Monitoring Impacts of WASH Interventions in Bangladesh...
Transcript of Monitoring Impacts of WASH Interventions in Bangladesh...
Monitoring Impacts of WASH Interventions in
Bangladesh, the Health Impact Study “Sanitation, Hygiene education, and Water supply intervention in rural
Bangladesh” (SHEWA-B)
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SHEWA-B Project
• Program targets 30 million rural Bangladeshi people
• Budget of over 100 million dollars
• Implemented by Government of Bangladesh with technical • Implemented by Government of Bangladesh with technical
support from UNICEF.
• Targets behavior change in sanitation & hygiene
– Support for water in arsenic-affected areas
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SHEWA-B Intervention
• Participatory, demand-driven approach at community level
• Local NGOs subcontracted by GOB
– 10,000 Community hygiene promoters (CHP)
– 500 to 550 households per CHP– 500 to 550 households per CHP
• Intervention method include:
– Household visits, court yard meetings
– Tea stall sessions, Watsan fair
– Village theatre
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SHEWA-B Intervention
• CHPs emphasized the promotion of:
– Hand washing with soap
– Appropriate feces disposal
– Latrine coverage and usage (without project subsidy)
– Appropriate waste disposal
– Appropriate menstrual hygiene
– Access to and use of arsenic-free water
– Safe collection and storage of drinking water
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Intervention
areas of
SHEWA-B
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SHEWA-B
Purpose of HIS
To investigate the health related impact of the
program interventions by:
– Assessing morbidity in children under 5 years
– Measure changes of hygiene, sanitation – Measure changes of hygiene, sanitation
and water related behavior
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Methodology of HIS
• Multiple integrated surveys conducted at baseline, interim
assessment and midline.
• Quarterly / monthly Sentinel Surveillance??
• Sampling: clusters randomly selected
– Probability proportional to size sampling (PPS)
– 50 intervention and 50 matched control clusters.
– 10 to 17 households per cluster
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Washing both hands with soap/ash
52 51
3430
30
40
50
60
Pe
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s
Reported baseline Observed Baseline Observed interim assessment
8
25
1311
0.7 0.4 0.7
22
17
1 0.9 1
30
0
10
20
30
Before
preparing food
Before eating Before feeding
a child
After cleaning
child’s anus*
After
defecation*
Pe
rce
nta
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s
Washing both hands with soap/ash-Observed
Data in next slide is not matching!
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3035
40
45
50
Pe
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sIntervention Baseline Intervention Midline
Control Baseline Control Midline Target
9
22
17
30
24
18
2723
0
5
10
15
20
25
30
35
After cleaning child’s anus* After defecation
Pe
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Washing hands after defecationin previous slide handwashing with soap, Intervention went up from 17 to 30 (minor
difference only), but for control areas, according to previous slides: 18 at baseline to
23 in midline
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2921
20
12 14 14 10
50%
60%
70%
80%
90%
100%
Washed hands with ash
Washed hands with
soap
10
125 3 6
59
5263
64
0%
10%
20%
30%
40%
Baseline Midline Baseline Midline
Intervention Control
Washed hands with
water only
Did not wash hands at
all*
Washing both hands with soap -Observed
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7
8
9
10
Pe
rce
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s
Intervention Baseline Intervention Midline
Control Baseline Control Midline
Target
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0.6 0.4 0.71 1
3
0.4 0.411 1
2
0
1
2
3
4
5
6
Before preparing food Before eating Before feeding a child
Pe
rce
nta
ge
s
Open defecation by wealth category
31
18
2220
20
25
30
35
Pe
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s
Intervention Baseline
Intervention Midline
12
13
6
1 .6
13
8
.5 0
13
21
0
10
53
2
0
5
10
15
Poorest Lower middle Middle Upper middle Richest
Pe
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s
Prevalence of diarrhea last 48 hours among children < 5
years of age in the intervention and control groups
(October 2007 -- June 2009)
15%
20%
Mea
n d
iarr
hea
pre
vale
nce
Intervention Control
15%
20%
Mea
n d
iarr
hea
pre
vale
nce
Intervention Control
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0%
5%
10%
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6
Mea
n d
iarr
hea
pre
vale
nce
Month
2007 2008 2009
0%
5%
10%
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6
Mea
n d
iarr
hea
pre
vale
nce
Month
2007 2008 2009
Month
2007 2008 2009
Summary of findings.
• Significant Improvement after cleaning child’s anus.
– But short of the revised target for 2009.
• Progress in Handwashing after defecation but not statistically better than in the control group
– and is short of the revised target for 2009.
• At the midline fewer than 3% of persons washed their hands with soap before food related events.
• At the midline fewer than 3% of persons washed their hands with soap before food related events.
– There was very little change from baseline to midline and very short of the revised target for 2009, set at 10%.
• The progress noted in SHEWA-B areas regarding opendefecation is much sharper within the poorest quintiles (31% at baseline and 18% at midline).
• no difference in the health of children under the age of five years between SHEWA-B and intervention communities
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Overall Summary
• Overall, the SHEWA-B intervention affected a handful of targeted
indicators.
• These included
– improvements in hand washing with soap after cleaning a child
who has defecated,
– improvements in sanitary facilities– improvements in sanitary facilities
– a reduction in the proportion of households that were drinking
arsenic contaminated drinking water,
– A higher proportion recalling hygiene messages.
In each of the areas of improvement, there is evidence that the
poor benefitted.
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Overall Summary 2
• The confirmed changes were quite modest.
• Big difference between reported and observed practices calls into
question the validity of including hand washing questions in
surveys.
• These changes in the minority of the indicators, even when • These changes in the minority of the indicators, even when
significant difference from the baseline, were typically quite short
of the program targets.
• Changes in the intervention community have not been substantial
enough to lead to a measurable reduction in childhood diarrhoea
or respiratory disease in the intervention communities.
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Points for discussion
• SHEWA-B behavioural and health targets not yet broadly
achieved
– Intervention design? Or
– implementation compromised?
– time?
• Revised intervention, perhaps smaller in scope, based on the
analysis of above points?
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