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 largescale 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 clusterrandomized 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

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)

Rural Transportation Infrastructure in Low- and Middle-Income Countries: A Review of Impacts, Implications, and Interventions

The rural transport infrastructure sector is a critical force for sustainable development that is interwoven with many other sectors. Rural transportation is an underlying driver of many of the Sustainable Development Goals (SDGs) and a crucial contributor to many socioeconomic benefits for rural people around the world. This review paper expands upon, enhances, and cross-references the perspectives outlined in previous rural infrastructure-focused review papers. Firstly, this work gives a thorough look into the progress of the rural transportation sector in recent years by focusing on the thematic relationships between infrastructure and other components of sustainable development, namely, economics and agriculture, policy and governance, health, gender, education, and climate change and the environment. Secondly, several strategies, approaches, and tools employed by governments and practitioners within the rural transport sector are analyzed and discussed for their contributions to the wellbeing of rural dwellers in low- and middle-income countries (LMICs). These include rural roads, bridges, maintenance, and non-infrastructural approaches that include concepts such as advanced technological innovations, intermediate modes of transport (IMTs), and transport services. This paper concludes that enhancement, improvement, and extension of rural transportation infrastructure brings significant benefits to rural dwellers. However, this paper also calls for additional integration of the sector and increased usage of systems approaches that view rural transport as an active part of many other sectors and a key leverage point within rural development as a whole. Further, this paper notes areas for future research and investigation, including increased investigation of the relationship between rural transportation infrastructure and education, improved data collection and management in support of improved policymaking, improved prioritization of interventions and institutionalization of maintenance, and expansion of pro-poor transportation strategies and interventions

A Cost-Benefit Analysis of Livelihood, Environmental and Health Benefits of a Large Scale

Public health interventions targeting contaminated drinking water and indoor air pollution may help to reduce two of the leading causes of death among children under 5 in Rwanda - diarrhea and pneumonia. These interventions also have the potential to provide economic benefits, including reduction in expenditures on fuelwood and time spent on fuelwood collection, environmental benefits through reductions in deforestation and greenhouse gas emissions, and additional economic benefits attributable to health impacts. We evaluate one such large scale intervention, the Tubeho Neza program in Western Rwanda using a cost-benefit analysis. This paper estimates monetized program benefits related to fuelwood savings, time savings, environmental and health benefits, which are then compared to the overall program cost, over a 5 year project year period. The total program cost is estimated at over $11.91 million, and total benefits at the means valued at over$66.67 million, for an estimated mean cost-benefit ratio of over 5.6. A sensitivity analysis of the major factors indicated a cost-benefit ratio range of approximately 1–16. The primary benefit identified is the environmental impact of woodfuel savings attributable to the improved cookstoves. This study estimates 118,000 tonnes of annual woodfuel savings in the Western Province may be attributable to the program in year 1, decreasing to 65,000 tonnes in year 5. These estimates suggest that this program may help to compensate for the government of Rwanda\u27s projected regional woodfuel deficit of 106,000 tonnes per year by 2020. Overall, this study suggests that the Tubeho Neza program provides benefits in excess of the program costs

Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda

Background: 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. Methods and Findings: 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. Conclusion: 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

Use of remotely reporting electronic sensors for assessing use of water filters and cookstoves in Rwanda.

Remotely reporting electronic sensors offer the potential to reduce bias in monitoring use of environmental health interventions. In the context of a five-month randomized controlled trial of household water filters and improved cookstoves in rural Rwanda, we collected data from intervention households on product compliance using (i) monthly surveys and direct observations by community health workers and environmental health officers, and (ii) sensor-equipped filters and cookstoves deployed for about two weeks in each household. The adoption rate interpreted by the sensors varied from the household reporting: 90.5% of households reported primarily using the intervention stove, while the sensors interpreted 73.2% use, and 96.5% of households reported using the intervention filter regularly, while the sensors interpreted no more than 90.2%. The sensor-collected data estimated use to be lower than conventionally collected data both for water filters (approximately 36% less water volume per day) and cookstoves (approximately 40% fewer uses per week). An evaluation of intrahousehold consistency in use suggests that households are not using their filters or stoves on an exclusive basis, and may be both drinking untreated water at times and using other stoves ("stove-stacking"). These results provide additional evidence that surveys and direct observation may exaggerate compliance with household-based environmental interventions

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

Abstract Background In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from inefficient combustion of biomass, the Rwanda Ministry of Health (MOH) partnered with DelAgua Health (DelAgua), a private social enterprise, to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households (Ubudehe 1 and 2) nationally, beginning in Western Province under a program branded Tubeho Neza (“Live Well”). The project is privately financed and earns revenue from carbon credits under the United Nations Clean Development Mechanism. Methods During a 3-month period in late 2014, over 470,000 people living in over 101,000 households were provided free water filters and cookstoves. Following the distribution, community health workers visited nearly 98 % of households to perform household level education and training activities. Over 87 % of households were visited again within 6 months with a basic survey conducted. Detailed adoption surveys were conducted among a sample of households, 1000 in the first round, 187 in the second. Results Approximately a year after distribution, reported water filter use was above 90 % (+/−4 % CI) and water present in filter was observed in over 76 % (+/−6 % CI) of households, while the reported primary stove was nearly 90 % (+/−4.4 % CI) and of households cooking at the time of the visit, over 83 % (+/−5.3 % CI) were on the improved stove. There was no observed association between household size and stove stacking behavior. Conclusions This program suggests that free distribution is not a determinant of low adoption. It is plausible that continued engagement in households, enabled by Ministry of Health support and carbon financed revenue, contributed to high adoption rates. Overall, the program was able to demonstrate a privately financed, public health intervention can achieve high levels of initial adoption and usage of household level water filtration and improved cookstoves at a large scale

Primary stove adoption and use outcomes.

<p>*Only records within 1.5 IQR were included.</p

Reasons for stove and filter problems, repairs and replacements.

<p>*366 total filters repaired - 25 had multiple problems.</p

Figure 1

<p>Program villages. RCT villages shown with blue pins.</p