Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
University of Pennsylvania, Philadelphia, PA, USA.
Int J Equity Health. 2021 Jan 6;20(1):16. doi: 10.1186/s12939-020-01353-7.
Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.
The current analysis selected 4 indicators from the WASH Benefits trial- presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.
For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (- 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, - 25% (- 35, - 15) Q2: - 34% (- 44, - 23%)] than the wealthiest household [Q5 DID: - 1% (- 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1-4 DID: 50-54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).
By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.
WASH Benefits Bangladesh: ClinicalTrials.gov , identifier: NCT01590095 . Date of registration: April 30, 2012 'Retrospectively registered'.
供应驱动型项目如果与社区需求没有紧密联系，而需求驱动型项目未能确保供应，两者都有可能加剧不平等。在理想的实验条件下，了解最贫困人群中行为的采用模式，例如在功效试验中，可以帮助确定在常规规划条件下可以加强哪些策略，以实现更公平的采用。WASH Benefits Bangladesh 是一项随机对照功效试验，为 WASH 硬件提供免费，并同时进行行为改变促进。本论文旨在确定在消除供应和需求限制的情况下，不同财富和教育水平的人对手卫生和卫生设施行为的采用情况。
本分析从 WASH Benefits 试验中选择了 4 个指标 - 家庭洗手站中是否存在水和肥皂、观察到母亲的手部清洁度、观察到厕所石板或地板上是否有可见粪便、以及报告上次儿童在便盆或厕所中排便。在登记后立即进行基线评估，大约 2 年后进行终点评估。我们比较了干预组和对照组在基线到终点之间，这 4 个指标（包括财富五分位数（Q））的采用情况的变化。
在手清洁度方面，最贫困的母亲的改善程度更大 [Q1 差异的差异，DID：16%（7，25%）]，而最富有的母亲则改善程度较小 [Q5 DID：7%（-4，17%）]。最贫困的家庭在手洗站中观察到水和肥皂的存在的改善最大 [Q1 DID：82%（75，90%）]，而最富有的家庭则改善较小 [Q5 DID：39%（30，50%）]。同样，较贫穷的家庭在厕所石板或地板上观察到的可见粪便减少更多 [Q1 DID，-25%（-35，-15）；Q2：-34%（-44，-23%）]，而最富有的家庭则减少较少 [Q5 DID：-1%（-11，8%）]。对于报告的最后一次儿童在便盆或厕所中排便，最贫困的母亲的改善程度更大 [Q1-4 DID：50-54%（44，60%）]，而最富有的母亲则改善较小 [Q5 DID：39%（31，46%）]。
通过同时解决最贫困人群的供应和需求限制，我们观察到公平性有了实质性的整体改善。在扩大的项目中，针对最贫困人群的单独有针对性的策略可以提高项目的公平性。
WASH Benefits Bangladesh：ClinicalTrials.gov，标识符：NCT01590095。注册日期：2012 年 4 月 30 日，“回溯注册”。
