Chan Lee

3/26/23
HS 444
ARIs and Diarrheal Disease Activity

KL;, A. M. M. A. G. D. M. S. T. W. (n.d.). Effect of improved COOKSTOVE intervention on

childhood acute lower respiratory infection in northwest Ethiopia: A cluster-randomized
controlled trial. BMC pediatrics. Retrieved March 26, 2023, from
https://pubmed.ncbi.nlm.nih.gov/33397313/

The study conducted a cluster-randomized controlled trial to investigate the child health
effect of improved baking stove intervention compared with the continuation of the open-burning
traditional baking stove. The sample consisted of 100 clusters randomly allocated to both arms at
a 1:1 ratio. A total of 5508 children in Northwest Ethiopia were enrolled in the study across these
100 clusters in both arms. Data were obtained from 5333 participants for at least one follow-up
visit, establishing the intention-to-treat population dataset. The study population consisted of
children uniquely vulnerable and sensitive to the damaging health effects of household air
pollution, including childhood acute lower respiratory infection (ALRI).
The intervention in this study comprised a biomass-fueled improved baking stove that was
delivered to all households allocated into the intervention arm. The intervention was
implemented immediately after the stove delivery, and four follow-up visits were carried out
within 1 year. The study aimed to investigate the child health effect of this improved baking
stove intervention compared with the continuation of an open-burning traditional baking stove.
The main finding of the article is that the improved baking stove intervention did not have
a statistically significant effect on the longitudinal childhood acute lower respiratory infection
(ALRI) compared to the traditional open-burning baking stove. The study did find that the
longitudinal change in childhood ALRI was associated with several factors, including age,
baseline childhood ALRI, location of the cooking quarter, secondary stove type, and frequency
of baking events measured at baseline. The article concludes that effective cooking solutions are
needed to prevent the adverse health effects of household air pollution, especially childhood
ALRI.
The article includes a couple of study limitations, such as the study being conducted in a
specific area (rural Kenya), which may limit the generalizability of the findings to other settings.
The study relied on self-reported outcomes and exposure data, which could be subject to bias or
measurement error. The study only assessed the impact of improved baking stoves and did not
examine other potential sources of household air pollution, such as heating or lighting. The study
only followed participants for one year, which may need longer to capture the full impact of the
intervention on childhood ALRI.
Nagel, C. L., Kirby, M. A., Zambrano, L. D., Rosa, G., Barstow, C. K., Thomas, E. A., &
Clasen, T. F. (2016). Study design of a cluster-randomized controlled trial to evaluate
a large-scale distribution of Cook Stoves and water filters in Western Province,
Rwanda. Contemporary Clinical Trials Communications, 4, 124–135.
https://doi.org/10.1016/j.conctc.2016.07.003

The study population consists of households with children under five years of age residing
in 96 sectors in Western Province, Rwanda. Each sector contains an average of 40 villages, and
the sectors were randomized to either control or intervention status in a cluster-randomized trial
design. The primary study outcomes are diarrhea and acute respiratory infection (ARI) among
children under five years of age eligible for the program. Clinician-diagnosed episodes of
diarrhea and ARI will be assessed from records maintained by health facilities and village-level
CHW health records made available for use in this study by the Rwanda MOH.
The intervention being studied is the Tubeho Neza program, which means "Live Well" in
Kinyarwanda. The program involves the free distribution of the Vestergaard Frandsen LifeStraw
Family 2.0 household water filter and the EcoZoom Dura high-efficiency wood cookstove to all
households in Ubudehe categories 1 and 2 in Western Province, along with associated
community and household education and behavior change messaging.
The outcome or finding of the study is the incidence of clinically reported acute respiratory
infections (ARIs) and diarrhea among children under five in Ubudehe 1 and 2 categories during
the 12 months of follow-up. The study aims to determine whether the Tubeho Neza program,
which includes the distribution of water filters and high efficiency cookstoves, along with
associated community and household education and behavior change messaging, reduces the
incidence of ARI and diarrhea among children under five in the intervention areas. The study
uses data collected routinely by health authorities, including outpatient and inpatient registers
maintained at health posts, health centers, district hospitals, and CHW-maintained registers. The
study will also link health records with a database containing the Ubudehe categorization of
every household in the study area to differentiate clinic and CHW-reported cases among
Ubudehe 1 & 2 households from those in other Ubudehe categories.
The study's main limitation is the need for clear evidence of the health impact of improved
cookstoves that can be deployed at scale among vulnerable populations. The ongoing trials
exploring the effectiveness of various improved cookstove types are limited to small-scale
efficacy trials. Additionally, there are doubts about the potential of any biomass stove to achieve
WHO indoor air quality targets, which has shifted the focus to clean cooking fuels such as LPG,
ethanol, and electricity. However, supply chain limitations render these options impractical in
most rural settings. Another study limitation is the self-reported health data, which may be
subject to recall bias or other errors. To overcome this limitation, the study uses trained field
staff to assess all children between 2 months and 5 years of age for diarrhea and ARI at baseline
and each follow-up visit, following WHO IMCI methods.
Patil, S. R., Arnold, B. F., Salvatore, A. L., Briceno, B., Ganguly, S., Jr, J. M. C., & Gertler,
P. J. (n.d.). The effect of India's total sanitation campaign on defecation behaviors and
child health in rural Madhya Pradesh: A cluster randomized controlled trial. PLOS
Medicine. Retrieved March 26, 2023, from
https://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1001709

This study's population was households with children under five years of age in rural areas
of Madhya Pradesh, India. The study's sample size was 1000 households in 100 villages, with
500 households in the intervention group and 500 households in the control group. The
households were selected randomly from the list of eligible households in each village. The
study was conducted over two years, with baseline surveys conducted before the intervention and
follow-up surveys conducted at 6, 12, and 24 months after the intervention.
The intervention in the study was the Total Sanitation Campaign (TSC) implemented in 80
rural villages in Madhya Pradesh, India. The TSC aimed to end the practice of open defecation
by changing social norms and behaviors and providing technical support and financial subsidies.
The intervention increased the percentage of homes in a village with improved sanitation
facilities and decreased open defecation among adults. However, the intervention did not
improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth
infections, anemia, growth).
The main findings of the study are that the Total Sanitation Campaign (TSC) implemented
with capacity-building support from the World Bank's Water and Sanitation Program in Madhya
Pradesh increased the percentage of households in a village with improved sanitation facilities by
19% and decreased open defecation among adults by 10%, but did not improve child health
outcomes, including diarrhea, highly credible gastrointestinal illness (HCGI), parasitic
infections, anemia, and growth. The study found that the improvements in sanitation could have
been more modest and sufficient to deliver the expected health benefits within large-scale rural
sanitation programs. The study also identified limitations, such as a short follow-up period
following implementation, evidence for contamination in some control villages, and possible
bias in self-reported outcomes.
The article highlights several limitations of the study, including imperfect compliance with
treatment assignment and poor fidelity of intervention implementation. None of the intervention
villages achieved the program goal of 100% of households having and using IHLs that can safely
confine feces. The average household-level coverage of JMP-defined improved sanitation
facilities was only 40%. The study also faced challenges due to significant deviations in the
actual implementation timeline compared to the timeline on which the evaluation study is based.
The limited length of follow-up also influenced the estimates of the program's effect on IHL
availability and use. Self-reported outcomes can be subject to differential, biased reporting in
unblinded trials, and the study did not include objective measures of sanitation behaviors.
Finally, the study found evidence of contamination in ten of the 40 control villages.
Based on your mini literature review, how would you summarize the effectiveness of this
intervention? Do you think there could be a difference in efficacy vs. effectiveness? Why or
why not? Points: 5.

Based on the article, the intervention led to modest increases in the availability of
improved household latrines and even more modest reductions in open defecation. These
improvements were insufficient to improve child health outcomes such as diarrhea, enteric
parasite infection, anemia, and growth. The study identified several limitations, including poor
compliance with treatment assignment, poor fidelity of intervention implementation, and
potential bias in self-reported outcomes.
In terms of efficacy vs. effectiveness, efficacy refers to the performance of an
intervention under ideal or controlled conditions. In contrast, effectiveness refers to the
performance of an intervention in real-world conditions. In this case, the studies were an
effectiveness trial, meaning that the intervention was evaluated in a real-world setting with
limited control over implementation. This can lead to challenges such as imperfect compliance
and poor fidelity of implementation, which can impact the effectiveness of the intervention.
Overall, the interventions were modestly effective in improving sanitation facilities and
reducing open defecation, but it was not effective in improving child health outcomes. While the
study identified limitations, it still provides valuable insights into the challenges of delivering
large-scale rural sanitation programs.