Randomized experiment of handwashing and sanitation campaigns in rural Tanzania Preliminary Results, 12 Feb 2014

Bertha Briceno (WB), Aidan Coville (WB), Sebastian Martinez (IDB) In collaboration with multiple partners from the Tanzanian Ministry of Health and Social Welfare, WSP and UC Berkeley

Motivation
Handwashing with soap at critical times is low; observed rates range from 0-34% (Scott et al 2003) Reviews estimate a percentage reduction in diarrhoeal risk of 42% (3151%) for high-quality studies; and 44% risk reduction when involving soap. (Curtis and Cairncross , 2003) Soap is rarely used for handwashing; laundry, bathing and washing dishes are prioritized (GHD Planners Guide) Handwashing with soap at critical times can reduce diarrhea by over 40% (Cairncross et. al, 2010; Waddington et. al, 2009) Most of the evidence is limited to highly-intense and smallscale interventions (efficacy trials)
Emerging evidence on large programs show modest behavior changes that have not resulted in health effects yet (SHEWA-B
evaluation)

Two questions
1. HWWS has been proven to have large impacts in efficacy trials, but what happens when we try to take this to scale?

We run a randomized control trial across rural Tanzania on a Government-led (WSP-supported) hygiene campaign

2. Are there potential complementarities with sanitation promotion?

Experimental design explores the effect of HWWS alone, sanitation promotion alone, and the combination of both

Addressing all of the pathways

1. 2. 3. 4.

Intervention summary Main results (the What) Contextualizing the results (the Why) Implications

Intervention Summary

Total sanitation and sanitation marketing (TSSM)

1. 2. 3. 4. Mass media (radio adverts and soap opera) CLTS village triggering Print materials (posters/wall murals) Direct consumer contact (DCC) drama, theater, dance 5. Supply side strengthening (mason training, improving supply chain)

Handwashing with soap (HWWS)

1. Mass media (radio adverts and soap opera) 2. Print materials (posters/calendars) 3. Direct consumer contact (DCC) drama, theater, dance 4. Frontline activators (IPC)

Intervention Areas and Study Timeline

10 project districts
181 wards

3619 Households
Groups are statistically balanced at baseline

Random assignment

Start Feb 2009

May 2012 Dec 2012

2013/14

T1 = HWWS (45 wards) T2 = TSSM (44 wards) T3= COMBO (46 wards) CONTROL (46 wards)

Mid 2009 IMPLEMENTATION

July 2011

Endline (n= 3600)

Final impact analysis

Theory of change

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

Improved health

HWWS RESULTS

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

Mass media recall

50% 45% 40% 35% 30%

*
33%

40%

40%

*
46%
Control HWWS TSSM COMBO

25%
20% 15% 10% 5% 0%

HWWS Intervention recall (excl. mass media)

70%

*
51%

* *
24%

Peru School > 1 channel Control: 0.717 Treatment: 0.781 *

60%
50% 40% 30% 20%

58%

Control
HWWS TSSM COMBO

14%

10%
0%

Exposed through >= 1 HWWS channel

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

HWWS knowledge (index)

1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0.3

Peru School Control: Treatment:

0.222 0.230
Control HWWS TSSM COMBO

*
0.34 0.3

*
0.34

Knows when to wash hands

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

HW stations and soap presence

Peru School (presence of W&S) Peru School (Station w/ SW) Control: 0.768 Control: 0.670 Treatment: 0.833 * Treatment: 0.732

60% 50% 40% 30% 20% 10%

51% 48%47% 48%

*22 HHs in 3619 found to use tippy taps (19 in combination ward)

27% 24% 22%23%

Control

* *
1%

*
6% 4% 5%

HWWS TSSM COMBO

11%

3%

1%

4%

0% Soap present in HH HH has a HW device HH has a fixed HW Device is within 6m of device toilet

HWWS practice
n (households) = 720; n (exposure events) = 2572
18% 16% 14% 14% 12% 16%

Peru School (HWWS- fecal contact) Control: 0.342 Treatment: 0.320

Peru School (HWWS- before eat) Control: 0.189 Treatment: 0.304 *

12%
10% 8% 6% 4%

*
8%

4%
2%

*
4%

Control
HWWS TSSM COMBO

3%

2%
0%

HWWS after fecal contact

HWWS before preparing/serving food or eating/feeding a baby

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

Cleanliness (caregiver index)

9 8 7 6
6.76

*
7.13

Peru School (hand cleanliness) Control: 7.403 Treatment: 7.613

7.18 6.69
Control HWWS TSSM

5
4 3

COMBO

Caregiver hand cleanliness

Cleanliness (child index)

3 2.5 2 1.5 1 0.5 0

*
1.7

1.92

*
1.75 1.88
Control HWWS TSSM COMBO

child cleanliness

HWWS Exposure (Intervention recall)

Awareness / Knowledge

Practice: HW Stations, HWWS at critical junctures

Cleanliness (child and caregiver)

Improved health

Health results (diarrhea)

18% 16% 14% 12%

Peru School (7 day diarrhea) Control: 0.069 Treatment: 0.064

N = 34,080
16.8% 15.6% 15.9%

*
14.5%
Control HWWS TSSM COMBO

N = 5,768
8.6%

10%
8% 6% 4% 2% 0%

8.2%

8.5%

7.6%

Diarrhea in past 7 days

Diarrhea in past 14 days (listing)

Health results (stunting/wasting)

Peru School (stunting) Control: -1.619 Treatment: -1.536
weight-for-age
-0.5

height-for-age

-1

Control

-1.04 -1.03 -1.08 -1.11

-1.5

HWWS TSSM COMBO

*
-1.94 -1.90 -1.95 -1.95

-2

-2.5

Health results (anemia)

*
50% 45% 40% 35% 30% 25% 41.4% 41.8% 43.7% 47.1%

Peru School (anemia) Control: 0.278 Treatment: 0.256

Control HWWS TSSM COMBO

20%
15% 10% 5% 0%

Anemic Hb < 110 g/L

Putting health results in context

Results are biologically small in real terms (100g difference in weight and an increase in 6 p.p in anemia rates, but this translates into a shift of HB levels from 11.14 to 10.98 g/dl) but some sub-groups are affected more than others
Study Peru Vietnam India Indonesia TZ HHWS TZ TSSM TZ COMBO Global (from recent Cochrane review) N (approx.) 4300 4200 1700 5884 4627 WAZ dif 0 X -0.05 0.037 0.016 -0.038 -0.068* 0.05 HAZ dif 0.08 X 0.002 0.014 0.04 0.007 -0.009 0.08 Anemia dif -0.02 X 0.03 0.02 0.004 0.023 0.057** -

Health impacts: possible mechanisms

1. Selective attrition due to reduced mortality in treatment areas 2. Increased contamination from washing hands with dirty water and no soap 3. Variation in malaria prevalence between T/C driving anemia results 4. Poor latrine facilities worse than OD 5. Diversion of resources away from other nutrition inputs to sanitation/hygiene 6. Shift away from other healthy practices

In summary
HWWS:
High recall of interventions Very low base rates for HWWS activities

Some positive effects on knowledge, HWWS practice and

cleanliness, but changes are very small No clear health impacts

Combined Wards:
Highest reported exposure in TSSM and HWWS
Similar changes in HW behavior and latrine improvement as

individual interventions Strong but biologically questionable health impacts this is an important, but puzzling issue

Thank You