Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda

Abstract

BackgroundIn 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/DesignWe 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.DiscussionAlthough 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 registrationThis trial is registered at Clinicaltrials.gov (NCT02239250).

Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: an analysis for the Global Burden of Disease Study 2017

“…34,35 A pair of randomised controlled trials found little statistical evidence of a reduction in pneumonia incidence with provision of chimneys 36 or cleaner burning cookstoves, 37 and several more studies investigating household air pollution and childhood pneumonia are in progress. 38,39 This suggests that the provision of chimneys or cleaner burning practices does not result in a sufficient reduction of air pollution to translate into a reduction in health effects. This finding is consistent with the analysis and recommendations by the WHO guidelines.…”

Prevalence and risk factors of acute lower respiratory infection among children living in biomass fuel using households: a community-based cross-sectional study in Northwest Ethiopia

“…The IMCI-pneumonia assessment protocol is a common diagnostic criterion for the classification and treatment of childhood pneumonia at health facilities in Ethiopia [21]. The Ethiopian Demographic and Health Survey (EDHS) [7] and other similar studies conducted in different parts of the world also used this diagnostic criterion for childhood pneumonia assessment; such as the randomized controlled trials conducted in Malawi [22], Rwanda [23], Ghana [24], Indian [25] and Guatemala [26]. In this study, we used the term childhood ALRI as a synonym for the IMCI-pneumonia, because the term childhood ALRI is the preferred expression for childhood pneumonia in peculiar to the developing world countries [27].…”

Use of Serologic Responses against Enteropathogens to Assess the Impact of a Point-of-Use Water Filter: A Randomized Controlled Trial in Western Province, Rwanda

“…We undertook this study in the context of a large-scale clusterrandomized controlled trial (CRT) described elsewhere. 25 We aimed to assess the effectiveness of a point-of-use water filter on seroconversion against a panel of viral, bacterial, and protozoan enteropathogens among young children. We also sought to explore the potential for using serologic response as an objective alternative to reported diarrhea to assess the effectiveness of water quality interventions, an approach that has been advocated in other serologic studies.…”