Incentivizing Elimination of Biomass Cooking Fuels with a Reversible Commitment and a Spare LPG Cylinder.

In India, approximately 480,000 deaths occur annually from exposure to household air pollution from the use of biomass cooking fuels. Displacing biomass use with clean fuels, such as liquefied petroleum gas (LPG), can help reduce these deaths. Through government initiatives, most Indian households now own an LPG stove and one LPG cylinder. Many households, however, continue to regularly use indoor biomass-fueled mud stoves (chulhas) alongside LPG. Focusing on this population in rural Maharashtra, India, this study (N = 186) tests the effects of conditioning a sales offer for a spare LPG cylinder on a reversible commitment requiring initially disabling indoor chulhas. We find that almost all relevant households (>98%) were willing to accept this commitment. Indoor chulha use decreased by 90% (95% CI = 80% to 101%) when the sales offer included the commitment, compared to a 23% decrease (95% CI = 14% to 32%) without it. For both treatment groups, we find that 80% purchased the spare cylinder at the end of the study.

Marriage-based pilot clean household fuel intervention in India for improved pregnancy outcomes.

INTRODUCTION: Health interventions often target pregnant women and their unborn children. Interventions in rural India targeting pregnant women, however, often do not cover the critical early windows of susceptibility during the first trimester and parts of the second trimester. This pilot seeks to determine if targeting newlyweds could protect entire pregnancies with a clean stove and fuel intervention. METHODS: We recruited 50 newlywed couples who use biomass as a cooking fuel into a clean cooking intervention that included a liquefied petroleum gas (LPG) stove, two gas cylinders, a table to place the stove on and health education. We first evaluated whether community health workers in this region could identify and recruit couples at marriage. We quantified how many additional days of pregnancy could be covered by an intervention if we recruited at marriage versus recruiting after detection of pregnancy. RESULTS: On average, we identified and visited newlywed couples within 40 (SD 21) days of marriage. Of the 50 couples recruited, 25 pregnancies and 18 deliveries were identified during this 1-year study. Due to challenges securing fuel from the LPG supply system, not all couples received their intervention prior to pregnancy. Regardless, couples recruited in the marriage arm had substantially more days with the intervention than couples recruited into a similar arm recruited at pregnancy (211 SD 46 vs 120 SD 45). At scale, a stove intervention targeting new marriages would cover about twice as many weeks of first pregnancies as an intervention recruiting after detection of pregnancy. CONCLUSIONS: We were able to recruit in early marriage using existing community health workers. Households recruited early in marriage had more days with clean fuel coverage than those recruited at pregnancy. Our findings indicate that recruitment at marriage is feasible and warrants further exploration for stove and other interventions targeting pregnancy-related outcomes.

Effectiveness of a community-based water, sanitation, and hygiene (WASH) intervention in reduction of diarrhoea among under-five children: Evidence from a repeated cross-sectional study (2007-2015) in rural Bangladesh.

Diarrhoea, the most common disease directly related to water, sanitation, and hygiene (WASH), still remains one of the most significant health problems among children under-five worldwide. In this reality, BRAC, the largest NGO in the world initiated a comprehensive WASH intervention in 50 upazilas (sub-districts) of Bangladesh in 2007 which was later scaled up to cover 150 upazilas in two subsequent phases. The intervention period of the programme was 2007-2011. The present study encompassed 30 upazilas of the first phase of intervention. The aim of the study was to investigate the effectiveness of this intervention on reduction of diarrhoea among under-five children, and to identify the factors associated with childhood diarrhoea. A repeated cross-sectional study design was followed, and a population-based survey was carried out on four occasions: baseline (2007), midline (2009), endline (2011), and post-endline (2015) among 4,775 households. This analysis considers only households having at least one under-five children. Absence of handwashing practice with soap after defecation and before eating food, unclean latrine condition, and unsafe disposal of child faeces were identified as significant risk factors associated with under-five diarrhoea from Log-binomial regression. The prevalence of under-five diarrhoea within the past 2 weeks of the survey declined from 13.7% at baseline to 3.6% at end-line (p < 0.001) in the WASH intervention area. However, the progress seemingly stalled after 2011, which may have occurred due to the lack of improvement in unsafe disposal of child faeces and unclean latrine condition after the intervention period. Study findings suggest that, to reduce the prevalence of childhood diarrhoea it is important to promote safe disposal of child faeces, maintaining cleanliness of latrines, and washing hand with soap at critical times, beyond merely increasing the sanitation coverage. Findings also underline the necessity of maintaining a small-scale monitoring component involving local community, such as a WatSan committee (a local committee comprising the user communities for supervising WASH related activities) for periodic monitoring at household level for a certain period after the program intervention works to make the behavioural change more sustainable and to keep the reduction rate of under-five diarrhoeal prevalence steady.

A community-based education programme to reduce insecticide exposure from indoor residual spraying in Limpopo, South Africa.

BACKGROUND: Indoor residual spraying (IRS), the coating of interior walls of houses with insecticides, is common in malaria-endemic areas. While important in malaria control, IRS potentially exposes residents to harmful insecticides. The World Health Organization recommends steps to minimize exposure; however, no programme has focused on educating populations. METHODS: A dramatic presentation and song were developed by study personnel and performed by lay performers in order to spread awareness of the importance of IRS and to minimize insecticide exposure. Performances were staged at 16 sprayed villages in the Vhembe District of Limpopo, South Africa, at which 592 attendees completed short questionnaires before and after the performance about behaviors that might limit insecticide exposure. Overall indices of the attendees' change in knowledge of precautions to take prior to and after spraying to prevent insecticide exposure were analyzed using hierarchical mixed models to assess the effect of the performance on change in participants' knowledge. RESULTS: Approximately half of attendees lived in homes that had been sprayed for malaria and 62% were female. Over 90% thought it better to allow IRS prior to the presentation, but knowledge of proper precautions to prevent exposure was low. The proportion answering correctly about proper distance from home during spraying increased from 49.4% pre-performance to 62.0% post-performance (RR = 1.26, 95% CI = 1.13, 1.41), and the proportion reporting correctly about home re-entry interval after spraying increased from 58.5 to 91.1% (RR = 1.54, 95% CI 1.35, 1.77). Attendees improved in their knowledge about precautions to take prior to and after spraying from mean of 57.9% correct to a mean of 69.7% (ß = 12.1%, 95% CI 10.9, 13.4). Specifically, increased knowledge in closing cupboards, removing food and bedding from the home, covering immoveable items with plastic, and leading animals away from the home prior to spraying were observed, as was increased knowledge in sweeping the floors, proper disposal of dead insects, and discarding dirty washrags after spraying. CONCLUSIONS: A dramatic presentation and song were able to increase the attendees' knowledge of precautions to take prior to and after spraying in order to limit their insecticide exposure resulting from IRS. This approach to community education is promising and deserves additional study.

Promoting LPG usage during pregnancy: A pilot study in rural Maharashtra, India.

Household air pollution from the combustion of biomass and coal is estimated to cause approximately 780,000 premature deaths a year in India. The government has responded by promoting uptake of liquefied petroleum gas (LPG) by tens of millions of poor rural families. Many poor households with new LPG stoves, however, continue to partially use traditional smoky chulhas. Our primary objective was to evaluate three strategies to transition pregnant women in rural Maharashtra to exclusive use of LPG for cooking. We also measured reductions in kitchen concentrations of PM2.5 before and after our interventions. Our core intervention was a free stove, 2 free LPG cylinders (one on loan until delivery), and repeated health messaging. We measured stove usage of both the traditional and intervention stoves until delivery. In households that received the core intervention, an average of 66% days had no indoor cooking on a chulha. In an adjacent area, we evaluated a conditional cash transfer (CCT) based on usage of LPG in addition to the core intervention. Results were less successful, due to challenges implementing the CCT. Pregnant women in a third nearby area received the core intervention plus a maximum of one 14.2 kg cylinder per month of free fuel. In their homes, 90% of days had no indoor cooking on a chulha. On average, exclusive LPG use decreased kitchen concentrations of PM2.5 by approximately 85% (from 520 to 72 µg/m3). 85% of participating households agreed to pay the deposit on the 2nd cylinder. This high purchase rate suggests they valued how the second cylinder permitted continuous LPG supply. A program to increase access to second cylinders may, thus, be a straightforward way to encourage use of clean fuels in rural areas.

The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda.

BACKGROUND: Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and what can be done to increase use. We hypothesized that price and inconvenience are important barriers to ORS use and tested whether eliminating financial and access constraints increases ORS coverage. METHODS AND FINDINGS: In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability. CONCLUSIONS: Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context. TRIAL REGISTRATION: Trial registry number AEARCTR-0001288.

Sensor data to measure Hawthorne effects in cookstove evaluation.

This data in brief article includes estimated time cooking based on temperature sensor data taken every 30 min from three stone fires and introduced fuel-efficient Envirofit stoves in approximately 168 households in rural Uganda. These households were part of an impact evaluation study spanning about six months to understand the effects of fuel-efficient cookstoves on fuel use and pollution. Daily particulate matter (pollution) and fuelwood use data are also included. This data in brief file only includes the weeks prior to, during, and after an in-person measurement team visited each home. The data is used to analyze whether households change cooking patterns when in-person measurement teams are present versus when only the temperature sensor is in the home.

Does peer use influence adoption of efficient cookstoves? Evidence from a randomized controlled trial in Uganda.

The authors examined the effect of peer usage on consumer demand for efficient cookstoves with a randomized controlled trial in rural Uganda. The authors tested whether the neighbors of buyers who ordered and received a stove are more likely to purchase an efficient cookstove than the neighbors of buyers who ordered but have not yet received a stove. The authors found that neighbors of buyers who have experience with the stove are not detectably more likely to purchase a stove than neighbors of buyers who have not yet received their stove. The authors found evidence of peer effects in opinions about efficient cookstoves. Knowing that a prominent member of the community has the efficient stove predicts 17-22 percentage points higher odds of strongly favoring the stove. However, this more favorable opinion seemingly has no effect on purchase decisions.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh.

OBJECTIVE: To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers. METHODS: After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use. RESULTS: Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level). CONCLUSION: The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

Randomized government safety inspections reduce worker injuries with no detectable job loss.

Controversy surrounds occupational health and safety regulators, with some observers claiming that workplace regulations damage firms' competitiveness and destroy jobs and others arguing that they make workplaces safer at little cost to employers and employees. We analyzed a natural field experiment to examine how workplace safety inspections affected injury rates and other outcomes. We compared 409 randomly inspected establishments in California with 409 matched-control establishments that were eligible, but not chosen, for inspection. Compared with controls, randomly inspected employers experienced a 9.4% decline in injury rates (95% confidence interval = -0.177 to -0.021) and a 26% reduction in injury cost (95% confidence interval = -0.513 to -0.083). We find no evidence that these improvements came at the expense of employment, sales, credit ratings, or firm survival.

Learning to dislike safe water products: results from a randomized controlled trial of the effects of direct and peer experience on willingness to pay.

Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.

What point-of-use water treatment products do consumers use? Evidence from a randomized controlled trial among the urban poor in Bangladesh.

BACKGROUND: There is evidence that household point-of-use (POU) water treatment products can reduce the enormous burden of water-borne illness. Nevertheless, adoption among the global poor is very low, and little evidence exists on why. METHODS: We gave 600 households in poor communities in Dhaka, Bangladesh randomly-ordered two-month free trials of four water treatment products: dilute liquid chlorine (sodium hypochlorite solution, marketed locally as Water Guard), sodium dichloroisocyanurate tablets (branded as Aquatabs), a combined flocculant-disinfectant powdered mixture (the PUR Purifier of Water), and a silver-coated ceramic siphon filter. Consumers also received education on the dangers of untreated drinking water. We measured which products consumers used with self-reports, observation (for the filter), and chlorine tests (for the other products). We also measured drinking water's contamination with E. coli (compared to 200 control households). FINDINGS: Households reported highest usage of the filter, although no product had even 30% usage. E. coli concentrations in stored drinking water were generally lowest when households had Water Guard. Households that self-reported product usage had large reductions in E. coli concentrations with any product as compared to controls. CONCLUSION: Traditional arguments for the low adoption of POU products focus on affordability, consumers' lack of information about germs and the dangers of unsafe water, and specific products not meshing with a household's preferences. In this study we provided free trials, repeated informational messages explaining the dangers of untreated water, and a variety of product designs. The low usage of all products despite such efforts makes clear that important barriers exist beyond cost, information, and variation among these four product designs. Without a better understanding of the choices and aspirations of the target end-users, household-based water treatment is unlikely to reduce morbidity and mortality substantially in urban Bangladesh and similar populations.

Do microfinance programs help families insure consumption against illness?

Families in developing countries face enormous financial risks from major illness both in terms of the cost of medical care and the loss in income associated with reduced labor supply and productivity. We test whether access to microfinancial savings and lending institutions helps Indonesian families smooth consumption after declines in adult health. In general, results support the importance of these institutions in helping families to self-insure consumption against health shocks.

Does trade affect child health?

Frankel and Romer [Frankel, J., Romer, D., 1999. Does trade cause growth? American Economic Review 89 (3), 379-399] documented positive effects of geographically determined trade openness on economic growth. At the same time, critics fear that openness can lead to a "race to the bottom" that increases pollution and reduces government resources for investments in health and education. We use Frankel and Romer's gravity model of trade to examine how openness to trade affects children. Overall, we find little harm from trade, and potential benefits largely through slightly faster GDP growth.

Do microfinance programs help families insure consumption against illness?

Families in developing countries face enormous financial risks from major illness both in terms of the cost of medical care and the loss in income associated with reduced labor supply and productivity. The paper concludes that governments should promote microfinance and micro savings programs in addition to traditional tools such as subsidies, mandates, or direct government provision of health insurance and disability insurance. Document in PDF format, required Acrobat Reader.