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Randomized Controlled Trial
. 2018 Jul 6;19(1):359.
doi: 10.1186/s13063-018-2709-1.

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

Leanne Unicomb  1 , Farzana Begum  2 , Elli Leontsini  3 , Mahbubur Rahman  2 , Sania Ashraf  3 , Abu Mohd Naser  4 , Fosiul A Nizame  2 , Kaniz Jannat  2 , Faruqe Hussain  2 , Sarker Masud Parvez  2 , Shaila Arman  2 , Moshammot Mobashara  2 , Stephen P Luby  5 , Peter J Winch  3
Affiliations
Randomized Controlled Trial

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

Leanne Unicomb et al. Trials. .

Abstract

Background: Water, 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.

Methods: Community 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.

Results: Sufficient 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.

Conclusions: The 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 registration: ClinicalTrials.gov, ID: NCC01590095 . Registered on 2 May 2012.

Keywords: Bangladesh; Behaviour change; Child nutrition; Handwashing; Intervention delivery; Sanitation; WASH Benefits trial; Water.

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Conflict of interest statement

Ethics approval and consent to participate

All households provided written informed consent at enrollment. The protocol was reviewed and approved by human subjects review committees at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and at the University of California, Berkeley. The WASH Benefits trial was registered at ClinicalTrials.gov (NCT01590095).

Consent for publication

All co-authors have reviewed this version of the manuscript and provided consent for manuscript submission.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Location of the WASH Benefits Bangladesh Study. a A map of Bangladesh showing districts in which the WASH Benefits study was conducted; Tangail (blue), Gazipur (green), Kishoreganj (pink) and Mymensingh (yellow). b WASH Benefits study clusters (indicated with black dots) within the four districts
Fig. 2
Fig. 2
WASH Benefits Bangladesh trial blocks. Each trial block comprised six intervention and two control clusters, each of 6 to 8 households with a pregnant woman (at enrollment) with 1 km buffer between consecutive clusters; W water treatment and safe storage, S sanitation, H handwashing, N nutrition, C control, WSH water treatment + sanitation + handwashing, N + WSH nutrition + water treatment + sanitation + handwashing
Fig. 3
Fig. 3
Organizational chart for the Bangladesh WASH Benefits study. 1DSMB; Data Safety Management Board; 2Technical Advisory Group, comprised members with expertise in anthropology, behavior change, biostatistics, child development, epidemiology, immunology, nutrition, parasitology, and WASH, from Emory University, Innovations for Poverty Action; International Centre for Diarrhoeal Disease Research, Bangladesh; Johns Hopkins Bloomberg School of Public Health; London School of Hygiene and Tropical Medicine; Stanford University; State University of New York; University of California, Davis; University of California, Berkeley; and the Bill & Melinda Gates Foundation; 3Village Education Resource Center (www.vercbd.org) 4installation of all hardware except latrines
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