Abstract
BackgroundUnimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia.MethodsTogether with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes.DiscussionWhile CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond.Trial registrationThis trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.
Highlights
Unimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being
We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to community-led total sanitation and hygiene (CLTSH) and inform sanitation and hygiene programming and policy in Ethiopia and beyond
Over one billion people are at risk of soil-transmitted helminthiasis, which leads to nearly five million disability adjusted life years (DALYs), and schistosomiasis leads to a further two million DALYs [10, 11]
Summary
Trial design Emory University and its consortium partners are conducting a two-year impact evaluation, designed as an ex-ante two-arm, parallel CRT. Study household inclusion criteria for the Andilaye Trial included any household randomly selected from the gott census book residing in the target gott(s) that: (1) had at least one child aged 1–9 years at baseline (i.e., the study’s index children) and consented to allowing study staff to observe the children, their faces and hands, and (2) provided consent to participate in the study, with at least one adult household member consenting to serve as the primary survey respondent. 38% of respondents’ primary place of defecation during the 2 days prior to survey administration was in the open, and only 46% of respondents had defecated in any latrine during the two-day reporting period These statistics, along with the fact that 39 of 50 kebele clusters randomly selected for inclusion in the Andilaye Trial have been triggered with CLTSH, and certified ODF, provide strong evidence that behavioral slippage is, an issue that needs to be addressed in Amhara and perhaps elsewhere in Ethiopia. We have performed such analyses in other studies [54, 55]
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