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, March 2014.

Ghislaine Rosa, Fiona Majorin, et al.

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.

Water Distribution System Deficiencies and Gastrointestinal Illness: A Systematic Review and Meta-Analysis. Env Health Perspec, Mar 2014.

Authors: Ayse Ercumen, Joshua S. Gruber, and John M. Colford Jr.

Background: Water distribution systems are vulnerable to performance deficiencies that can cause (re)contamination of treated water and plausibly lead to increased risk of gastrointestinal illness (GII) in consumers.

Objectives: It is well established that large system disruptions in piped water networks can cause GII outbreaks. We hypothesized that routine network problems can also contribute to background levels of waterborne illnessand conducted a systematic review and meta-analysis to assess the impact of distribution system deficiencies on endemic GII.

Methods: We reviewed published studies that compare direct tap water consumption to consumption of tap water re-treated at the point of use (POU) and studies of specific system deficiencies such as breach of physical or hydraulic pipe integrity and lack of disinfectant residual.

Results: In settings with network malfunction, consumers of tap versus POU-treated water had increased GII (incidence density ratio (IDR) = 1.34; 95% CI: 1.00, 1.79). The subset of non-blinded studies showed a significant association between GII and tap versus POU-treated water consumption (IDR = 1.52; 95% CI: 1.05, 2.20), but there was no association based on studies that blinded participants to their POU water treatment status (IDR = 0.98; 95% CI: 0.90, 1.08). Among studies focusing on specific network deficiencies, GII was associated with temporary water outages (relative risk = 3.26; 95% CI: 1.48, 7.19) as well as chronic outages in intermittently operated distribution systems (odds ratio = 1.61; 95% CI: 1.26, 2.07).

Conclusions: Tap water consumption is associated with GII in malfunctioning distribution networks. System deficiencies such as water outages also are associated with increased GII, suggesting a potential health risk for consumers served by piped water networks.

A critique of boiling as a method of household water treatment in South India. Journal of Water and Health In Press, 2014 | doi:10.2166/wh.2014.010

Authors: Luke Juran and Morgan C. MacDonaldDepartment of Geography and Virginia Water Resources Research Center, Virginia Tech, 125 Major Williams Hall, Blacksburg, VA 24061, USA E-mail:; School of Engineering, University of Guelph, 3120 Thornbrough, Guelph, ON N1G 2W1, Canada

This article scrutinizes the boiling of water in Tamil Nadu and Puducherry, India. Boiling, as it is commonly practiced, improves water quality, but its full potential is not being realized. Thus, the objective is to refine the method in practice, promote acceptability, and foster the scalability of boiling and household water treatment (HWT) writ large. The study is based on bacteriological samples from 300 households and 80 public standposts, 14 focus group discussions (FGDs), and 74 household interviews. Collectively, the data fashion both an empirical and ethnographic understanding of boiling. The rate and efficacy of boiling, barriers to and caveats of its adoption, and recommendations for augmenting its practice are detailed. While boiling is scientifically proven to eliminate bacteria, data demonstrate that pragmatics inhibit their total destruction. Furthermore, data and the literature indicate that a range of cultural, economic, and ancillary health factors challenge the uptake of boiling. Fieldwork and resultant knowledge arrive at strategies for overcoming these impediments. The article concludes with recommendations for selecting, introducing, and scaling up HWT mechanisms. A place-based approach that can be sustained over the long-term is espoused, and prolonged exposure by the interveners coupled with meaningful participation of the target population is essential.

Going to scale with safe water – what changes are needed to remove the barriers to scale? 2014.

By Urs Heierli and Paul Osborn, Discussion paper for 300in6.

Event the most successful projects – as described in the Hystra study: “Access to Safe Water for the Base of the Pyramid” look more like oases in the middle of a huge desert. It is unlikely that scaling these projects will lead to universal access. What is badly needed are not more oasis, but a greening of the desert in-between, and this requires significant changes from business as usual.

This discussion paper attempts to sketch out a change agenda and will describe what is needed to go to scale. Scaling-up is not a linear process of replicating successful models or pilot projects at a larger scale: it means to apply a much more holistic, better coordinated and orchestrated approach involving not only project partners but mainstream institutions of the society.

Evidence-based tailoring of behavior-change campaigns: increasing fluoride-free water consumption in rural Ethiopia with persuasion. Appl Psychol Health Well Being. 2014 Mar;6(1):96-118. doi: 10.1111/aphw.12018.

Authors: Huber AC1, Tobias R, Mosler HJ.

Two hundred million people worldwide are at risk of developing dental and skeletal fluorosis due to excessive fluoride uptake from their water. Since medical treatment of the disease is difficult and mostly ineffective, preventing fluoride uptake is crucial. In the Ethiopian Rift Valley, a fluoride-removal community filter was installed. Despite having access to a fluoride filter, the community used the filter sparingly. During a baseline assessment, 173 face-to-face interviews were conducted to identify psychological factors that influence fluoride-free water consumption. Based on the results, two behavior-change campaigns were implemented: a traditional information intervention targeting perceived vulnerability, and an evidence-based persuasion intervention regarding perceived costs.

The interventions were tailored to household characteristics. The campaigns were evaluated with a survey and analyzed in terms of their effectiveness in changing behavior and targeted psychological factors. While the intervention targeting perceived vulnerability showed no desirable effects, cost persuasion decreased the perceived costs and increased the consumption of fluoride-free water. This showed that altering subjective perceptions can change behavior even without changing objective circumstances. Moreover, interventions are more effective if they are based on evidence and tailored to specific households.

Designing and Piloting a Program to Provide Water Filters and Improved Cookstoves in Rwanda. PLoS One, March 2014.

Authors: Christina K. Barstow, Fidele Ngabo, Ghislaine Rosa, Fiona Majorin, Sophie Boisson, Thomas Clasen, Evan A. Thomas

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.

Video Surveillance Captures Student Hand Hygiene Behavior, Reactivity to Observation, and Peer Influence in Kenyan Primary Schools. PLoS One, March 2014.

Authors: Amy J. Pickering, Annalise G. Blum, Robert F. Breiman, Pavani K. Ram, Jennifer Davis

Background – In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.

Methods – Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.

Findings – Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio = 1.14 [95% CI 1.01–1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.

Conclusion – Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs.

Solar Disinfection of Pseudomonas aeruginosa in Harvested Rainwater: A Step towards Potability of Rainwater. PLoS One, Mar 2014.

Authors: Muhammad T. Amin, Mohsin Nawaz, Muhammad N. Amin, and Mooyoung Han

Efficiency of solar based disinfection of Pseudomonas aeruginosa (P. aeruginosa) in rooftop harvested rainwater was evaluated aiming the potability of rainwater. The rainwater samples were exposed to direct sunlight for about 8–9 hours and the effects of water temperature (°C), sunlight irradiance (W/m2), different rear surfaces of polyethylene terephthalate bottles, variable microbial concentrations, pH and turbidity were observed on P. aeruginosa inactivation at different weathers. In simple solar disinfection (SODIS), the complete inactivation of P. aeruginosa was obtained only under sunny weather conditions (>50°C and >700 W/m2) with absorptive rear surface. Solar collector disinfection (SOCODIS) system, used to improve the efficiency of simple SODIS under mild and weak weather, completely inactivated the P. aeruginosa by enhancing the disinfection efficiency of about 20% only at mild weather.

Both SODIS and SOCODIS systems, however, were found inefficient at weak weather. Different initial concentrations of P. aeruginosa and/or Escherichia coli had little effects on the disinfection efficiency except for the SODIS with highest initial concentrations. The inactivation of P. aeruginosa increased by about 10–15% by lowering the initial pH values from 10 to 3. A high initial turbidity, adjusted by adding kaolin, adversely affected the efficiency of both systems and a decrease, about 15–25%; in inactivation of P. aeruginosa was observed. The kinetics of this study was investigated by Geeraerd Model for highlighting the best disinfection system based on reaction rate constant. The unique detailed investigation of P. aeruginosa disinfection with sunlight based disinfection systems under different weather conditions and variable parameters will help researchers to understand and further improve the newly invented SOCODIS system.

A global brief on vector-borne diseases,  2014. World Health Organization.

Vector-borne diseases cause more than one million deaths each year. But death counts, though alarming, vastly underestimate the human misery and hardship caused by these diseases, as many people who survive infection are left permanently debilitated, disfigured, maimed, or blind.As vectors thrive under conditions where housing is poor, water is unsafe, and environments are contaminated with filth, these diseases exact their heaviest toll on the poor – the people left behind by development. Measures that control the vectors, the agents of disease, provide an excellent, but underutilized opportunity to help these people catch up.