Providing evidence to assess the integration of household water filters into Rwanda's national environmental health promotion program Open Access

Haque, Sabrina (Spring 2022)

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Enteric infections are the third leading cause of death in young children globally and are linked to ailments such as diarrheal disease, environmental enteropathy, growth faltering, and undernutrition. The disease burden is highest in low-income settings that have limited access to safe water, sanitation, and hygiene (WASH). Household water treatment and safe storage (HWTS) is shown to be effective in reducing exposure to fecal pathogens and preventing disease in these settings. However, HWTS is seldom delivered at scale and its effectiveness seldom assessed over more than one year. This dissertation seeks to provide evidence to assess the effectiveness of integrating an advanced household water filter within Rwanda’s national environmental health program on increasing access to safe drinking water. 

This research has three aims, all conducted within the context of Rwanda’s Community-Based Environmental Health Promotion Programme (CBEHPP). The first aim was to evaluate the effectiveness of integrating a household-based water filter to improve drinking water quality. Using a cluster randomized-controlled trial design, we enrolled 1,199 CBEHPP beneficiary households with young children or a pregnant person across 60 randomly selected villages in Rwamagana district. A random half of villages received the filter-integrated program, while the other half received the program’s original form. We conducted follow-up visits over 13-16 months and reported effects on drinking water quality (primary outcome) and 7-day diarrhea prevalence of children under 5. We found that the intervention reduced the proportions of households with detectable E.coli in water samples and children under 5 experiencing diarrhea.

The second aim was to assess the longer-term effectiveness of the CBEHPP-filter intervention by following intervention households for an additional 16 months. We assessed uptake, water quality, and child diarrhea outcomes at approximately 6, 12, 24, and 30 months among households enrolled in the intervention arm and estimated the effects of time on the outcomes, adjusting for household and seasonal factors. We found that uptake declined throughout the study duration but remained relatively high, with most households reporting to use the filter for treating drinking water after 2 years. Water quality and child health outcomes were unchanged through the study period.

The third aim was to assess various indicators of water access and water insecurity in the study population over 30 months. We estimated associations of rainfall, temperature, basic water access, and the filter intervention with household experiences of water insecurity. We found that water insecurity varied between and within households overtime and is affected by changing temperature, access to basic water sources, and access to the filter with safe storage. Effects of the filter intervention were additionally assessed with the context of the trial and found to be effective in lowering the prevalence of water insecurity.

This research suggests that a household filter with safe storage delivered as a part of the CBEHPP can improve microbial water quality and reduce child diarrhea in a population that largely lacked access to safe water. The uptake and water quality and child health effects of the intervention can be sustained for over 2 years. Household experiences of water insecurity are influenced by seasons and may decrease with interventions that improve access to safe drinking water.

Table of Contents

Table of Contents

Acknowledgments. 1

Chapter 1 – Introduction. 7

1.1     Drinking water supply and health. 7

1.2     Limitations of water service delivery in low- and middle-income countries. 8

1.3     Household water treatment and safe storage interventions: Advantages and implementation challenges. 10

1.4     Delivery of HWTS interventions in Rwanda. 13

1.5     Dissertation Aims. 13

1.5.1      Research Aim 1. 14

1.5.2      Research Aim 2. 14

1.5.3      Research Aim 3. 15

1.5.4      Commentary – Implementation Science in WASH.. 15

1.6     References. 16

Chapter 2 – Research Aim 1: Effects of adding household water filters to Rwanda's Community-Based Environmental Health Promotion Programme: A cluster-randomized controlled trial in Rwamagana district 21

2.1     Abstract 21

2.2     Background. 22

2.3     Results. 25

2.3.1      Study participants. 25

2.3.2      Filter Coverage, Use, and Acceptability. 29

2.3.3      Drinking water quality. 31

2.3.4      Child Diarrhea. 34

2.4     Discussion. 36

2.5     Methods. 38

2.5.1      Intervention. 38

2.5.2      Study design. 40

2.5.3      Randomization and blinding. 41

2.5.4      Baseline and follow-ups. 41

2.5.5      Primary and secondary outcomes. 42

2.5.6      Statistical approach. 43

2.5.7      Ethics and registration. 45

2.5.8      Data availability. 46

2.5.9      Role of the funding source. 46

2.6     Acknowledgements. 46

2.7     References. 47

Chapter 3 – Research Aim 2: Assessing the sustained effects of a water filter intervention in Rwamagana, Rwanda: a 30-month longitudinal study. 53

3.1     Abstract 53

3.2     Background. 54

3.3      Methods. 56

3.3.1      Study context and post-intervention follow-up visits. 56

3.3.2      Intervention. 57

3.3.3      Eligibility and inclusion criteria. 58

3.3.4      Outcomes. 59

3.3.5      Statistical Approach. 60

3.3.6      Ethics. 61

3.4       Results. 62

3.4.1      Filter uptake, microbial water quality, and child diarrhea over 30-months in the intervention group. 62

3.4.2      Microbial drinking water quality and child diarrhea prevalence between shorter- and longer-filter exposed groups in the same period. 68

3.5     Discussion. 70

3.6      References. 73

Chapter 4 – Research Aim 3: Household water insecurity in rural Rwanda: a 30-month study to assess effects of a water filter intervention and associations with water services, precipitation, and temperature. 80

4.1     Abstract 80

4.2     Background. 81

4.3     Methods. 83

4.3.1      Study setting and population. 84

4.3.2      Data. 86

4.3.3      Statistical approach. 89

4.4     Results. 91

4.4.1      Study population. 91

4.4.2      Water insecurity, water access, and water fetching trends over 30 months 92

4.4.3      Associations with household water insecurity. 96

4.4.4      Impact of the filter-storage intervention with household water insecurity 98

4.5     Discussion. 98

4.6     References. 102

Chapter 5 – Summary, implications, and future directions. 107

5.1.1   Summary of findings. 107

5.1.2   Limitations. 108

5.2      Implications. 110

5.3      Future directions. 113

5.4      References. 115

Appendix: Household Questionnaire. 119

Annex - The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice. 159

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