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BackgroundUptake matters for evaluating the health impact of water, sanitation and hygiene (WASH) interventions. Many large-scale WASH interventions have been plagued by low uptake. For the WASH Benefits Bangladesh efficacy trial, high uptake was a prerequisite. We assessed the degree of technology and behavioral uptake among participants in the trial, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.MethodsThis study is a cluster randomized trial comprised of geographically matched clusters among four districts in rural Bangladesh. We randomly allocated 720 clusters of 5551 pregnant women to individual or combined water, sanitation, handwashing, and nutrition interventions, or a control group. Behavioral objectives included; drinking chlorine-treated, safely stored water; use of a hygienic latrine and safe feces disposal at the compound level; handwashing with soap at key times; and age-appropriate nutrition behaviors (pregnancy to 24 months) including a lipid-based nutrition supplement (LNS). Enabling technologies and behavior change were promoted by trained local community health workers through periodic household visits. To monitor technology and behavioral uptake, we conducted surveys and spot checks in 30-35 households per intervention arm per month, over a 20-month period, and structured observations in 324 intervention and 108 control households, approximately 15 months after interventions commenced.ResultsIn the sanitation arms, observed adult use of a hygienic latrine was high (94-97% of events) while child sanitation practices were moderate (37-54%). In the handwashing arms, handwashing with soap was more common after toilet use (67-74%) than nonintervention arms (18-40%), and after cleaning a child's anus (61-72%), but was still low before food handling. In the water intervention arms, more than 65% of mothers and index children were observed drinking chlorine-treated water from a safe container. Reported LNS feeding was > 80% in nutrition arms. There was little difference in uptake between single and combined intervention arms.ConclusionsRigorous implementation of interventions deployed at large scale in the context of an efficacy trial achieved high levels of technology and behavioral uptake in individual and combined WASH and nutrition intervention households. Further work should assess how to achieve similar uptake levels under programmatic conditions.Trial registrationWASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095 . Registered on April 30, 2012.

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Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations – a dedicated, convenient location where both soap and water are available for handwashing – are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Methods: We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs. Results: Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials. Conclusions: A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework. [ABSTRACT FROM AUTHOR]

Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)