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www.icddrb.orgSolving public health problems through innovative scientific research
The Magnitude of WASH Behavior Change by
Wealth Category in a Cluster-Randomized
Controlled Trial in Rural Bangladesh
Sarker Masud Parvez, Musarrat Jabeen Rahman, Rashidul Azad, Mahbubur
Rahman, Leanne Unicomb, Sania Ashraf, Peter J. Winch, Stephen P. Luby
icddr,b, Bangladesh
University of Pennsylvania
Johns Hopkins University
Stanford University
Background
Access to sanitation, handwashing station: lower in LMIC
Soap availability: wealthier households
Poor households: less likely to wash hands after defecation
Child safe sanitation practices: richest households practice 8
times higher odds compare to poorest
Unsafe WASH practices: 5% of DALY’s among poor
communities
Diarrhea, intestinal parasitic & respiratory infection
are attributed to poor hygiene
Premature mortality & morbidity is
higher among poor households
Impoverished populations are less likely to practice healthy behaviors.
Evidence showed:
Rationale & Objective
Many affordable and effective interventions do not
improve health due to difficulties to achieve behavior
More scientific information about the distribution of
behaviors based on demographic characteristics may
help explain low health impact
Assess whether wealth category associated with
differential intervention behavior impact after 2
years; comparing intervention households to
controls for change from baseline to endline in
WASH benefits trial.
WASH Benefits: A Randomized Control TrialCore scientific objective: To generate rigorous evidence about
the impacts of water, sanitation, hygiene and nutrition
interventions alone or in combination on child health and
development.
Design
Women in their 1st or 2nd
trimester of pregnancy
1 Cluster=8 mothers
8 Clusters=1 Block
Random assignment
WASH Benefits Cluster (1 km buffer between
consecutive clusters)
720 Clusters
5760 children
Water treatment [W]
Sanitation [S]
Hand washing [H]
W + S + H [WSH]
Nutrition [N]
W + S + H + N [WSH+N]
Control [X 2] [C ]
Intervention Arms Measurements
WASH Benefits Bangladesh Study Sites
WASH benefits Clusters
WASH Indicators
Observed mother’s hand cleanliness
Observed presence of water and soap in HW
stations
Observed visible feces on latrine slab or floor
Reported last defecation in potty or
toilet
3 observed & 1 reported behavior
Analysis: Difference in difference (DiD)
DiD: (Endline intervention-Baseline intervention)
(Baseline control-endline control)
DiD, Observed mother’s hand cleanliness
Observed mother’s hand cleanliness
0 10 20 30 40 50 60
Q1
Q2
Q3
Q4
Q5DID: 7%, 95% CI: -4%,17%
DID: 5%, 95% CI: -5%,16%
DID: 14%, 95% CI:4%,23%
DID: 11%, 95% CI:2%,20%
DID: 16%, 95% CI: 7%,25%
(Q1-lowest to Q5-wealthiest)
Poor
Wealthy
Observed presence of water, soap in HW station
DID: 58%; 95% CI: 50%,70%
DID: 81%; 95% CI:
75%,90%
DID: 83%; 95% CI:
75%,90%
DID: 82%; 95% CI:
75%,90%
(Q1-lowest to Q5-wealthiest)
Observed visible feces on latrine slab or floor
DID: -25%; 95% CI: -35%,-15%
DID: -34%; 95% CI: -44%,23%
DID: -19%; 95% CI: -30%,-9%
DID: -30%; 95% CI: -40%,-20%
DID: -1%%; 95% CI: -11%,8%
(Q1-lowest to Q5-wealthiest)
Reported last defecation in potty/toilet
among under 3 child
DID: 54%; 95% CI: 48%,60%
DID: 52%; 95% CI: 46%,58%
DID: 52%; 95% CI: 46%,58%
DID: 50%; 95% CI: 44%,55%
(Q1-lowest to Q5-wealthiest)
Conclusion
Intervention households from lower wealth categories
exhibited greater improvement in targeted practices
compared with wealthier households.
It is important to note that, the hardware and supplies
for WASH Benefits interventions were provided at no
cost, thus, overcoming an important barrier associated
with poverty.
The possible explanation is that, the poorer
households started at a lower level that might show big
difference.
15 [Insert presentation title]
Conclusion
Interventions targeted at vulnerable populations may
be more cost-effective & contribute to alleviating existing
social disparity in WASH-related behaviors.
Appropriate intervention design along with addressing
cost barriers should be considered for low income
households.
icddr,b thanks its core donors for their on-going support
This project has been funded