Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh

Sarker Masud Parvez, Musarrat Jabeen Rahman, Rashidul Azad, Mahbubur Rahman, Leanne Unicomb, Sania Ashraf, Momenul Haque Mondol, Farjana Jahan, Peter J Winch, Stephen P Luby, Sarker Masud Parvez, Musarrat Jabeen Rahman, Rashidul Azad, Mahbubur Rahman, Leanne Unicomb, Sania Ashraf, Momenul Haque Mondol, Farjana Jahan, Peter J Winch, Stephen P Luby

Abstract

Background: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.

Methods: The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.

Results: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (- 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, - 25% (- 35, - 15) Q2: - 34% (- 44, - 23%)] than the wealthiest household [Q5 DID: - 1% (- 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).

Conclusion: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.

Trial registration: WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.

Keywords: Equity; Handwashing; Sanitation; Uptake; WASH benefits; Wealth quintiles.

Conflict of interest statement

We declare no competing interests.

References

    1. Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Health CoSDo Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661–1669. doi: 10.1016/S0140-6736(08)61690-6.
    1. Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, França GV, et al. Equity in maternal, newborn, and child health interventions in countdown to 2015: a retrospective review of survey data from 54 countries. Lancet. 2012;379(9822):1225–1233. doi: 10.1016/S0140-6736(12)60113-5.
    1. Meheus F, Van Doorslaer E. Achieving better measles immunization in developing countries: does higher coverage imply lower inequality? Soc Sci Med. 2008;66(8):1709–1718. doi: 10.1016/j.socscimed.2007.12.036.
    1. Victora CG, Joseph G, Silva IC, Maia FS, Vaughan JP, Barros FC, et al. The inverse equity hypothesis: analyses of institutional deliveries in 286 national surveys. Am J Public Health. 2018;108(4):464–471. doi: 10.2105/AJPH.2017.304277.
    1. Rheingans R, Kukla M, Faruque ASG, Sur D, Zaidi AK, Nasrin D, et al. Determinants of household costs associated with childhood diarrhea in 3 South Asian settings. Clin Infect Dis. 2012;55(suppl_4):S327–SS35. doi: 10.1093/cid/cis764.
    1. Barros FC, Victora CG, Scherpbier R, Gwatkin D. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Rev Saude Publica. 2010;44:1–16. doi: 10.1590/S0034-89102010000100001.
    1. Robinson A. Sanitation finance in rural Cambodia. 2012.
    1. UNICEF . United Nations Children’s Fund Narrowing the gaps: the power of investing in the poorest children. New York: UNICEF; 2017.
    1. Prüss-Ustün A, Wolf J, Bartram J, Clasen T, Cumming O, Freeman MC, et al. Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: an updated analysis with a focus on low-and middle-income countries. Int J Hyg Environ Health. 2019;222(5):765–777. doi: 10.1016/j.ijheh.2019.05.004.
    1. Armah FA, Ekumah B, Yawson DO, Odoi JO, Afitiri A-R, Nyieku FE. Access to improved water and sanitation in sub-Saharan Africa in a quarter century. Heliyon. 2018;4(11):e00931. doi: 10.1016/j.heliyon.2018.e00931.
    1. WHO, UNICEF . Progress on household drinking water, sanitation and hygiene 2000–2017: special focus on inequalities. New York: WHO; 2019.
    1. Rahman MS, Rahman MM, Gilmour S, Swe KT, Abe SK, Shibuya K. Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995–2030: a Bayesian analysis of population-based household data. Lancet Glob Health. 2018;6(1):e84–e94. doi: 10.1016/S2214-109X(17)30413-8.
    1. Luby SP, Halder AK, Tronchet C, Akhter S, Bhuiya A, Johnston RB. Household characteristics associated with handwashing with soap in rural Bangladesh. Am J Trop Med Hyg. 2009;81(5):882–887. doi: 10.4269/ajtmh.2009.09-0031.
    1. Luby SP, Halder AK. Associations among handwashing indicators, wealth, and symptoms of childhood respiratory illness in urban Bangladesh. Tropical Med Int Health. 2008;13(6):835–844. doi: 10.1111/j.1365-3156.2008.02074.x.
    1. Kumar S, Loughnan L, Luyendijk R, Hernandez O, Weinger M, Arnold F, et al. Handwashing in 51 countries: analysis of proxy measures of handwashing behavior in multiple indicator cluster surveys and demographic and health surveys, 2010–2013. Am J Tropl Med Hyg. 2017;97(2):447–459. doi: 10.4269/ajtmh.16-0445.
    1. Schmidt WP, Aunger R, Coombes Y, Maina PM, Matiko CN, Biran A, et al. Determinants of handwashing practices in Kenya: the role of media exposure, poverty and infrastructure. Tropical Med Int Health. 2009;14(12):1534–1541. doi: 10.1111/j.1365-3156.2009.02404.x.
    1. Rosa G, Clasen T. Estimating the scope of household water treatment in low-and medium-income countries. Am J Trop Med Hyg. 2010;82(2):289–300. doi: 10.4269/ajtmh.2010.09-0382.
    1. Geremew A, Damtew YT. Household water treatment using adequate methods in sub-Saharan countries: evidence from 2013–2016 demographic and health surveys. J Water Sanit Hyg Dev. 2020;10(1):66–75. doi: 10.2166/washdev.2019.107.
    1. Jenkins MW, Sugden S. Rethinking sanitation: Lessons and innovation for sustainability and success in the new millennium (No. HDOCPA-2006-27). Human Development Report Office (HDRO), United Nations Development Programme (UNDP); 2006.
    1. Trémolet S, Kolsky P, Perez E. Financing on-site sanitation for the poor: a six country comparative review and analysis. Washington, DC: World Bank; 2010.
    1. Barnard S, Routray P, Majorin F, Peletz R, Boisson S, Sinha A, et al. Impact of Indian Total sanitation campaign on latrine coverage and use: a cross-sectional study in Orissa three years following programme implementation. PLoS One. 2013;8(8):e71438. doi: 10.1371/journal.pone.0071438.
    1. Coffey D, Gupta A, Hathi P, Khurana N, Spears D, Srivastav N, et al. Revealed preference for open defecation. Econ Polit Wkly. 2014;49(38):43.
    1. Coffey D, Gupta A, Hathi P, Spears D, Srivastav N, Vyas S. International Growth Centre Working Paper, April. 2015. Culture and the health transition: understanding sanitation behavior in rural North India.
    1. Foster T, Furey S, Banks B, Willetts J. Functionality of handpump water supplies: a review of data from sub-Saharan Africa and the Asia-Pacific region. Int J Water Resour Dev. 2020;36(5):855–69. doi: 10.1080/07900627.2018.1543117.
    1. Alzúa ML, Djebbari H, Pickering AJ. A community-based program promotes sanitation. Econ Dev Cult Chang. 2020;68(2):357–390. doi: 10.1086/701214.
    1. Pattanayak SK, Yang J-C, Dickinson KL, Poulos C, Patil SR, Mallick RK, et al. Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bull World Health Organ. 2009;87:580–587. doi: 10.2471/BLT.08.057422.
    1. Harvey PA. Zero subsidy strategies for accelerating access to rural water and sanitation services. Water Sci Technol. 2011;63(5):1037–1043. doi: 10.2166/wst.2011.287.
    1. Cameron L, Olivia S, Shah M. Scaling up sanitation: evidence from an RCT in Indonesia. J Dev Econ. 2019;138:1–16. doi: 10.1016/j.jdeveco.2018.12.001.
    1. Slekiene J, Mosler H-J. Characterizing the last latrine nonowners in rural Malawi. Am J Trop Med Hyg. 2018;98(1):295–299. doi: 10.4269/ajtmh.17-0578.
    1. O'Loughlin R, Fentie G, Flannery B, Emerson PM. Follow-up of a low cost latrine promotion programme in one district of Amhara, Ethiopia: characteristics of early adopters and non-adopters. Tropical Med Int Health. 2006;11(9):1406–1415. doi: 10.1111/j.1365-3156.2006.01689.x.
    1. Holm R, Tembo M, Njera D, Kasulo V, Malota M, Chipeta W, et al. Adopters and non-adopters of low-cost household latrines: a study of corbelled pit latrines in 15 districts of Malawi. Sustainability. 2016;8(10):917. doi: 10.3390/su8100917.
    1. Njuguna J. Progress in sanitation among poor households in Kenya: evidence from demographic and health surveys. BMC Public Health. 2019;19(1):135. doi: 10.1186/s12889-019-6459-0.
    1. Cole B, DeGabriele J, Ho G, Anda M. Exploring the utility of diffusion theory to evaluate social marketing approaches to improve urban sanitation in Malawi. J Water Sanit Hyg Dev. 2015;5(2):289–300. doi: 10.2166/washdev.2014.202.
    1. Peletz R, Cock-Esteb A, Ysenburg D, Haji S, Khush R, Dupas P. Supply and demand for improved sanitation: results from randomized pricing experiments in rural Tanzania. Environ Sci Technol. 2017;51(12):7138–7147. doi: 10.1021/acs.est.6b03846.
    1. Langford R, Panter-Brick C. A health equity critique of social marketing: where interventions have impact but insufficient reach. Soc Sci Med. 2013;83:133–141. doi: 10.1016/j.socscimed.2013.01.036.
    1. Wymer W. Developing more effective social marketing strategies. J Soc Mark. 2011;1(1):17–31. doi: 10.1108/20426761111104400.
    1. Harris JR, Patel MK, Juliao P, Suchdev PS, Ruth LJ, Were V, et al. Addressing inequities in access to health products through the use of social marketing, community mobilization, and local entrepreneurs in rural Western Kenya. Int J Popul Res. 2012;2012:1–9. doi: 10.1155/2012/470598.
    1. Noor AM, Amin AA, Akhwale WS, Snow RW. Increasing coverage and decreasing inequity in insecticide-treated bed net use among rural Kenyan children. PLoS Med. 2007;4(8):e255. doi: 10.1371/journal.pmed.0040255.
    1. Freeman MC, Quick RE, Abbott DP, Ogutu P, Rheingans R. Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya. J Water Health. 2009;7(3):527–534. doi: 10.2166/wh.2009.063.
    1. Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. Lancet Glob Health. 2018;6(3):e302–ee15. doi: 10.1016/S2214-109X(17)30490-4.
    1. Rahman M, Ashraf S, Unicomb L, Mainuddin A, Parvez SM, Begum F, et al. WASH benefits Bangladesh trial: system for monitoring coverage and quality in an efficacy trial. Trials. 2018;19(1):360. doi: 10.1186/s13063-018-2708-2.
    1. Unicomb L, Begum F, Leontsini E, Rahman M, Ashraf S, Naser AM, et al. WASH benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial. Trials. 2018;19(1):359. doi: 10.1186/s13063-018-2709-1.
    1. Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, et al. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health. 2013;13(1):1015. doi: 10.1186/1471-2458-13-1015.
    1. Pickering AJ, Ercumen A, Arnold BF, Kwong LH, Parvez SM, Alam M, et al. Fecal indicator bacteria along multiple environmental transmission pathways (water, hands, food, soil, flies) and subsequent child diarrhea in rural Bangladesh. Environ Sci Technol. 2018;52(14):7928–36. doi: 10.1021/acs.est.8b00928.
    1. Hutton G, Chase C. The knowledge base for achieving the sustainable development goal targets on water supply, sanitation and hygiene. Int J Environ Res Public Health. 2016;13(6):536. doi: 10.3390/ijerph13060536.
    1. Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, et al. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open. 2013;3(8):1–17. doi: 10.1136/bmjopen-2013-003476.
    1. Ashraf S, Nizame FA, Islam M, Dutta NC, Yeasmin D, Akhter S, et al. Nonrandomized trial of feasibility and acceptability of strategies for promotion of soapy water as a handwashing agent in rural Bangladesh. Am J Trop Med Hyg. 2017;96(2):421–429. doi: 10.4269/ajtmh.16-0304.
    1. Garn JV, Sclar GD, Freeman MC, Penakalapati G, Alexander KT, Brooks P, et al. The impact of sanitation interventions on latrine coverage and latrine use: a systematic review and meta-analysis. Int J Hyg Environ Health. 2017;220(2):329–340. doi: 10.1016/j.ijheh.2016.10.001.
    1. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, et al. Systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Med Int Health. 2014;19(8):906–916. doi: 10.1111/tmi.12339.
    1. Ashraf N, Berry J, Shapiro JM. Can higher prices stimulate product use? Evidence from a field experiment in Zambia. Am Econ Rev. 2010;100(5):2383–2413. doi: 10.1257/aer.100.5.2383.
    1. Cohen J, Dupas P. Free distribution or cost-sharing? Evidence from a randomized malaria prevention experiment. Q J Econ. 2010;125(1):1. doi: 10.1162/qjec.2010.125.1.1.
    1. Odagiri M, Muhammad Z, Cronin AA, Gnilo ME, Mardikanto AK, Umam K, et al. Enabling factors for sustaining open defecation-free communities in rural Indonesia: a cross-sectional study. Int J Environ Res Public Health. 2017;14(12):1572. doi: 10.3390/ijerph14121572.
    1. Robinson A, Gnilo M. Sustainable Sanitation for All: Experiences, Challenges and Innovations. 2016. Promoting choice: smart finance for rural sanitation development.
    1. Robinson A, Gnilo M. Sustainable Sanitation for All: Experiences, challenges, and innovations. 2016. Beyond ODF: a phased approach to rural sanitation development; p. 155.
    1. Galvin M. Talking shit: is community-led Total sanitation a radical and revolutionary approach to sanitation? Wiley Interdiscip Rev Water. 2015;2(1):9–20. doi: 10.1002/wat2.1055.
    1. Dupas P, Hoffmann V, Kremer M, Zwane AP. Targeting health subsidies through a nonprice mechanism: a randomized controlled trial in Kenya. Science. 2016;353(6302):889–895. doi: 10.1126/science.aaf6288.
    1. Dupas P. Health behavior in developing countries. Annu Rev Econ. 2011;3(1):425–449. doi: 10.1146/annurev-economics-111809-125029.
    1. Dupas P. Getting essential health products to their end users: subsidize, but how much? Science. 2014;345(6202):1279–1281. doi: 10.1126/science.1256973.
    1. Kremer M, Holla A. What Works in Development: Thinking Big and Thinking Small. 2009. Pricing and access: lessons from randomized evaluations in education and health; pp. 91–129.
    1. Guiteras R, Levinsohn J, Mobarak AM. Encouraging sanitation investment in the developing world: a cluster-randomized trial. Science. 2015;348(6237):903–906. doi: 10.1126/science.aaa0491.
    1. Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, et al. The millennium development goals: a cross-sectoral analysis and principles for goal setting after 2015: lancet and London international development Centre commission. Lancet. 2010;376(9745):991–1023. doi: 10.1016/S0140-6736(10)61196-8.
    1. Akter T, Ali AR, Dey NC. Transition overtime in household latrine use in rural Bangladesh: a longitudinal cohort study. BMC Public Health. 2014;14(1):721. doi: 10.1186/1471-2458-14-721.
    1. Ritter M, Camille E, Velcine C, Guillaume R-K, Lantagne D. Optimizing household chlorination marketing strategies: a randomized controlled trial on the effect of price and promotion on adoption in Haiti. Am J Trop Med Hyg. 2017;97(1):271–280. doi: 10.4269/ajtmh.16-0820.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅