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