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• 1. [Article] Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda

  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 ...

  Citation × Citation Citation Abstract Copy Title: Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda Author: Barstow, Christina K., Nagel, Corey, Clasen, Thomas, Thomas, Evan A. Year: 2016 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. Title: Process Evaluation and Assessment of Use of a Large Scale Water Filter and Cookstove Program in Rwanda Author: Barstow, Christina K., Nagel, Corey, Clasen, Thomas, Thomas, Evan A. Year: 2016 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. Close

• 2. [Article] 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 ...

  Citation × Citation Citation Abstract Copy Title: Study Design of a Cluster-Randomized Controlled Trial to Evaluate a Large-scale Distribution of Cook Stoves and Water Filters in Western Province, Rwanda Author: Nagel, Corey L., Kirby, Miles, Zambrano, Laura D., Rosa, Ghislaine, Barstow, Christina K., Thomas, Evan A., Clasen, Thomas Year: 2016 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. Title: Study Design of a Cluster-Randomized Controlled Trial to Evaluate a Large-scale Distribution of Cook Stoves and Water Filters in Western Province, Rwanda Author: Nagel, Corey L., Kirby, Miles, Zambrano, Laura D., Rosa, Ghislaine, Barstow, Christina K., Thomas, Evan A., Clasen, Thomas Year: 2016 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. Close

• 3. [Article] Household Water Filter Use Characterization in Rural Rwanda: Signal Interpretation, Development and Validation

  Access to safe drinking water is an important health factor in many developing countries. Studies have shown that unsafe drinking water and poor sanitation practices leads to diarrheal disease, which is ...

  Citation × Citation Citation Abstract Copy Title: Household Water Filter Use Characterization in Rural Rwanda: Signal Interpretation, Development and Validation Author: Tellez Sanchez, Sarita Lucia Year: 2016 Access to safe drinking water is an important health factor in many developing countries. Studies have shown that unsafe drinking water and poor sanitation practices leads to diarrheal disease, which is one of the leading causes of death of children under five in developing countries. Provision and proper use of household water filters have been shown to effectively improve health. This thesis is focused on the refinement and validation of algorithms for data collected from pressure transducer sensors that are used in household water filters (the Vestergaard Frandsen LifeStraw Family 2.0) deployed in Rwanda by the social enterprise DelAgua Health. Statistical and signal processing techniques were used to detect the use of the LifeStraw water filters and to estimate the amount of water filtered at the time of usage. An algorithm developed by Dr. Carson Wick at Georgia Institute of Technology was the baseline for the analysis of the data. The algorithm was then refined based on data collected in the SweetLab at Portland State University, which was then applied to field data. Laboratory results indicated that the mean error of the improved algorithm is 11.5% as compared with the baseline algorithm mean error of 39%. The validation of the algorithm with field data yielded a mean error of 5%. Errors may be attributed to real-world behavior of the water filter, electronic noise, ambient temperature, and variations in the approximation made to the field data. This work also presents some consideration of the algorithm applied to soft-sided water backpacks. Title: Household Water Filter Use Characterization in Rural Rwanda: Signal Interpretation, Development and Validation Author: Tellez Sanchez, Sarita Lucia Year: 2016 Access to safe drinking water is an important health factor in many developing countries. Studies have shown that unsafe drinking water and poor sanitation practices leads to diarrheal disease, which is one of the leading causes of death of children under five in developing countries. Provision and proper use of household water filters have been shown to effectively improve health. This thesis is focused on the refinement and validation of algorithms for data collected from pressure transducer sensors that are used in household water filters (the Vestergaard Frandsen LifeStraw Family 2.0) deployed in Rwanda by the social enterprise DelAgua Health. Statistical and signal processing techniques were used to detect the use of the LifeStraw water filters and to estimate the amount of water filtered at the time of usage. An algorithm developed by Dr. Carson Wick at Georgia Institute of Technology was the baseline for the analysis of the data. The algorithm was then refined based on data collected in the SweetLab at Portland State University, which was then applied to field data. Laboratory results indicated that the mean error of the improved algorithm is 11.5% as compared with the baseline algorithm mean error of 39%. The validation of the algorithm with field data yielded a mean error of 5%. Errors may be attributed to real-world behavior of the water filter, electronic noise, ambient temperature, and variations in the approximation made to the field data. This work also presents some consideration of the algorithm applied to soft-sided water backpacks. Close