Claire Chase

Animal Feces Contribute to Domestic Fecal Contamination: Evidence from E. coli Measured in Water, Hands, Food, Flies, and Soil in Bangladesh

Fecal-oral pathogens are transmitted through complex, environmentally mediated pathways. Sanitation interventions that isolate human feces from the environment may reduce transmission but have shown limited impact on environmental contamination. We conducted a study in rural Bangladesh to (1) quantify domestic fecal contamination in settings with high on-site sanitation coverage; (2) determine how domestic animals affect fecal contamination; and (3) assess how each environmental pathway affects others. We collected water, hand rinse, food, soil, and fly samples from 608 households. We analyzed samples with IDEXX Quantitray for the most probable number (MPN) of E. coli. We detected E. coli in source water (25%), stored water (77%), child hands (43%), food (58%), flies (50%), ponds (97%), and soil (95%). Soil had >120 000 mean MPN E. coli per gram. In compounds with vs without animals, E. coli was higher by 0.54 log10 in soil, 0.40 log10 in stored water and 0.61 log10 in food (p < 0.05). E. coli in stored water and food increased with increasing E. coli in soil, ponds, source water and hands. We provide empirical evidence of fecal transmission in the domestic environment despite on-site sanitation. Animal feces contribute to fecal contamination, and fecal indicator bacteria do not strictly indicate human fecal contamination when animals are present.

Handwashing Behavior Change at Scale: Evidence from a Randomized Evaluation in Vietnam

This brief summarizes the results of a gender impact evaluation study, entitled Hand washing behavior change at scale : evidence from a randomized evaluation in Vietnam, conducted in 2010 in Vietnam. The study evaluates a large-scale hand washing campaign in three provinces of Vietnam on the household level. The program did not have an impact on hand washing with soap behavior. Knowledge about the correct way to wash was high at baseline, and some areas of knowledge improved, but it did not have an impact on the already high access to soap within households and modest effects on the self-reported hand washing behavior of mothers. Observed hand washing behaviors remained very low; mostly caregivers wash their hands with water only. Funding for the study derived from the Bill and Melinda Gates Foundation.

Malaria eradication and economic outcomes in sub-Saharan Africa: Evidence from Uganda☆

This study evaluates the economic consequences of a 1959-1960 malaria eradication campaign in southwestern Uganda. The effort constitutes a rare, large-scale, and well-documented attempt to eliminate malaria in sub-Saharan Africa and produced an immediate disease reduction. We use this quasi-experimental health shock to identify long-term changes in educational and economic outcomes. Comparing the treatment district to a similar synthetic control, we find malaria eradication raised educational attainment by about a half year for both males and females, increased primary school completion among females and generated an almost 40% rise in the likelihood of male wage employment.

Cost-efficiency of rural sanitation promotion : activity-based costing and experimental evidence from Tanzania

This paper applies cost-efficiency analysis to an intervention that promotes behaviour change for rural sanitation in Tanzania. The campaign targets a number of potential beneficiaries, out of which some are effectively encouraged to adopt the new practices (beneficiaries). As a result, the cost-efficiency of the programme depends on the extent of take-up of improved sanitation by the target population, unknown in advance. To correctly account for the costs of households gaining access under this demand-driven approach, both costs (investments) and increased access to sanitation are considered outcomes and are estimated from samples of beneficiary and control populations, using a randomised-controlled trial design. Results show that sanitation promotion did not lead to higher investment relative to the control group and that the cost-per-person effectively gaining access to sanitation is substantially higher than the cost-per-person targeted or at-reach of the campaign. Using these estimates, the authors found that universal coverage can be obtained for the equivalent of 4 per cent of Tanzania’s national GDP (2013). They also used parameters estimated from the study to simulate cost-per-person of the programme when take-up increases (efficiency gains).

Addressing the behavioural constraints to latrine uptake: effectiveness of a behaviour-change campaign in rural Cambodia

Cambodia has the lowest coverage of improved water and sanitation facilities in South-east Asia. Research suggests that rural Cambodians prefer a high-quality latrine over one provided for free. Market-based approaches are often used to increase sanitation coverage, but private operators lack sufficient incentives and resources to stimulate demand among households that are not immediately responsive to sales events. This study assessed the effectiveness of a Behaviour Change Communications (BCC) intervention designed to address behavioural factors that may limit uptake of latrines. The study applies a quasi-experimental matching technique to estimate the causal effect of the intervention on latrine uptake in rural areas. Communes that received both the BCC intervention and sanitation marketing were matched to similar communes where only sanitation marketing was carried out. Multivariate linear regression analysis is used to estimate the impact of the BCC intervention on latrine uptake. Results show that l...

Do Sanitation Improvements Reduce Fecal Contamination of Water, Hands, Food, Soil, and Flies? Evidence from a Cluster-Randomized Controlled Trial in Rural Bangladesh

Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial’s control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, Escherichia coli prevalence in stored drinking water was reduced by 62% (prevalence ratio = 0.38 (0.32, 0.44)) and E. coli concentration by 1-log (Δlog10 = −0.88 (−1.01, −0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include noncommunity-level sanitation coverage, child open defecation, animal fecal sources, or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.

Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh

Enteric pathogens can be transmitted through multiple environmental pathways, yet little is known about the relative contribution of each pathway to diarrhea risk among children. We aimed to identify fecal transmission pathways in the household environment associated with prospectively measured child diarrhea in rural Bangladesh. We measured the presence and levels of Escherichia coli in tube wells, stored drinking water, pond water, child hand rinses, courtyard soil, flies, and food in 1843 households. Gastrointestinal symptoms among children ages 0–60 months were recorded concurrently at the time of environmental sample collection and again a median of 6 days later. Incident diarrhea (3 or more loose stools in a 24-h period) was positively associated with the concentration of E. coli on child hands measured on the first visit (incidence rate ratio [IRR] = 1.23, 95% CI 1.06, 1.43 for a log10 increase), while other pathways were not associated. In cross-sectional analysis, there were no associations between concurrently measured environmental contamination and diarrhea. Our findings suggest higher levels of E. coli on child hands are strongly associated with subsequent diarrheal illness rates among children in rural Bangladesh.

Trade-Offs and Risks in Results-Based Approaches

The growth in results-based approaches (RBA) to development financing is motivated by the underlying assumption that these approaches will incentivize implementing agencies to more closely align their actions and exert more focused effort on achieving the objectives of the program that have been agreed upon by the recipient and donor. At the same time RBAs strengthen accountability of both recipient and donor, by generating objective evidence that the agreed upon results have been achieved. But it should not necessarily be taken for granted that they are a more efficient approach to development just because payments are tied to results. If donor and government objectives are misaligned, RBA can help focus government actions towards a clear target that they may not otherwise focus on, but this comes with a shift in the risk burden towards the government agency, which is likely to come with an implicit risk premium.