Bertha Briceno

Optimal Recall Period for Caregiver-reported Illness in Risk Factor and Intervention Studies: A Multicountry Study

Many community-based studies of acute child illness rely on cases reported by caregivers. In prior investigations, researchers noted a reporting bias when longer illness recall periods were used. The use of recall periods longer than 2-3 days has been discouraged to minimize this reporting bias. In the present study, we sought to determine the optimal recall period for illness measurement when accounting for both bias and variance. Using data from 12,191 children less than 24 months of age collected in 2008-2009 from Himachal Pradesh in India, Madhya Pradesh in India, Indonesia, Peru, and Senegal, we calculated bias, variance, and mean squared error for estimates of the prevalence ratio between groups defined by anemia, stunting, and underweight status to identify optimal recall periods for caregiver-reported diarrhea, cough, and fever. There was little bias in the prevalence ratio when a 7-day recall period was used (<10% in 35 of 45 scenarios), and the mean squared error was usually minimized with recall periods of 6 or more days. Shortening the recall period from 7 days to 2 days required sample-size increases of 52%-92% for diarrhea, 47%-61% for cough, and 102%-206% for fever. In contrast to the current practice of using 2-day recall periods, this work suggests that studies should measure caregiver-reported illness with a 7-day recall period.

Institutionalisation of government evaluation: balancing trade-offs

Carefully designed and implemented evaluations can improve peoples welfare and enhance development effectiveness. This paper investigates institutions in Mexico, Chile, and Colombia, and shows that for the successful inception of an institutionalised system for evaluation, three common factors stand out: the existence of a democratic system with a vocal opposition, the existence of influential monitoring and evaluation (M&E) champions to lead the process, and a clear powerful stakeholder. Mexicos CONEVAL is the most independent of the three bodies, mainly due to the fact that it is reporting to an executive board of independent academics; Chiles Dipres is the best placed in terms of enforcement, with its location within the Ministry of Finance and control of an independent budget; and Colombias SINERGIA helps promote a culture of utilisation of evaluations as a project management tool. However, actual usage of M&E information and the resulting effect upon development effectiveness are the benchmarks of success. The paper concludes that an explicit and thoughtful process of assessing the needs, the focus, and the emphasis of the system should serve officials and champions to identify adequate arrangements for the particular country context and understand how to better respond to the forces pushing for the creation of new M&E units and bodies.

A randomized, controlled study of a rural sanitation behavior change program in Madhya Pradesh, India

Poor sanitation and open defecation are thought to be a major cause of diarrhea and intestinal parasite infections among young children. In 1999, India launched the Total Sanitation Campaign with the goal of achieving universal toilet coverage in rural India by 2012. This paper reports on a cluster-randomized, controlled trial that was conducted in 80 rural villages in Madhya Pradesh to measure the effect of the program on toilet access, sanitation behavior, and child health outcomes. The study analyzed a random sample of 3,039 households and 5,206 children under five years of age. Field staff collected baseline measures of sanitation conditions, behavior, and child health, and re-visited households 21 months later. The analysis finds that implementation of the program activities was slower than the original timeline (only 35 percent of villages were triggered more than six months before the follow-up survey). Nevertheless, the Total Sanitation Campaign successfully increased toilet coverage by 19 percent in intervention villages compared with control villages (41 percent v. 22 percent), while reported open defecation decreased by 10 percent among adults (74 percent v. 84 percent). The intervention also led to some improvements in water quality and protozoan infection, but consistent improvements were not observed across multiple child health outcomes (diarrhea, helminth infections, child growth). However, the exposure period was likely to have been too short to result in any benefit of the sanitation interventions on child health. Given the large improvements in toilet construction documented, an additional follow-up survey with a longer period of exposure would yield valuable information on the effects of improved sanitation conditions on health outcomes.

Behind the Scenes : Experience Managing and Conducting Large Impact Evaluations in Colombia

As more resources are being allocated to impact evaluation of development programmes, the need to map out the utilisation and influence of evaluations has been increasingly highlighted. This paper aims at filling this gap by describing and discussing experiences from four large impact evaluations in Colombia on case- study basis. On the basis of learning from our prior experience in both managing and conducting impact evaluations, desk review of available documentation from the monitoring and evaluation system, and structured interviews with government actors, evaluators and programme managers, we benchmark each evaluation against 11 standards of quality. From this benchmarking exercise, we derive five key lessons for conducting high-quality and influential impact evaluations: investing in preparation of good terms of reference and identification of evaluation questions; choosing the best methodological approach to address the evaluation questions; adopting mechanisms to ensure evaluation quality; laying out the incentives for involved parties in order to foster evaluation buy-in; and carrying out a plan for quality dissemination.

Are there synergies from combining hygiene and sanitation promotion campaigns: Evidence from a large-scale cluster-randomized trial in rural Tanzania

Summary The current evidence on handwashing and sanitation programs suggests limited impacts on health when at-scale interventions have been tested in isolation. However, no published experimental evidence currently exists that tests the interaction effects between sanitation and handwashing. We present the results of two large-scale, government-led handwashing and sanitation promotion campaigns in rural Tanzania, with the objective of tracing the causal chain from hygiene and sanitation promotion to changes in child health outcomes and specifically testing for potential interaction effects of combining handwashing and sanitation interventions. Methods The study is a factorial cluster-randomized control trial where 181 rural wards from 10 districts in Tanzania were randomly assigned to receive sanitation promotion, handwashing promotion, both interventions together or neither (control). Interventions were rolled out from February 2009 to June 2011 and the endline survey was conducted from May to November 2012, approximately one year after program completion. The sample was composed of households with children under 5 years old in the two largest villages in each ward. Masking was not possible due to the nature of the intervention, but enumerators played no part in the intervention and were blinded to treatment status. The primary outcome of interest was 7-day diarrhea prevalence for children under five. Intermediate outcomes of behavior change including improved latrine construction, levels of open defecation and handwashing with soap were also analyzed. Secondary health outcomes included anemia, height-for-age and weight-for-age of children under 5. An intention-to-treat analysis was used to assess the relationship between the interventions and outcomes of interest. Findings One year after the end of the program, ownership of improved latrines increased from 49.7% to 64.8% (95% CI 57.9%-71.7%) and regular open defecation decreased from 23.1% to 11.1% (95% CI 3.5%-18.7%) in sanitation promotion-only wards. Households in handwashing promotion-only wards showed marginal improvements in handwashing behavior related to food preparation but not at other critical junctures. There were no detectable interaction effects for the combined intervention. The associated cost-per-household gaining access to improved sanitation is estimated to be USD

The effect of India’s total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh : a cluster randomized controlled trial

194. Final effects on child health measured through diarrhea, anemia, stunting and wasting were absent in all treatment groups. Interpretation Although statistically significant, the changes in intermediate outcomes achieved through each intervention in isolation were not large enough to generate meaningful health impacts. With no observable signs of interaction, the combined intervention produced similar results. The study highlights the importance of focusing on intermediate outcomes of take up and behavior change as a critical first step in large-scale programs before realizing the changes in health that sanitation and hygiene interventions aim to deliver. Trial registration Clinicaltrials.gov NCT01465204