Monitoring for household energy and health projects: 1 What health outcomes are of interest and why

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Monitoring for household energy and health
projects 1 What health outcomes are of
interest and why

• Nigel Bruce
• Department of Pubic Health
• University of Liverpool

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1 Health outcomes

• Why monitor HEH work? For whom?
• Hence, what information would be most useful?
• Perspectives on health impacts
• Issues in the assessment of health outcomes

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2 Towards integrated protocol

• Evaluation design options
• Sample size
• Provisional plan for studies
• Summary key steps

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Why monitor?

• Important opportunity at a crucial time to assess
  impact of sustainable interventions, in practice
• Shell HEH (to be extended to African countries)
• DFID (Kenya, Sudan, Nepal)
• USEPA Partnership
• Winrock
• A time of development and learning
• Good evidence will support development and
  advocacy
• Part of a package of evidence, together with
  epidemiology (RCT, etc.)

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What information? For whom?
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What information? For whom?
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Perspectives on health impacts

• Specific disease outcomes and risks
• Broader perspective on health and the
  determinants of health
• Health implications of approaches adopted to
  achieve effective and sustainable change

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Perspectives on health impacts

• Specific disease outcomes and risks
• Broader perspective on health and the
  determinants of health
• Health implications of approaches adopted to
  achieve effective and sustainable change

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(No Transcript)
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Burden of disease due to selected risk factors
World Health Report 2002

• Global
• 1.6 million deaths
• 2.7 DALYs
• Ranked 8th

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IAP health outcomes
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Reduction in Ca lung risk ChinaImproved coal
burning stoves
Lan Q et al J Natl Cancer Inst 200294826-35
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IAP health outcomes
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IAP health outcomes
Of exacerbations
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Assessment of ARI in young children

• Upper (colds, etc.,) and Lower respiratory
  infections (pneumonia, bronchiolitis)
• In communities where care seeking is incomplete,
  use (weekly) home visits, with clinical
  assessment
• Best way to distinguish upper and lower ARI
• Resource intensive
• A number of studies have used recall of ALRI
• Includes large studies, e.g. DHS
• Recall period 2 weeks

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Guatemala traditional fires and plancha improved
stove
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Overview of main health outcomes assessment and
patient management process
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Assessment of ARI in young children

• Home visit and MD assessment very resource
  intensive, unlikely to be suitable for HEH
  project monitoring
• Study design is critical (later)
• Can assess respiratory symptoms by recall
• Typically 2-week period
• Repeat at intervals to obtain sufficient
  child-weeks
• Uncertain recall of signs of severe illness (fast
  breathing)
• Mothers perception of childs health? (could
  carry out comparative studies)

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COPD Classification by Severity
Stage Characteristics 0 At risk
Normal spirometry Chronic symptoms (cough,
sputum)  I Mild FEV1/FVC lt 70 FEV1 gt
80 predicted With/without chronic
symptoms (cough, sputum) II Moderate
FEV1/FVC lt 70 50 lt FEV1 lt 80 predicted
With/without chronic symptoms (cough, sputum,
dyspnea) III Severe FEV1/FVC lt 70 30
lt FEV1 lt 50 predicted With/without chronic
symptoms (cough, sputum, dyspnea) IV Very
Severe FEV1/FVC lt 70 FEV1 lt 30 predicted or
FEV1 lt 50 predicted plus chronic
respiratory failure GOLD
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Adult lung health assessment

• Improvement depends on how advanced (age)
• Symptoms
• Chronic cough chronic phlegm (amount, colour)
• Chest tightness/difficulty breathing/etc.
• Wheeze
• Standard questionnaires available (local
  adaptation)
• Spirometry (lung function tests)
• Requires careful technique hence resource
  intensive
• Consider where local partners interested in lung
  health
• Changes? Established disease prevents more
  damage

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Guatemala study respiratory symptoms in women
16-45 yr (n504)
Chronic frequent for at least 3 months
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Symptoms reported as associated with cooking smoke

• ITDG/DFID study in 3 communities Kisumu (Kenya),
  Kassala (Sudan), Gatlang (Nepal)
• N30 homes per country, all with young children,
  using mainly biomass
• Asked what health problems associated with smoke,
  if any
• Open ended (post coded)
• For herself (woman) age group 16-45
• For young children

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Need to understand local terms and meanings for
symptoms
ITDG/DFID smoke and health study
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ITDG/DFID smoke and health study
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ITDG/DFID smoke and health study
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Assessment of changes in perceived health problems

• It should be possible to study this
• Non-leading questions that allow response of no
  change or worse
• Qualitative methods to explore further
• Expect to be quite sensitive
• Unsure of validity as a health outcome
• Of value at community level
• Comparative studies
• Guatemala, etc., where formal assessment of ALRI
  and adult lung health available

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Perspectives on health impacts

• Specific disease outcomes and risks
• Broader perspective on health and the
  determinants of health
• Health implications of approaches adopted to
  achieve effective and sustainable change

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What do we understand by health? What are the
determinants of health?

• WHO State of physical and mental well-being, not
  just absence of disease
• Ottawa charter for health promotion, Health for
  All (Health-21) have been very influential
• Socio-environmental model of health determination

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Determinants of health
Dahlgren, G. and Whitehead, M. (1991) Policies
and Strategies to Promote Social Equity in
Health, Institute for Future Studies, Stockholm.
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Health, environment and development impacts of
household energy use
Household Energy
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Assessment of other health impacts

• Burns and scalds
• Can expect immediate effect if risk reduced
• How common?
• Recall by interview
• Poisoning from ingestion of kerosene
• Can expect immediate effect if risk changes
• Context (country) specific (how common?)
• Recall by interview (?)
• Injuries collecting fuel
• Impact if change from wood to commercial fuel, or
  marked reduction in wood use
• Context specific (e.g. wood bought vs.
  collected)
• Recall by interview

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Other direct health impacts

• Eye irritation and headaches
• commonly reported
• Recall by interview
• Backache
• Common?
• A number of causes, including bending down to
  tend to fire on floor
• Recall by interview
• What else?

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Guatemala study survey results (n504)
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Guatemala study aggravating factors for back
pain
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Energy and the household

• Energy affects many aspects of households
  everyday life and well-being, particularly for
  women
• Many aspects of health
• Time and drudgery (collecting fuel) - opportunity
  cost
• Income generation, and impacts on household
  budget
• Quality of environment for children to study,
  carry out hand crafts, etc.
• And much more
• If interventions are to succeed, must address
  these issues in an appropriate way
• All are highly context specific
• We need to understand needs and impacts from the
  households perspective

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Contribution of qualitative methods

• Much of evidence to date anecdote, case studies
• Need more systematic approach to researching
  these issues
• Useful to quantify through surveys
• Qualitative methods best suited to understanding
  users perspectives on needs and impacts of
  interventions
• Important component of evaluation of household
  energy work

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Perspectives on health impacts

• Specific disease outcomes and risks
• Broader perspective on health and the
  determinants of health
• Health implications of approaches adopted to
  achieve effective and sustainable change

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Approach

• Built on experience of 30 years success and
  failures
• Involves users to assess needs and ensure these
  are met
• Focus on women, community groups, credit, etc.,
  facilitates uptake through markets
• Can impact on other health and well being issues
  through empowerment
• Basis of community health development
• Important to monitor process and outcomes

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Issues for assessment

• Process
• Assessment of needs
• Involvement of users in choosing and developing
  interventions
• Financing options
• Outcomes
• How well needs met over time
• Outcomes resulting from greater involvement in
  decision-making, experience with credit, etc.
• Use mix of quantitative and qualitative methods

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Conclusions

• Effectiveness (and efficiency), complementing
  efficacy studies (RCT)
• Local partners have key role in identifying
  priority issues
• Important to consider health impacts
• Measuring major disease outcomes is demanding,
  but local information is valuable
• Broader view of health useful in identifying
  topics for monitoring
• Include impacts of process for sustainable change
• Combine quantitative and qualitative methods for
  understanding of user perspective