Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol

Background: Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. Methods: We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at community level and behavior change activities at group and household level. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. Results: A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR] 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR=1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. Discussion: We report limited impact of the intervention, as delivered, on changes inbehavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond.

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The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

PLOS Global Public Health ◽

10.1371/journal.pgph.0000056 ◽

2022 ◽

Vol 2 (1) ◽

pp. e0000056

Author(s):

Matthew C. Freeman ◽

Maryann G. Delea ◽

Jedidiah S. Snyder ◽

Joshua V. Garn ◽

Mulusew Belew ◽

...

Keyword(s):

Behavior Change ◽

Disease Transmission ◽

Prevalence Ratio ◽

Well Being ◽

Personal Hygiene ◽

Demand Side ◽

Knowledge Gaps ◽

Sanitation And Hygiene ◽

The Impact ◽

Mental Well Being

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

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Design and rationale of the Longitudinal Evaluation of Norms and Networks Study (LENNS): A cluster-randomized trial assessing the impact of a norms-centric intervention on exclusive toilet use and maintenance in peri urban communities of Tamil Nadu

10.1101/2020.06.26.20140830 ◽

2020 ◽

Cited By ~ 1

Author(s):

Sania Ashraf ◽

Cristina Bicchieri ◽

Maryann G. Delea ◽

Upasak Das ◽

Kavita Chauhan ◽

...

Keyword(s):

Behavior Change ◽

Randomized Trial ◽

Low Income ◽

Tamil Nadu ◽

Cluster Randomized Trial ◽

List Type ◽

Behavior Change Intervention ◽

Ex Ante ◽

Cluster Randomized ◽

The Impact

AbstractIntroductionInconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norms-centric behavior change interventions to increase toilet use in low-income settings. This protocol details the rationale and design of an ex-ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norms-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India.Methods and AnalysisFollowing two years of formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for “Our wellbeing”). The multi-level intervention aims to shift collective beliefs by shifting empirical expectations or beliefs about other relevant people’s sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to build, consistently use and maintain their toilets. This trial includes 76 wards in Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining serve as counterfactuals. During baseline and endline (conducted one year after the initiation of intervention) assessments, we collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, wellbeing outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We will also conduct a process evaluation to understand the extent to which the intervention was implemented, as designed.Ethics and DisseminationThe study protocol has been reviewed and approved by the ethics board at the University of Pennsylvania, USA and the Catalyst Foundation, India. Research findings will be disseminated through open access peer reviewed publications and presentations to stakeholders, government officials and conferences.Trial registrationNCT04269824.Strengths and limitations of this studyThis ex-ante, parallel cluster randomized trial assesses the impact of a norm-centric behavior change intervention strategy to improve sanitation practices. These behavior change techniques are novel to the sanitation sector but has been effective in changing a variety of behaviors, such as water use, drinking behavior, and energy consumption.The study outcomes include health, wellbeing outcomes, and a careful assessment of changes in social beliefs, expectations, and social determinants of collective sanitation behaviors.This study is being rolled out during the ongoing COVID-19 pandemic. This can potentially impact the effectiveness of this intervention package that uses community and network-based group activities. However, through a detailed process monitoring and evaluation we will be able to assess the impact on delivery, and subsequent behavior change in this unique setting.

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A Cluster Randomized Trial of the Impact of Education through Listening (a Novel Behavior Change Technique) on Household Water Treatment with Chlorine in Vihiga District, Kenya, 2010–2011

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.20-0215 ◽

2021 ◽

Vol 104 (1) ◽

pp. 382-390

Author(s):

Christine E. Stauber ◽

Bobbie Person ◽

Ronald Otieno ◽

Jared Oremo ◽

Katharine Schilling ◽

...

Keyword(s):

Water Treatment ◽

Behavior Change ◽

Randomized Trial ◽

Cluster Randomized Trial ◽

Household Water Treatment ◽

Change Technique ◽

Household Water ◽

Cluster Randomized ◽

Behavior Change Technique ◽

The Impact

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Impact of a school-based water, sanitation, and hygiene intervention on school absence, diarrhea, respiratory infection, and soil-transmitted helminths: results from the WASH HELPS cluster-randomized trial

Journal of Global Health ◽

10.7189/jogh.09.020402 ◽

2019 ◽

Vol 9 (2) ◽

Cited By ~ 10

Author(s):

Anna N Chard ◽

Joshua V Garn ◽

Howard H Chang ◽

Thomas Clasen ◽

Matthew C Freeman

Keyword(s):

Randomized Trial ◽

Respiratory Infection ◽

Cluster Randomized Trial ◽

Soil Transmitted Helminths ◽

School Absence ◽

School Based ◽

Sanitation And Hygiene ◽

Hygiene Intervention ◽

Cluster Randomized

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A cluster-randomized trial assessing the impact of school water, sanitation and hygiene improvements on pupil enrolment and gender parity in enrolment

Journal of Water Sanitation and Hygiene for Development ◽

10.2166/washdev.2013.217 ◽

2013 ◽

Vol 3 (4) ◽

pp. 592-601 ◽

Cited By ~ 24

Author(s):

Joshua V. Garn ◽

Leslie E. Greene ◽

Robert Dreibelbis ◽

Shadi Saboori ◽

Richard D. Rheingans ◽

...

Keyword(s):

Randomized Trial ◽

Primary Schools ◽

Cluster Randomized Trial ◽

Water Source ◽

Dry Season ◽

Water Access ◽

Gender Parity ◽

Sanitation And Hygiene ◽

Cluster Randomized ◽

The Impact

We employed a cluster-randomized trial design to measure the impact of a school-based water, sanitation and hygiene (WASH) improvement on pupil enrolment and on gender parity in enrolment, in primary schools in Nyanza Province, Kenya (2007–2009). Among schools with poor water access during the dry season, those that received a water supply, hygiene promotion and water treatment (HP&WT) and sanitation improvement demonstrated increased enrolment (β = 0.091 [0.009, 0.173] p = 0.03), which translates to 26 additional pupils per school on average. The proportion of girls enrolled in school also increased by 4% (prevalence ratio (PR) = 1.04 [1.00, 1.07] p = 0.02). Among schools with better baseline water access during the dry season (schools that did not receive a water source), we found no evidence of increased enrolment in schools that received a HP&WT intervention (β = 0.016 [–0.039, 0.072] p = 0.56) or the HP&WT and sanitation intervention (β = 0.027 [–0.028, 0.082] p = 0.34), and there was no evidence of improved gender parity (PR = 0.99 [0.96, 1.02] p = 0.59, PR = 1.00 [0.97, 1.02] p = 0.75, respectively). Our findings suggest that increased school enrolment and improved gender parity may be influenced by a comprehensive WASH programme that includes an improved water source; schools with poor water access during the dry season may benefit most from these interventions.

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