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Monitoring Impacts of WASH Interventions in
Bangladesh, the Health Impact Study “Sanitation, Hygiene education, and Water supply intervention in rural
Bangladesh” (SHEWA-B)
1
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
2
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
3
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
4
Intervention
areas of
SHEWA-B
5
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
6
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
7
Washing both hands with soap/ash
52 51
3430
30
40
50
60
Pe
rce
nta
ge
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
ge
s
Washing both hands with soap/ash-Observed
Data in next slide is not matching!
36
3035
40
45
50
Pe
rce
nta
ge
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
rce
nta
ge
s
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
17
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
6
7
8
9
10
Pe
rce
nta
ge
s
Intervention Baseline Intervention Midline
Control Baseline Control Midline
Target
11
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
rce
nta
ge
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
rce
nta
ge
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
13
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
14
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.
15
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.
16
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?
17
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