Is the glass half full or half empty? Examining the impact of Swatch Bharat interventions on sanitation and hygiene in rural Punjab, India

Wolf J., Johnston R.B., Ambelu A., Arnold B.F., Bain R., Brauer M., Brown J., Caruso B.A., Clasen T., Colford J.M., Mills J.E., Evans B., Freeman M.C., Gordon B., Kang G., et. al.

BackgroundAssessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels.MethodsWe assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure–response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH.FindingsWe estimate that 1·4 (95% CI 1·3–1·5) million deaths and 74 (68–80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65–0·72), 0·14 (0·13–0·17) for acute respiratory infections, and 0·10 (0·09–0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH.InterpretationWASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns.FundingWHO and Foreign, Commonwealth & Development Office.

Arora N.K., Mishra I.

Augsburg B., Bancalari A., Durrani Z., Vaidyanathan M., White Z.

We implement a randomized controlled trial and a qualitative study to assess whether, and if so how, behavioral change can be sustained. We do so in the context of Pakistan’s national sanitation strategy to combat open defecation, Community-Led Total Sanitation. Our findings demonstrate that continued follow-up activities that build on the original intervention lead to only modest reductions in reversal to unsafe sanitation on average, but gain in importance where initial conditions are unfavorable, i.e. poor public infrastructure and sanitation facilities. Promotion efforts are hence best targeted towards those who face larger difficulties in constructing and maintaining high-quality sanitation. The effects were sustained at least one year after the implementation of activities. • We study the effectiveness of follow-up activities in sustaining behavior change. • Without follow-up activities, the likelihood of reverting to open defecation doubled in a 2-year period. • Continued follow-up activities lead to only modest reductions in reversal to unsafe sanitation, on average. • The effectiveness of follow-up activities are however significant where initial conditions are unfavorable. • The effects were sustained at least one year after the implementation of activities.

Pradhan N.A., Mughis W., Ali T.S., Naseem M., Karmaliani R.

Poor personal hygiene and inadequate sanitation practices among young children leads to communicable diseases. There remains a gap in the holistic assessment of school children’s hygiene literacy, practices and effectiveness of school-based hygiene interventions in Pakistan. Therefore, a school-based intervention protocol has been designed to promote personal and environmental hygiene practices for primary school children. Towards improving children’s hygiene behaviors, the study will also focus on enhancing mothers' hygiene knowledge and practices. Using quasi-experimental design with mixed methods data collection approaches, this study will be conducted in schools located in an urban squatter settlements in Pakistan. To assess primary grade children and their mothers‘ hygiene status, a survey will be held in the pre-intervention phase. This phase also includes qualitative exploration of key stakeholders (mothers, teachers, health & education authorities representatives’) perceptions about the factors facilitating and impeding the adaption of hygiene behaviors among school children. In-depth guides and focus group discussion tools will be used for this purpose. This will be followed by multi-component intervention phase with behavior change strategies to improve children‘s and mothers’ hygiene literacy and behaviors. The post-intervention phase will assess the intervention effectiveness in terms of enhancing hygiene knowledge and practices among school children and mothers, alongside exploration of mothers and teachers’ insights into whether or not the intervention has been effective in improving hygiene practices among children. Paired t-test will be applied pre and post-intervention to measure the differences between the mothers and children's hygiene literacy and knowledge scores. Similar test will be performed to assess the differences in children’s hygiene knowledge and practice scores, pre and post-intervention (< 50 = poor, 50–75 = good and > 75 = excellent). Thematic analysis will be carried out for qualitative data. Multi-component intervention aimed at improving personal and environmental hygiene among primary school children offers an opportunity to design and test various behavioral change strategies at school and in home settings. The study findings will be significant in assessing the intervention’s effectiveness in improving children‘s overall hygiene. Retrospectively registered with ClinicalTrials.gov ( NCT03942523 ) on 5th May 2019.

Vally, McMichael, Doherty, Li, Guevarra, Tobias

A school-based water, sanitation, and hygiene (WASH) intervention in the Philippines was evaluated. Students and households from four schools that received the WASH intervention (intervention schools) were compared with four schools that had not (comparison schools). Knowledge of critical handwashing times was high across all schools, but higher in intervention schools. Students reported higher rates of handwashing after toilet use (92% vs. 87%; RR = 1.06; p = 0.003) and handwashing with soap (83% vs. 60%; RR = 1.4; p < 0.001) in intervention versus comparison schools. In intervention schools, 89% of students were directly observed to handwash after toilet use versus 31% in comparison schools (RR = 2.84; p < 0.0001). Observed differences in handwashing with soap after toilet use were particularly marked (65% vs. 10%; RR = 6.5; p < 0.0001). Reported use of school toilets to defecate (as opposed to use of toilet elsewhere or open defecation) was higher among intervention versus comparison schools (90% vs. 63%; RR = 1.4; p < 0.001). Multilevel modelling indicated that students from intervention schools reported a 10-fold reduction in odds (p < 0.001) of school absence due to diarrhoea. In addition to school-based findings, self-reported handwashing at critical times was found to be higher among household members of students from intervention schools. This school-based WASH program appeared to increase knowledge and hygiene behaviours of school students, reduce absences due to diarrhoea, and increase handwashing at critical times among household members.

Giné-Garriga R., Flores-Baquero Ó., Jiménez-Fdez de Palencia A., Pérez-Foguet A.

International monitoring of drinking water and sanitation has been jointly carried out by WHO and UNICEF through their Joint Monitoring Programme (JMP). With the end of the Millennium Development Goals (MDGs) era in 2015, the JMP has proposed a post-2015 framework for integrated monitoring of water and sanitation targets included in the Sustainable Development Goal no. 6. This article discusses how each element of the proposed sanitation target and corresponding indicators can be understood from a human rights perspective. Building on the MDGs, and although some of the weaknesses and gaps persist, the discussion suggests that the post-2015 proposal is a step forward towards a monitoring framework where human rights elements related to sanitation are effectively promoted. In addition, to support the interpretation and implementation of the normative content of human rights obligations related to sanitation, the study proposes a reduced set of easy-to-assess indicators to measure the normative criteria of this right, which are then grouped in a multidimensional framework to describe increasing levels of sanitation service. To do this, the study combines literature review and specific local experience from three case studies. It is shown that the proposed monitoring tools, namely the indicators and the multidimensional indicator framework, provide guidance on monitoring the human right to sanitation. In doing so, they might ultimately help sector stakeholders in the realization of this right.

Crocker J., Abodoo E., Asamani D., Domapielle W., Gyapong B., Bartram J.

We used a cluster-randomized field trial to evaluate training natural leaders (NLs) as an addition to a community-led total sanitation (CLTS) intervention in Ghana. NLs are motivated community members who influence their peers' behaviors during CLTS. The outcomes were latrine use and quality, which were assessed from surveys and direct observation. From October 2012, Plan International Ghana (Plan) implemented CLTS in 60 villages in three regions in Ghana. After 5 months, Plan trained eight NLs from a randomly selected half of the villages, then continued implementing CLTS in all villages for 12 more months. The NL training led to increased time spent on CLTS by community members, increased latrine construction, and a 19.9 percentage point reduction in open defecation (p < 0.001). The training had the largest impact in small, remote villages with low exposure to prior water and sanitation projects, and may be most effective in socially cohesive villages. For both interventions, latrines built during CLTS were less likely to be constructed of durable materials than pre-existing latrines, but were equally clean, and more often had handwashing materials. CLTS with NL training contributes to three parts of Goal 6 of the Sustainable Development Goals: eliminating open defecation, expanding capacity-building, and strengthening community participation.

Pickering A.J., Djebbari H., Lopez C., Coulibaly M., Alzua M.L.

Community-led total sanitation (CLTS) uses participatory approaches to mobilise communities to build their own toilets and stop open defecation. Our aim was to undertake the first randomised trial of CLTS to assess its effect on child health in Koulikoro, Mali.We did a cluster-randomised trial to assess a CLTS programme implemented by the Government of Mali. The study population included households in rural villages (clusters) from the Koulikoro district of Mali; every household had to have at least one child aged younger than 10 years. Villages were randomly assigned (1:1) with a computer-generated sequence by a study investigator to receive CLTS or no programme. Health outcomes included diarrhoea (primary outcome), height for age, weight for age, stunting, and underweight. Outcomes were measured 1·5 years after intervention delivery (2 years after enrolment) among children younger than 5 years. Participants were not masked to intervention assignment. The trial is registered with ClinicalTrials.gov, number NCT01900912.We recruited participants between April 12, and June 23, 2011. We assigned 60 villages (2365 households) to receive the CLTS intervention and 61 villages (2167 households) to the control group. No differences were observed in terms of diarrhoeal prevalence among children in CLTS and control villages (706 [22%] of 3140 CLTS children vs 693 [24%] of 2872 control children; prevalence ratio [PR] 0·93, 95% CI 0·76-1·14). Access to private latrines was almost twice as high in intervention villages (1373 [65%] of 2120 vs 661 [35%] of 1911 households) and reported open defecation was reduced in female (198 [9%] of 2086 vs 608 [33%] of 1869 households) and in male (195 [10%] of 2004 vs 602 [33%] of 1813 households) adults. Children in CLTS villages were taller (0·18 increase in height-for-age Z score, 95% CI 0·03-0·32; 2415 children) and less likely to be stunted (35% vs 41%, PR 0·86, 95% CI 0·74-1·0) than children in control villages. 22% of children were underweight in CLTS compared with 26% in control villages (PR 0·88, 95% CI 0·71-1·08), and the difference in mean weight-for-age Z score was 0·09 (95% CI -0·04 to 0·22) between groups. In CLTS villages, younger children at enrolment (

de Boer M.R., Waterlander W.E., Kuijper L.D., Steenhuis I.H., Twisk J.W.

According to the CONSORT statement, significance testing of baseline differences in randomized controlled trials should not be performed. In fact, this practice has been discouraged by numerous authors throughout the last forty years. During that time span, reporting of baseline differences has substantially decreased in the leading general medical journals. Our own experience in the field of nutrition behavior research however, is that co-authors, reviewers and even editors are still very persistent in their demand for these tests. The aim of this paper is therefore to negate this demand by providing clear evidence as to why testing for baseline differences between intervention groups statistically is superfluous and why such results should not be published. Testing for baseline differences is often propagated because of the belief that it shows whether randomization was successful and it identifies real or important differences between treatment arms that should be accounted for in the statistical analyses. Especially the latter argument is flawed, because it ignores the fact that the prognostic strength of a variable is also important when the interest is in adjustment for confounding. In addition, including prognostic variables as covariates can increase the precision of the effect estimate. This means that choosing covariates based on significance tests for baseline differences might lead to omissions of important covariates and, less importantly, to inclusion of irrelevant covariates in the analysis. We used data from four supermarket trials on the effects of pricing strategies on fruit and vegetables purchases, to show that results from fully adjusted analyses sometimes do appreciably differ from results from analyses adjusted for significant baseline differences only. We propose to adjust for known or anticipated important prognostic variables. These could or should be pre-specified in trial protocols. Subsequently, authors should report results from the fully adjusted as well as crude analyses, especially for dichotomous and time to event data. Based on our arguments, which were illustrated by our findings, we propose that journals in and outside the field of nutrition behavior actively adopt the CONSORT 2010 statement on this topic by not publishing significance tests for baseline differences anymore.

Senn S.

I consider seven misunderstandings that may be encountered about the nature, purpose and properties of randomisation in clinical trials. Some concern the practical realities of clinical research on patients. Others are to do with the value and purpose of balance. Still others are to do with a confusion about the role of conditioning in valid statistical inference. I consider a simple game of chance involving two dice to illustrate some points about inference and then consider the seven misunderstandings in turn. I conclude that although one should not make a fetish of randomisation, when proposing alternatives to randomisation in clinical trials, one should be very careful to be precise about the exact nature of the alternative being considered if one is to avoid the danger of underestimating the advantages that randomisation can offer.

McKenzie D.

The vast majority of randomized experiments in economics rely on a single baseline and single follow-up survey. While such a design is suitable for study of highly autocorrelated and relatively precisely measured outcomes in the health and education domains, it is unlikely to be optimal for measuring noisy and relatively less autocorrelated outcomes such as business profits, and household incomes and expenditures. Taking multiple measurements of such outcomes at relatively short intervals allows one to average out noise, increasing power. When the outcomes have low autocorrelation and budget is limited, it can make sense to do no baseline at all. Moreover, I show how for such outcomes, more power can be achieved with multiple follow-ups than allocating the same total sample size over a single follow-up and baseline. I also highlight the large gains in power from ANCOVA analysis rather than difference-in-differences analysis when autocorrelations are low.

Imbens G.W., Wooldridge J.M.

Many empirical questions in economics and other social sciences depend on causal effects of programs or policies. In the last two decades, much research has been done on the econometric and statistical analysis of such causal effects. This recent theoretical literature has built on, and combined features of, earlier work in both the statistics and econometrics literatures. It has by now reached a level of maturity that makes it an important tool in many areas of empirical research in economics, including labor economics, public finance, development economics, industrial organization, and other areas of empirical microeconomics. In this review, we discuss some of the recent developments. We focus primarily on practical issues for empirical researchers, as well as provide a historical overview of the area and give references to more technical research.

Anderson M.L.

Duflo E., Glennerster R., Kremer M.

This paper is a practical guide (a toolkit) for researchers, students and practitioners wishing to introduce randomization as part of a research design in the field. It first covers the rationale for the use of randomization, as a solution to selection bias and a partial solution to publication biases. Second, it discusses various ways in which randomization can be practically introduced in a field settings. Third, it discusses designs issues such as sample size requirements, stratification, level of randomization and data collection methods. Fourth, it discusses how to analyze data from randomized evaluations when there are departures from the basic framework. It reviews in particular how to handle imperfect compliance and externalities. Finally, it discusses some of the issues involved in drawing general conclusions from randomized evaluations, including the necessary use of theory as a guide when designing evaluations and interpreting results.

David L.K., Wang M.J., Brooks W., Angel V.

Seth P., Pingali P.

Background Open defecation (OD) remains a significant public health challenge in India, contributing to adverse child health outcomes. Eliminating OD and improving child health necessitates both universal access and adoption of toilets. Despite the success of removing credit constraints and enhancing access to subsidized toilets through national sanitation campaigns, the adoption of these toilets is still lagging in India. This is because households might also be lacking information about the benefits of using toilets (information constraint). Methods In this paper, we test for the joint efficacy of the removal of information and credit constraints versus solely addressing the credit constraint at eliminating OD, based on a cluster randomized control trial in rural India. We implemented two interventions: a universal community-led behavior change campaign along with subsidized construction of individual household toilets for every household that opted for subsidy (cluster A) and only subsidized construction of individual household toilet construction for every household that opted for the subsidy (cluster B). No behavior change was provided in cluster B. The control group did not receive any intervention. Results We find that the removal of information and credit constraints at a near-universal level in cluster A resulted in improved toilet access and adoption, eliminating OD at the community level, with a significant gain in child weight-for-age z-scores (WAZ scores). There was an increase in the percentage of households that owned individual household toilets from 2% to 98% and a decline in female respondents practicing OD from 98% to 4% in cluster A. In cluster B, ownership of individual household toilets improved by 78 percentage points (from 6% to 84%), but OD decreased by only 45 percentage points (from 95% to 50%) for the respondents. The control group saw no significant changes. For children under five, there was a statistically significant increase in WAZ scores by 0.68-0.69 standard deviations in cluster A, while cluster B showed insignificant changes when compared to the control group. Conclusions The study implies that supplementing universal financial support with community-level information intervention enhances sustainable adoption of improved sanitation facilities, aiding India’s progress towards an open defecation-free nation and improving child health outcomes.

Augsburg B., Foster A., Johnson T., Lipscomb M.

Governments face trade-offs in investing in many different inputs to markets in an effort to make them function more smoothly, and often these inputs are managed by bureaucrats with their own priorities. Many of these markets are acutely dependent on all elements of the system functioning well in order to reach a reasonably high level of equilibrium provision (education, public works, infrastructure, etc). In sanitation markets in particular, failure at any level of the supply chain creates downstream effects. In addition, local demand depends on enforcement, education, and spatial correlation. We provide a weakest link theory of agent choices for sanitation markets that demonstrates the difficulties of decentralized decision making and suggests key implications for policy implementation. The theory demonstrates that while the welfare implications of improvements in overall sanitation are substantial, incremental changes in one area may have little to no impact on overall sanitation provision. Our model provides context for thinking about lessons the sanitation literature provides in terms of policy and investment.