adopters said the cookstoves blackened and damaged cooking pots and produced excessive smoke. Our findings suggest that correct use of the stove mediates user experience. Cost was likewise reported as a facilitator among some adopters and a barrier among other adopters and non-adopters. Peer influence played a significant role as both a barrier and a facilitator to adoption and transcended other factors. Positive peer influence describing the cleanliness, affordability, and efficiency of the cookstove system encouraged adoption and use, while negative comments by peers regarding excessive smoke and damaged cooking pots discouraged adoption. Commentaries by some participants suggest that inadequate training and instruction may be primary causes of the discrepancies.ConclusionCost, cleanliness, communication among peer networks, and adequate training and instruction are important factors associated with the adoption and use of improved cookstoves and should be prioritized in the implementation of improved cookstove programs.

Dataset Information

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.

Publications

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.

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