1
|
Haque S, Kirby MA, Iyakaremye L, Gebremariam A, Tessema G, Thomas E, Chang HH, Clasen T. Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: a cluster-randomized controlled trial in Rwamagana district. NPJ CLEAN WATER 2022; 5:42. [PMID: 36118619 PMCID: PMC9464616 DOI: 10.1038/s41545-022-00185-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- Sabrina Haque
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Miles A. Kirby
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | | | | | - Evan Thomas
- Mortenson Center in Global Engineering, University of Colorado, Boulder, CO USA
| | - Howard H. Chang
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA USA
| |
Collapse
|
2
|
Meyer DD, Hill C, McCain K, Smith JA, Bessong PO, Rogawski McQuade ET, Wright NC. Embedding Usage Sensors in Point-of-Use Water Treatment Devices: Sensor Design and Application in Limpopo, South Africa. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:8955-8964. [PMID: 34133882 PMCID: PMC9207768 DOI: 10.1021/acs.est.0c08683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Health benefits from point-of-use (POU) water treatment devices come only with consistent use. Embedded sensors can measure the consistency of POU-device use and can provide insights about improving it. We demonstrate both potentials with data from SmartSpouts: accelerometer-based sensors embedded in spigot handles that record the duration and timing of use. In the laboratory, most sensor readings correlated well (>0.98) with manually timed water withdrawals. In the field, SmartSpouts measured >60,000 water withdrawals across 232 households in Limpopo, South Africa. Sensors proved critical to understanding consistent use; surveys overestimated it by 53 percentage points. Sensor data showed when households use POU devices (evening peaks and delayed weekend routines) and user preferences (safe storage over filters). We demonstrate analytically and with data that (i) consistent use (e.g., 7 continuous days) is extremely sensitive to single-day use prevalence and (ii) use prevalence affects the performance of contact-time-based POU devices, exemplified with silver tablets. Deployed SmartSpouts had limitations, including memory overflows and confounding device relocation with water withdrawal. Nevertheless, SmartSpouts provided useful and objective data on the prevalence of single-day and consistent use. Considerably less expensive than alternatives, SmartSpouts enable an order of magnitude increase in how many POU-device sensors can be deployed.
Collapse
Affiliation(s)
- David D Meyer
- Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Courtney Hill
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - Kelly McCain
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - James A Smith
- University of Virginia, Charlottesville, Virginia 22904, United States
| | - Pascal O Bessong
- University of Virginia, Charlottesville, Virginia 22904, United States
- University of Venda, Thohoyandou 0950, Limpopo, South Africa
| | | | - Natasha C Wright
- Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| |
Collapse
|
3
|
Piedrahita R, Johnson M, Bilsback KR, L'Orange C, Kodros JK, Eilenberg SR, Naluwagga A, Shan M, Sambandam S, Clark M, Pierce JR, Balakrishnan K, Robinson AL, Volckens J. Comparing regional stove-usage patterns and using those patterns to model indoor air quality impacts. INDOOR AIR 2020; 30:521-533. [PMID: 31943353 PMCID: PMC8886689 DOI: 10.1111/ina.12645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 05/05/2023]
Abstract
Monitoring improved cookstove adoption and usage in developing countries can help anticipate potential health and environmental benefits that may result from household energy interventions. This study explores stove-usage monitor (SUM)-derived usage data from field studies in China (52 stoves, 1422 monitoring days), Honduras (270 stoves, 630 monitoring days), India (19 stoves, 565 monitoring days), and Uganda (38 stoves, 1007 monitoring days). Traditional stove usage was found to be generally similar among four seemingly disparate countries in terms of cooking habits, with average usage of between 171 and 257 minutes per day for the most-used stoves. In Honduras, where survey-based usage data were also collected, there was only modest agreement between sensor data and self-reported user data. For Indian homes, we combined stove-usage data with a single-zone Monte Carlo box model to estimate kitchen-level PM2.5 and CO concentrations under various scenarios of cleaner cookstove adoption. We defined clean cookstove performance based on the International Standards Organization (ISO) voluntary guidelines. Model results showed that even with 75% displacement of traditional stoves with the cleanest available stove (ISO tier-5), World Health Organization 24 hours PM2.5 standards were exceeded in 96.4% of model runs, underscoring the importance of full displacement.
Collapse
Affiliation(s)
| | | | - Kelsey R Bilsback
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO
| | - Christian L'Orange
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO
| | - John K Kodros
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO
| | - Sarah Rose Eilenberg
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA
| | - Agnes Naluwagga
- Centre for Research in Energy and Energy Conservation (CREEC), Kampala, Uganda
| | - Ming Shan
- Department of Building Science, School of Architecture, Tsinghua University, Beijing, China
| | - Sankar Sambandam
- Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Maggie Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
| | - Jeffrey R Pierce
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Allen L Robinson
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA
| | - John Volckens
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO
| |
Collapse
|
4
|
Brown J, Hayashi MAL, Eisenberg JNS. The Critical Role of Compliance in Delivering Health Gains from Environmental Health Interventions. Am J Trop Med Hyg 2020; 100:777-779. [PMID: 30675842 DOI: 10.4269/ajtmh.18-0624] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Gains in reducing childhood disease burden rely heavily on effective means of preventing environmental exposures. For many environmental health interventions, such as point-of-use water treatment, sanitation, or cookstoves, exposures are strongly influenced by user behaviors and the degree to which participants adhere to the prescribed preventive measures. In this commentary, we articulate the need for increased attention on user behaviors-critically, the careful measurement and inclusion of compliance-to strengthen exposure assessment and health impact trials in environmental health intervention research. We focus here on water, sanitation, and hygiene interventions to illustrate the problem with the understanding that this issue extends to other environmental health interventions.
Collapse
Affiliation(s)
- Joe Brown
- Georgia Institute of Technology, Atlanta, Georgia
| | | | | |
Collapse
|
5
|
Jagger P, Das I, Handa S, Nylander-French LA, Yeatts KB. Early Adoption of an Improved Household Energy System in Urban Rwanda. ECOHEALTH 2019; 16:7-20. [PMID: 30617588 PMCID: PMC6592015 DOI: 10.1007/s10393-018-1391-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 10/25/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Pamela Jagger
- School for Environment and Sustainability, University of Michigan, Ann Arbor, MI, USA.
- Carolina Population Center, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, USA.
- Department of Geography, UNC-CH, Chapel Hill, NC, USA.
| | - Ipsita Das
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Sudhanshu Handa
- Carolina Population Center, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, USA
- Department of Public Policy, UNC-CH, Chapel Hill, NC, USA
| | - Leena A Nylander-French
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, USA
| | - Karin B Yeatts
- Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, USA
| |
Collapse
|
6
|
Delea MG, Nagel CL, Thomas EA, Halder AK, Amin N, Shoab AK, Freeman MC, Unicomb L, Clasen TF. Comparison of respondent-reported and sensor-recorded latrine utilization measures in rural Bangladesh: a cross-sectional study. Trans R Soc Trop Med Hyg 2018; 111:308-315. [PMID: 29126213 PMCID: PMC5914303 DOI: 10.1093/trstmh/trx058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/11/2017] [Indexed: 11/26/2022] Open
Abstract
Background Health improvements realized through sanitation are likely achieved through high levels of facilities utilization by all household members. However, measurements of sanitation often rely on either the presence of latrines, which does not guarantee use, or respondent-reported utilization of sanitation facilities, which is prone to response bias. Overstatement of sanitation metrics limits the accuracy of program outcome measures, and has implications for the interpretation of related health impact data. Methods We conducted a cross-sectional study of 213 households in 14 village water, sanitation and hygiene committee clusters throughout rural Bangladesh and used a combined data- and relationship-scale approach to assess agreement between respondent-reported latrine utilization and sensor-recorded measurement. Results Four-day household-level respondent-reported defecation averaged 28 events (inter-quartile range [IQR] 20–40), while sensor-recorded defecation averaged 17 events (IQR 11–29). Comparative analyses suggest moderately high accuracy (bias correction factor=0.84), but imprecision in the data (broad scatter of data, Pearson’s r=0.35) and thus only weak concordance between measures (ρc=0.29 [95% BCa CI 0.15 to 0.43]). Conclusions Respondent-reported latrine utilization data should be interpreted with caution, as evidence suggests use is exaggerated. Coupling reported utilization data with objective measures of use may aid in the estimation of latrine use.
Collapse
Affiliation(s)
- Maryann G Delea
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Corey L Nagel
- School of Public Health, Oregon Health and Science University, Portland State University, Portland, OR, USA
| | - Evan A Thomas
- School of Public Health, Oregon Health and Science University, Portland State University, Portland, OR, USA
| | - Amal K Halder
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nuhu Amin
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abul K Shoab
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Leanne Unicomb
- Environmental Intervention Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Garland C, Gould CF, Pennise D. Usage and impacts of the Envirofit HM-5000 cookstove. INDOOR AIR 2018; 28:640-650. [PMID: 29575293 DOI: 10.1111/ina.12460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/15/2018] [Indexed: 05/22/2023]
Abstract
Burning solid fuels to fulfill daily household energy needs results in chronic exposure to household air pollution (HAP), which is among the world's greatest health risks. This paper presents the results of a cross-sectional study of cookstove usage, fuel consumption, and indoor PM2.5 concentrations in rural and urban Honduran homes cooking with the Envirofit HM-5000 metal plancha stove (n = 32) as compared to control households using baseline cooking technologies (n = 33). Temperature-based stove usage measurements showed high HM-5000 acceptance, with significant displacement of the traditional cookstoves at both the urban (99%, P < .05) and rural study sites (75%, P < .05). However, longer-term usage data collected in peri-urban households showed that participants cooked on the HM-5000 more frequently during the 3-day monitoring period than during the following 3 weeks. Average indoor PM2.5 was 66% lower in HM-5000 households as compared to control households (P < .05). Lower indoor PM2.5 concentrations observed in participant homes as compared to control households, supported by high usage and traditional stove displacement, suggest the potential for the HM-5000 to yield health improvements in adopting Honduran households.
Collapse
Affiliation(s)
- C Garland
- Berkeley Air Monitoring Group, Berkeley, CA, USA
| | - C F Gould
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, NY, USA
| | - D Pennise
- Berkeley Air Monitoring Group, Berkeley, CA, USA
| |
Collapse
|
8
|
Kirby MA, Nagel CL, Rosa G, Umupfasoni MM, Iyakaremye L, Thomas EA, Clasen TF. Use, microbiological effectiveness and health impact of a household water filter intervention in rural Rwanda—A matched cohort study. Int J Hyg Environ Health 2017; 220:1020-1029. [DOI: 10.1016/j.ijheh.2017.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 11/27/2022]
|
9
|
Li Z, Commodore A, Hartinger S, Lewin M, Sjödin A, Pittman E, Trinidad D, Hubbard K, Lanata CF, Gil AI, Mäusezahl D, Naeher LP. Biomonitoring Human Exposure to Household Air Pollution and Association with Self-reported Health Symptoms - A Stove Intervention Study in Peru. ENVIRONMENT INTERNATIONAL 2016; 97:195-203. [PMID: 27680405 PMCID: PMC5154792 DOI: 10.1016/j.envint.2016.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/12/2016] [Accepted: 09/13/2016] [Indexed: 05/21/2023]
Abstract
BACKGROUND Household air pollution (HAP) from indoor biomass stoves contains harmful pollutants, such as polycyclic aromatic hydrocarbons (PAHs), and is a leading risk factor for global disease burden. We used biomonitoring to assess HAP exposure and association with self-reported symptoms in 334 non-smoking Peruvian women to evaluate the efficacy of a stove intervention program. METHODS We conducted a cross-sectional study within the framework of a community randomized control trial. Using urinary PAH metabolites (OH-PAHs) as the exposure biomarkers, we investigated whether the intervention group (n=155, with new chimney-equipped stoves) were less exposed to HAP compared to the control group (n=179, with mostly open-fire stoves). We also estimated associations between the exposure biomarkers, risk factors, and self-reported health symptoms, such as recent eye conditions, respiratory conditions, and headache. RESULTS We observed reduced headache and ocular symptoms in the intervention group than the control group. Urinary 2-naphthol, a suggested biomarker for inhalation PAH exposure, was significantly lower in the intervention group (GM with 95% CI: 13.4 [12.3, 14.6] μg/g creatinine) compared to control group (16.5 [15.0, 18.0] μg/g creatinine). Stove type and/or 2-naphthol was associated with a number of self-reported symptoms, such as red eye (adjusted OR with 95% CI: 3.80 [1.32, 10.9]) in the past 48h. CONCLUSIONS Even with the improved stoves, the biomarker concentrations in this study far exceeded those of the general populations and were higher than a no-observed-genotoxic-effect-level, indicating high exposure and a potential for increased cancer risk in the population.
Collapse
Affiliation(s)
- Zheng Li
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, USA; Agency for Toxic Substances and Disease Registry, Division of Toxicology and Human Health Sciences, Atlanta, USA.
| | | | - Stella Hartinger
- Instituto de Investigación Nutricional, Lima, Perú; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Michael Lewin
- Agency for Toxic Substances and Disease Registry, Division of Toxicology and Human Health Sciences, Atlanta, USA
| | - Andreas Sjödin
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, USA
| | - Erin Pittman
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, USA
| | - Debra Trinidad
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, USA
| | - Kendra Hubbard
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, USA
| | | | - Ana I Gil
- Instituto de Investigación Nutricional, Lima, Perú
| | - Daniel Mäusezahl
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Luke P Naeher
- Universidad Peruana Cayetano Heredia, Lima, Perú; University of Georgia, Athens, USA
| |
Collapse
|
10
|
Wilson DL, Coyle J, Kirk A, Rosa J, Abbas O, Adam MI, Gadgil AJ. Measuring and Increasing Adoption Rates of Cookstoves in a Humanitarian Crisis. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2016; 50:8393-9. [PMID: 27435285 DOI: 10.1021/acs.est.6b02899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Traditional smoky cooking fires are one of today's greatest environmental threats to human life. These fires, used by 40% of the global population, cause 3.9 million annual premature deaths. "Clean cookstoves" have potential to improve this situation; however, most cookstove programs do not employ objective measurement of adoption to inform design, marketing, subsidies, finance, or dissemination practices. Lack of data prevents insights and may contribute to consistently low adoption rates. In this study, we used sensors and surveys to measure objective versus self-reported adoption of freely-distributed cookstoves in an internally displaced persons camp in Darfur, Sudan. Our data insights demonstrate how to effectively measure and promote adoption, especially in a humanitarian crisis. With sensors, we measured that 71% of participants were cookstove "users" compared to 95% of respondents reporting the improved cookstove was their "primary cookstove." No line of survey questioning, whether direct or indirect, predicted sensor-measured usage. For participants who rarely or never used their cookstoves after initial dissemination ("non-users"), we found significant increases in adoption after a simple followup survey (p = 0.001). The followup converted 83% of prior "non-users" to "users" with average daily adoption of 1.7 cooking hours over 2.2 meals. This increased adoption, which we posit resulted from cookstove familiarization and social conformity, was sustained for a 2-week observation period post intervention.
Collapse
Affiliation(s)
- Daniel L Wilson
- University of California , Berkeley, California 94720, United States
| | - Jeremy Coyle
- University of California , Berkeley, California 94720, United States
| | - Angeli Kirk
- University of California , Berkeley, California 94720, United States
| | - Javier Rosa
- University of California , Berkeley, California 94720, United States
| | - Omnia Abbas
- Potential Energy, Berkeley, California 94704, United States
| | | | - Ashok J Gadgil
- University of California , Berkeley, California 94720, United States
- Lawrence Berkeley National Laboratory, Berkeley, California 94720, United States
| |
Collapse
|
11
|
Nagel CL, Kirby MA, Zambrano LD, Rosa G, Barstow CK, Thomas EA, Clasen TF. Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda. Contemp Clin Trials Commun 2016; 4:124-135. [PMID: 29736475 PMCID: PMC5935890 DOI: 10.1016/j.conctc.2016.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/11/2016] [Accepted: 07/29/2016] [Indexed: 02/01/2023] Open
Abstract
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).
Collapse
Key Words
- ARI, acute respiratory infection
- Acute respiratory infection
- CHW, community health worker
- Cluster randomized controlled trial
- DBSS, dried blood spot samples
- Diarrhea
- H-PEM, Harvard Personal Exposure Monitor
- HAP, household air pollution
- Household water treatment
- ICCM, Integrated Community Case Management of Childhood Illness
- IMCI, Integrated Management of Childhood Illness
- Improved stoves
- MFI, mean fluorescence intensity
- MOH, Rwanda Ministry of Health
- MOLG, Rwandan Ministry of Local Government
- RCT, randomized controlled trial
- Rwanda
Collapse
Affiliation(s)
- Corey L Nagel
- OHSU/PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Miles A Kirby
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura D Zambrano
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ghislane Rosa
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Christina K Barstow
- Department of Civil, Environmental and Architectural Engineering, University of Colorado, Boulder, CO, USA
| | - Evan A Thomas
- Department of Mechanical Engineering, Portland State University, Portland, OR, USA
| | - Thomas F Clasen
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK.,Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
12
|
Barstow CK, Nagel CL, Clasen TF, Thomas EA. Process evaluation and assessment of use of a large scale water filter and cookstove program in Rwanda. BMC Public Health 2016; 16:584. [PMID: 27421646 PMCID: PMC4947312 DOI: 10.1186/s12889-016-3237-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 06/08/2016] [Indexed: 12/21/2022] Open
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. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3237-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Christina K Barstow
- Civil, Environmental and Architectural Engineering, University of Colorado, Boulder, CO, USA
| | - Corey L Nagel
- School of Public Health, Oregon Health and Science University, Portland State University, Portland, OR, USA
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Evan A Thomas
- Mechanical and Materials Engineering, Portland State University, Portland, OR, USA.
| |
Collapse
|
13
|
Jagger P, Jumbe C. Stoves or Sugar? Willingness to Adopt Improved Cookstoves in Malawi. ENERGY POLICY 2016; 92:409-419. [PMID: 27346912 PMCID: PMC4918052 DOI: 10.1016/j.enpol.2016.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Malawi has set a target of adoption of two million improved cookstoves (ICS) by 2020. Meeting this objective requires knowledge about determinants of adoption, particularly in rural areas where the cost of traditional cooking technologies and fuels are non-monetary, and where people have limited capacity to purchase an ICS. We conducted a discrete choice experiment with 383 households in rural Malawi asking them if they would chose a locally made ICS or a package of sugar and salt of roughly equal value. Six months later, we assessed adoption and stove use patterns. Sixty-six percent of households chose the ICS. We find that having a larger share of crop residues in household fuel supply, awareness of the environmental impacts of woodfuel reliance, time the primary cook devotes to collecting fuelwood, and peer effects at the village-level increase the odds of choosing the ICS. Having a large labor supply for fuelwood collection and experience with a non-traditional cooking technology decreased the odds of choosing the ICS. In a rapid assessment six months after stoves were distributed, we found 80% of households were still using the ICS, but not exclusively. Our findings suggest considerable potential for wide-scale adoption of ICS in Malawi.
Collapse
Affiliation(s)
- Pamela Jagger
- Department of Public Policy and Carolina Population Center, University of North Carolina at Chapel Hill, CB#8120, 211 West Cameron Avenue, Chapel Hill, NC, USA
| | - Charles Jumbe
- Center for Agricultural Research and Development, Lilongwe University of Agriculture and Natural Resources, P.O. Box 219, Lilongwe, Malawi
| |
Collapse
|
14
|
Thomas EA, Tellez-Sanchez S, Wick C, Kirby M, Zambrano L, Abadie Rosa G, Clasen TF, Nagel C. Behavioral Reactivity Associated With Electronic Monitoring of Environmental Health Interventions--A Cluster Randomized Trial with Water Filters and Cookstoves. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2016; 50:3773-80. [PMID: 26986617 DOI: 10.1021/acs.est.6b00161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
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.
Collapse
Affiliation(s)
- Evan A Thomas
- Department of Mechanical Engineering, Portland State University , Portland, Oregon 97201, United States
| | - Sarita Tellez-Sanchez
- Department of Mechanical Engineering, Portland State University , Portland, Oregon 97201, United States
| | - Carson Wick
- School of Electrical and Computer Engineering, Georgia Institute of Technology , Atlanta, Georgia 30332, United States
| | - Miles Kirby
- London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - Laura Zambrano
- Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta Georgia 30322 United States
| | | | - Thomas F Clasen
- London School of Hygiene and Tropical Medicine , London, United Kingdom
- Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta Georgia 30322 United States
| | - Corey Nagel
- School of Public Health, Oregon Health & Science University , Portland Oregon United States
| |
Collapse
|
15
|
Stelmach RD, Clasen T. Household water quantity and health: a systematic review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:5954-74. [PMID: 26030467 PMCID: PMC4483681 DOI: 10.3390/ijerph120605954] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 12/02/2022]
Abstract
While the quantity of water used in the home is thought to be an important determinant of health, much of the evidence relies on using water access as a proxy for quantity. This review examines the health effects of household water quantity using studies that directly measured water quantity. We searched MEDLINE, EMBASE, the Cochrane Library, Web of Science, and article reference lists. Eligible studies included experimental and observational studies that measured a difference in water quantity and quantified an association between water quantity and health outcomes. 21 studies, divided into six of the many possible water-quantity associated outcomes, met the eligibility criteria. Due to heterogeneity in designs, settings, methods, and outcomes, a meta-analysis was inappropriate. Overall results showed a positive association between water quantity and health outcomes, but the effect depended on how the water was used. Increased water usage for personal hygiene was generally associated with improved trachoma outcomes, while increased water consumption was generally associated with reduced gastrointestinal infection and diarrheal disease and improved growth outcomes. In high-income countries, increased water consumption was associated with higher rates of renal cell carcinoma and bladder cancer but not associated with type II diabetes, cardiac-related mortality, or all-cause mortality.
Collapse
Affiliation(s)
- Rachel D Stelmach
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| |
Collapse
|
16
|
Summers SK, Rainey R, Kaur M, Graham JP. CO2 and H2O: Understanding Different Stakeholder Perspectives on the Use of Carbon Credits to Finance Household Water Treatment Projects. PLoS One 2015; 10:e0122894. [PMID: 25928139 PMCID: PMC4416006 DOI: 10.1371/journal.pone.0122894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/24/2015] [Indexed: 11/23/2022] Open
Abstract
Background Carbon credits are an increasingly prevalent market-based mechanism used to subsidize household water treatment technologies (HWT). This involves generating credits through the reduction of carbon emissions from boiling water by providing a technology that reduces greenhouse gas emissions linked to climate change. Proponents claim this process delivers health and environmental benefits by providing clean drinking water and reducing greenhouse gases. Selling carbon credits associated with HWT projects requires rigorous monitoring to ensure households are using the HWT and achieving the desired benefits of the device. Critics have suggested that the technologies provide neither the benefits of clean water nor reduced emissions. This study explores the perspectives of carbon credit and water, sanitation and hygiene (WASH) experts on HWT carbon credit projects. Methods Thirteen semi-structured, in-depth interviews were conducted with key informants from the WASH and carbon credit development sectors. The interviews explored perceptions of the two groups with respect to the procedures applied in the Gold Standard methodology for trading Voluntary Emission Reduction (VER) credits. Results Agreement among the WASH and carbon credit experts existed for the concept of suppressed demand and parameters in the baseline water boiling test. Key differences, however, existed. WASH experts’ responses highlighted a focus on objectively verifiable data for monitoring carbon projects while carbon credit experts called for contextualizing observed data with the need for flexibility and balancing financial viability with quality assurance. Conclusions Carbon credit projects have the potential to become an important financing mechanism for clean energy in low- and middle-income countries. Based on this research we recommend that more effort be placed on building consensus on the underlying assumptions for obtaining carbon credits from HWT projects, as well as the approved methods for monitoring correct and consistent use of the HWT technologies in order to support public health impacts.
Collapse
Affiliation(s)
- Sarah K. Summers
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
| | - Rochelle Rainey
- United States Agency for International Development (USAID), Washington D.C., United States of America
| | - Maneet Kaur
- Berkeley Air Monitoring Group, Berkeley, California, United States of America
| | - Jay P. Graham
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
- * E-mail:
| |
Collapse
|
17
|
Dickinson KL, Kanyomse E, Piedrahita R, Coffey E, Rivera IJ, Adoctor J, Alirigia R, Muvandimwe D, Dove M, Dukic V, Hayden MH, Diaz-Sanchez D, Abisiba AV, Anaseba D, Hagar Y, Masson N, Monaghan A, Titiati A, Steinhoff DF, Hsu YY, Kaspar R, Brooks B, Hodgson A, Hannigan M, Oduro AR, Wiedinmyer C. Research on Emissions, Air quality, Climate, and Cooking Technologies in Northern Ghana (REACCTING): study rationale and protocol. BMC Public Health 2015; 15:126. [PMID: 25885780 PMCID: PMC4336492 DOI: 10.1186/s12889-015-1414-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/14/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cooking over open fires using solid fuels is both common practice throughout much of the world and widely recognized to contribute to human health, environmental, and social problems. The public health burden of household air pollution includes an estimated four million premature deaths each year. To be effective and generate useful insight into potential solutions, cookstove intervention studies must select cooking technologies that are appropriate for local socioeconomic conditions and cooking culture, and include interdisciplinary measurement strategies along a continuum of outcomes. METHODS/DESIGN REACCTING (Research on Emissions, Air quality, Climate, and Cooking Technologies in Northern Ghana) is an ongoing interdisciplinary randomized cookstove intervention study in the Kassena-Nankana District of Northern Ghana. The study tests two types of biomass burning stoves that have the potential to meet local cooking needs and represent different "rungs" in the cookstove technology ladder: a locally-made low-tech rocket stove and the imported, highly efficient Philips gasifier stove. Intervention households were randomized into four different groups, three of which received different combinations of two improved stoves, while the fourth group serves as a control for the duration of the study. Diverse measurements assess different points along the causal chain linking the intervention to final outcomes of interest. We assess stove use and cooking behavior, cooking emissions, household air pollution and personal exposure, health burden, and local to regional air quality. Integrated analysis and modeling will tackle a range of interdisciplinary science questions, including examining ambient exposures among the regional population, assessing how those exposures might change with different technologies and behaviors, and estimating the comparative impact of local behavior and technological changes versus regional climate variability and change on local air quality and health outcomes. DISCUSSION REACCTING is well-poised to generate useful data on the impact of a cookstove intervention on a wide range of outcomes. By comparing different technologies side by side and employing an interdisciplinary approach to study this issue from multiple perspectives, this study may help to inform future efforts to improve health and quality of life for populations currently relying on open fires for their cooking needs.
Collapse
Affiliation(s)
- Katherine L Dickinson
- National Center for Atmospheric Research, PO Box 3000, Boulder, CO, 80307, USA.
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Ernest Kanyomse
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | | | - Evan Coffey
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Isaac J Rivera
- National Center for Atmospheric Research, PO Box 3000, Boulder, CO, 80307, USA.
| | - James Adoctor
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | - Rex Alirigia
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | | | - MacKenzie Dove
- Relief International, 5455 Wilshire Blvd., Suite 1280, Los Angeles, CA, 90036, USA.
| | - Vanja Dukic
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Mary H Hayden
- National Center for Atmospheric Research, PO Box 3000, Boulder, CO, 80307, USA.
| | - David Diaz-Sanchez
- EPA Human Studies Facility, 104 Mason Farm Road, Chapel Hill, NC, 27514-4512, USA.
| | - Adoctor Victor Abisiba
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | - Dominic Anaseba
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | - Yolanda Hagar
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Nicholas Masson
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Andrew Monaghan
- National Center for Atmospheric Research, PO Box 3000, Boulder, CO, 80307, USA.
| | - Atsu Titiati
- Relief International, 5455 Wilshire Blvd., Suite 1280, Los Angeles, CA, 90036, USA.
| | - Daniel F Steinhoff
- National Center for Atmospheric Research, PO Box 3000, Boulder, CO, 80307, USA.
| | - Yueh-Ya Hsu
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Rachael Kaspar
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Bre'Anna Brooks
- University of Colorado - Boulder, Boulder, CO, 80309-0427, USA.
| | - Abraham Hodgson
- Ghana Health Service, Private Mail Bag, Ministries, Accra, Ghana.
| | | | - Abraham Rexford Oduro
- Navrongo Health Research Centre, Behind Navrongo War Memorial Hospital, Navrongo, Ghana.
| | | |
Collapse
|
18
|
Pillarisetti A, Vaswani M, Jack D, Balakrishnan K, Bates MN, Arora NK, Smith KR. Patterns of stove usage after introduction of an advanced cookstove: the long-term application of household sensors. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2014; 48:14525-33. [PMID: 25390366 PMCID: PMC4270394 DOI: 10.1021/es504624c] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/11/2014] [Accepted: 11/12/2014] [Indexed: 05/21/2023]
Abstract
Household air pollution generated from solid fuel use for cooking is one of the leading risk factors for ill-health globally. Deployment of advanced cookstoves to reduce emissions has been a major focus of intervention efforts. However, household usage of these stoves and resulting changes in usage of traditional polluting stoves is not well characterized. In Palwal District, Haryana, India, we carried out an intervention utilizing the Philips HD4012 fan-assisted stove, one of the cleanest biomass stoves available. We placed small, unobtrusive data-logging iButton thermometers on both the traditional and Philips stoves to collect continuous data on use patterns in 200 homes over 60 weeks. Intervention stove usage declined steadily over time and stabilized after approximately 200 days; use of the traditional stove remained relatively constant. We additionally evaluated how well short-duration usage measures predicted long-term use. Measuring usage over time of both traditional and intervention stoves provides better understanding of cooking behaviors and can lead to more precise quantification of potential exposure reductions and consequent health benefits attributable to interventions.
Collapse
Affiliation(s)
- Ajay Pillarisetti
- Division
of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California 94720, United States
- Phone: +1 (318) 229 9909; e-mail:
| | - Mayur Vaswani
- The
INCLEN Trust International, Okhla Industrial Area, Phase-I, New Delhi-110020, India
| | - Darby Jack
- Department
of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York 10032, United States
| | - Kalpana Balakrishnan
- Department
of Environmental Health Engineering, Sri
Ramachandra University, Chennai-600116, India
| | - Michael N. Bates
- Division
of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California 94720, United States
| | - Narendra K. Arora
- The
INCLEN Trust International, Okhla Industrial Area, Phase-I, New Delhi-110020, India
| | - Kirk R. Smith
- Division
of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California 94720, United States
| |
Collapse
|
19
|
Hodge JM, Clasen TF. Carbon financing of household water treatment: background, operation and recommendations to improve potential for health gains. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2014; 48:12509-15. [PMID: 25314642 DOI: 10.1021/es503155m] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Household water treatment (HWT) provides a means for vulnerable populations to take charge of their own drinking water quality as they patiently wait for the pipe to finally reach them. In many low-income countries, however, promoters have not succeeded in scaling up the intervention among the target population or securing its consistent and sustained use. Carbon financing can provide the funding for reaching targeted populations with effective HWT solutions and the incentives to ensure their long-term uptake. Nevertheless, programs have been criticized because they do not actually reduce carbon emissions. We summarize the background and operation of carbon financing of HWT interventions, including the controversial construct of "suppressed demand". We agree that these programs have limited potential to reduce greenhouse gas emissions and that their characterization of trading "carbon for water" is misleading. Nevertheless, we show that the Kyoto Protocol expressly encouraged the use of suppressed demand as a means of allowing low-income countries to benefit from carbon financing provided it is used to advance development priorities such as health. We conclude by recommending changes to existing criteria for eligible HWT programs that will help ensure that they meet the conditions of microbiological effectiveness and actual use that will improve their potential for health gains.
Collapse
Affiliation(s)
- James M Hodge
- Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, Georgia 30322, United States
| | | |
Collapse
|
20
|
Patil SR, Arnold BF, Salvatore AL, Briceno B, Ganguly S, Colford JM, Gertler PJ. The effect of India's total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial. PLoS Med 2014; 11:e1001709. [PMID: 25157929 PMCID: PMC4144850 DOI: 10.1371/journal.pmed.1001709] [Citation(s) in RCA: 285] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/17/2014] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). METHODS AND FINDINGS We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May-July 2009), and revisited households 21 months later (February-April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%-26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%-15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors. CONCLUSIONS The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs. TRIAL REGISTRATION ClinicalTrials.gov NCT01465204. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Sumeet R. Patil
- Network for Engineering and Economics Research and Management (NEERMAN), Mumbai, Maharashtra, India
- School of Public Health, University of California, Berkeley, California, United States of America
| | - Benjamin F. Arnold
- School of Public Health, University of California, Berkeley, California, United States of America
| | - Alicia L. Salvatore
- Stanford School of Medicine, Stanford University, Stanford, California, United States of America
| | - Bertha Briceno
- Water and Sanitation Program, the World Bank, Washington (D.C.), United States of America
| | - Sandipan Ganguly
- National Institute for Cholera and Enteric Diseases, Kolkata, West Bengal, India
| | - John M. Colford
- School of Public Health, University of California, Berkeley, California, United States of America
| | - Paul J. Gertler
- School of Public Health, University of California, Berkeley, California, United States of America
- Haas School of Business, University of California, Berkeley, California, United States of America
| |
Collapse
|
21
|
Designing and piloting a program to provide water filters and improved cookstoves in Rwanda. PLoS One 2014; 9:e92403. [PMID: 24676210 PMCID: PMC3967988 DOI: 10.1371/journal.pone.0092403] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 02/21/2014] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
|
22
|
Rosa G, Majorin F, Boisson S, Barstow C, Johnson M, Kirby M, Ngabo F, Thomas E, Clasen T. Assessing the impact of water filters and improved cook stoves on drinking water quality and household air pollution: a randomised controlled trial in Rwanda. PLoS One 2014; 9:e91011. [PMID: 24614750 PMCID: PMC3948730 DOI: 10.1371/journal.pone.0091011] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/05/2014] [Indexed: 11/25/2022] Open
Abstract
Diarrhoea and respiratory infections remain the biggest killers of children under 5 years in developing countries. We conducted a 5-month household randomised controlled trial among 566 households in rural Rwanda to assess uptake, compliance and impact on environmental exposures of a combined intervention delivering high-performance water filters and improved stoves for free. Compliance was measured monthly by self-report and spot-check observations. Semi-continuous 24-h PM2.5 monitoring of the cooking area was conducted in a random subsample of 121 households to assess household air pollution, while samples of drinking water from all households were collected monthly to assess the levels of thermotolerant coliforms. Adoption was generally high, with most householders reporting the filters as their primary source of drinking water and the intervention stoves as their primary cooking stove. However, some householders continued to drink untreated water and most continued to cook on traditional stoves. The intervention was associated with a 97.5% reduction in mean faecal indicator bacteria (Williams means 0.5 vs. 20.2 TTC/100 mL, p<0.001) and a median reduction of 48% of 24-h PM2.5 concentrations in the cooking area (p = 0.005). Further studies to increase compliance should be undertaken to better inform large-scale interventions. Trial registration: Clinicaltrials.gov; NCT01882777; http://clinicaltrials.gov/ct2/results?term=NCT01882777&Search=Search
Collapse
Affiliation(s)
- Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Fiona Majorin
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sophie Boisson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christina Barstow
- Department of Civil, Environmental and Architectural Engineering, University of Colorado at Boulder, Boulder, Colorado, United States of America
| | - Michael Johnson
- Berkeley Air Monitoring Group, Berkeley, California, United States of America
| | - Miles Kirby
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fidele Ngabo
- Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - Evan Thomas
- Department of Mechanical and Materials Engineering, Portland State University, Portland, Oregon, United States of America
| | - Thomas Clasen
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Environmental Health, Emory University, Atlanta, Georgia, United States of America
| |
Collapse
|