Achieving optimal technology and behavioral uptake of single and combined interventions of water, sanitation hygiene and nutrition, in an efficacy trial (WASH benefits) in rural Bangladesh

Abstract

BackgroundUptake matters for evaluating the health impact of water, sanitation and hygiene (WASH) interventions. Many large-scale WASH interventions have been plagued by low uptake. For the WASH Benefits Bangladesh efficacy trial, high uptake was a prerequisite. We assessed the degree of technology and behavioral uptake among participants in the trial, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.MethodsThis study is a cluster randomized trial comprised of geographically matched clusters among four districts in rural Bangladesh. We randomly allocated 720 clusters of 5551 pregnant women to individual or combined water, sanitation, handwashing, and nutrition interventions, or a control group. Behavioral objectives included; drinking chlorine-treated, safely stored water; use of a hygienic latrine and safe feces disposal at the compound level; handwashing with soap at key times; and age-appropriate nutrition behaviors (pregnancy to 24 months) including a lipid-based nutrition supplement (LNS). Enabling technologies and behavior change were promoted by trained local community health workers through periodic household visits. To monitor technology and behavioral uptake, we conducted surveys and spot checks in 30–35 households per intervention arm per month, over a 20-month period, and structured observations in 324 intervention and 108 control households, approximately 15 months after interventions commenced.ResultsIn the sanitation arms, observed adult use of a hygienic latrine was high (94–97% of events) while child sanitation practices were moderate (37–54%). In the handwashing arms, handwashing with soap was more common after toilet use (67–74%) than nonintervention arms (18–40%), and after cleaning a child’s anus (61–72%), but was still low before food handling. In the water intervention arms, more than 65% of mothers and index children were observed drinking chlorine-treated water from a safe container. Reported LNS feeding was > 80% in nutrition arms. There was little difference in uptake between single and combined intervention arms.ConclusionsRigorous implementation of interventions deployed at large scale in the context of an efficacy trial achieved high levels of technology and behavioral uptake in individual and combined WASH and nutrition intervention households. Further work should assess how to achieve similar uptake levels under programmatic conditions.Trial registrationWASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Registered on April 30, 2012.

Effectiveness of a large‐scale handwashing promotion intervention on handwashing behaviour in Dhaka, Bangladesh

“…The handwashing adherence rate in our study was lower than in the WASH Benefits Bangladesh cluster randomised trial that enrolled pregnant women in Bangladesh and promoted handwashing for>2 years afterwards . However, the WASH Benefits Bangladesh was an efficacy study where community health workers averaged six visits per month to the participants in the intervention households, and each intervention household received two handwashing stations and a regular supply of detergent sachets for making soapy water.…”

Complementary feeding practices among rural Bangladeshi mothers: Results from WASH Benefits study

“…Nevertheless, this resulted in a parallel intervention; the participants were equally likely to report improved complementary feeding and display evidence of improved WSH practices. Though the context and challenges were different than that of a large-scale programme, WASH Benefits Bangladesh provided evidence of feasibility of integrated intervention including delivery, monitoring, and evaluation Parvez et al, 2018;Rahman et al, 2018).…”

Effect of sanitation improvements on soil-transmitted helminth eggs in courtyard soil from rural Bangladesh: Evidence from a cluster-randomized controlled trial

“…Open defecation by children commonly occurs in the compound courtyard and child feces are typically disposed of unhygienically, i.e., thrown into bushes, open waste heaps and drains, or left on the ground (34). In a structured observation 9 months before our STH assessment, 84% of control-arm households and 64% of sanitation-arm households did not safely dispose of child feces (33). Hence, human feces were observed in 21% of sanitation-arm compounds and 30% of control-arm compounds at the time of our STH assessment (33).…”

“…In structured observations, adults were observed to use a hygienic latrine, defined as a latrine with a functional water seal and no feces visible on the latrine slab or floor, in 94% of the sanitation arm households and 40% of the control arm households 9 months before our STH assessment (33). However, open defecation, especially among young children, remained prevalent.…”

“…In a structured observation 9 months before our STH assessment, 84% of control-arm households and 64% of sanitation-arm households did not safely dispose of child feces (33). Hence, human feces were observed in 21% of sanitation-arm compounds and 30% of control-arm compounds at the time of our STH assessment (33). Further details of the trial design, intervention delivery and uptake assessments have been described elsewhere (33,(35)(36)(37).…”