WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial

Leanne Unicomb,Mahbubur Rahman,Kaniz Jannat,Farzana Begum,Peter J Winch,Fosiul A Nizame,Sania Ashraf,Moshammot Mobashara,Faruqe Hussain,Sarker Masud Parvez,Stephen P Luby,Elli Leontsini,Abu Mohd Naser,Shaila Arman

doi:10.1186/s13063-018-2709-1

Abstract

BackgroundWater, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.MethodsCommunity Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2–2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study.ResultsSufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers.ConclusionsThe intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness.Trial registrationClinicalTrials.gov, ID: NCC01590095. Registered on 2 May 2012.

Highlights

Introduction of choleraPopulation; 240,000 vaccine in Bangladesh3 Location: urban slums, DhakaDuration: 2011–2013 (2-year intervention exposure)1:290 community health workers (CHWs); N = 55CHW oversight Single NGO with close project staff involvement, ~ 16 CHWs/supervisor Training Delivered by NGO, developed by project staff Dissemination: NGO-hired CHWs from the local community-delivered interpersonal communications
In this paper we describe both the intervention delivery system necessary to achieve the high level of uptake, and the difficulties encountered during intervention delivery and how they were addressed
For intervention uptake we draw a distinction between actions taken by CHWs to achieve behavioural versus technology uptake and further divide these between optimal and routine uptake to illustrate the differences in CHW-delivered interventions (Table 2)

Summary

Introduction

Sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. WASH efficacy studies typically examine the effects of specific WASH technologies and behaviors on outcomes of interest in order to inform their subsequent inclusion in routine programs (Table 1). CHWs deliver different combinations of WASH interventions to the target population under optimal or ideal conditions (Table 1). To examine how to achieve high uptake of WASH interventions under near real-world and real-world conditions, researchers build on outcomes from efficacy research and conduct effectiveness research and implementation research (Tables 1 and 2)

Methods

Results

Discussion

Conclusion