Christina K. Barstow

Assessing the Impact of Water Filters and Improved Cook Stoves on Drinking Water Quality and Household Air Pollution: A Randomised Controlled Trial in Rwanda

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

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.

Constructed wetlands combined with UV disinfection systems for removal of enteric pathogens and wastewater contaminants.

Water shortage is an ongoing cardinal issue in the Middle East region. Wastewater reuse offers some remediation, but to-date many rural communities in the Palestinian Authority (PA) and in Jordan are not connected to centralized wastewater treatment plants (WWTPs), many of them are disposing of their wastewater using infiltration septic tanks. This highlights the need for a small, local, low cost WWTP that can directly benefit local communities, producing effluents suitable for unrestricted irrigation. Constructed wetlands (CWs) could offer a solution as they are relatively easy and cheap to construct and maintain, and effective in removal of many pollutants. Nevertheless, pathogen removal in CWs is often not adequate, calling for additional disinfection. Here we describe the use of low-cost, consumer level, UV based disinfection systems coupled to CWs for wastewater treatment in three CWs: in Israel, Jordan and in the PA. Once mature, our adapted CWs reduced chemical oxygen demand (COD) load, and, given proper use of the UV systems, inactivated indicator bacteria (faecal and E. coli) to levels suitable for irrigation, even when UV transmission (UVT) levels were low (∼40%). Our results demonstrate the promise in this combined treatment technique for cheap and simple wastewater treatment suitable for the Middle East region.

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).

Proving Sustainability: The International Development Monitoring Initative

Nearly a billion people in the world lack access to safe drinking water, two billion have inadequate sanitation facilities, three billion use biomass for their daily energy needs and nearly half the worlds population live in rural isolation, lacking access to the most basic human services. Combined, these limitations are a leading cause of the perpetuating cycle of poverty and political insecurity. Meanwhile, the majority of international development agencies are responsible for self-reporting project outcomes. At best, expert spot-checks are conducted in the field occasionally. These results tend to show individual project success, while meta-surveys indicate on-going challenges in the sector. This disconnect may be addressed through independent data monitoring technologies that provide objective data on system performance and use and can be used to demonstrate success and identify project weaknesses. By demonstrating which technologies and programs are truly successful, these successes can be targeted for scaling, through savings realized by eliminating unsuccessful approaches. This will benefit developing communities by providing proven and accountable programs. The Sustainable Water, Energy and Environmental Technologies Laboratory, the SWEETLab™, at Portland State University is working with partners to demonstrate this concept across several applications and countries. The SWEETSense™ technology can provide objective, qualitative and continuous operational data on the usage and performance of programs across a range of sectors and communities. The data is then directly integrated into SWEETData™, an internet database presenting summary statistics on performance and usage of the monitored technologies to front-end users. The SWEETLab™ is currently demonstrating this concept in water, sanitation, household energy and rural infrastructure programs with diverse partners including Mercy Corps, the Lemelson Foundation, Bridges to Prosperity, Manna Energy Limited and Vestergaard Frandsen, in several countries including Indonesia, Haiti, Guatemala and Rwanda. Remote monitoring systems are an innovative method to ensure the success of appropriate technology projects. Rather than infrequent engagement, remote monitoring systems ensure that community partnerships are maintained through continuous monitoring. This approach seeks to raise the quality and accountability of these projects internationally.

Assessing point-of-use ultraviolet disinfection for safe water in urban developing communities

Residents of urban developing communities often have a tap in their home providing treated and sometimes filtered water but its microbial quality cannot be guaranteed. Point-of-use (POU) disinfection systems can provide safe drinking water to the millions who lack access to clean water in urban communities. While many POU systems exist, there are several concerns that can lead to low user acceptability, including low flow rate, taste and odor issues, high cost, recontamination, and ineffectiveness at treating common pathogens. An ultraviolet (UV) POU system was constructed utilizing developing community-appropriate materials and simple construction techniques based around an inexpensive low-wattage, low pressure UV bulb. The system was tested at the bench scale to characterize its hydrodynamic properties and microbial disinfection efficacy. Hydraulically the system most closely resembled a plug flow reactor with minor short-circuiting. The system was challenge tested and validated for a UV fluence of 50 mJ/cm(2) and greater, over varying flow rates and UV transmittances, corresponding to a greater than 4 log reduction of most pathogenic bacteria, viruses, and protozoa of public health concern. This study presents the designed system and testing results to demonstrate the potential architecture of a low-cost, open-source UV system for further prototyping and field-testing.

Incentivizing Impact – Privately Financed Public Health in Rwanda

There is effectively universal agreement that clean air and clean water are human rights. Yet there is not universal agreement on effective ways of ensuring these rights. 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. In this chapter, a program in Rwanda illustrates the potential of public-private partnerships, combined with objective measurement tools and metrics, to deliver a sustained impact in poor households.