title: Designing and piloting a program to provide water filters and improved cookstoves in Rwanda.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Civil, Environmental and Architectural Engineering, University of Colorado, Boulder, Colorado, United States of America.
authors.forename: Christina K
authors.initials: CK
authors.lastname: Barstow
authors.affiliation: Maternal and Child Health, Ministry of Health, Kigali, Republic of Rwanda.
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Ghislaine
authors.initials: G
authors.lastname: Rosa
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Fiona
authors.initials: F
authors.lastname: Majorin
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sophie
authors.initials: S
authors.lastname: Boisson
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.
authors.forename: Thomas
authors.initials: T
authors.lastname: Clasen
authors.affiliation: Mechanical and Materials Engineering, Portland State University, Portland, Oregon, United States of America.
authors.forename: Evan A
authors.initials: EA
authors.lastname: Thomas
mesh_terms: D016902:Air Pollution, Indoor; D005191:Family Characteristics; D006801:Humans; D012432:Rwanda; D012499:Sanitation; D060753:Water Quality