Feasibility Trial : Intervention Design & Findings Improving Handwashing with Soap and Complementary Feeding Brownbag , May 30, 2012 FHI360 SUMITRO ROY Deputy Country Director, A&T Bangladesh May 30, 2012
Feasibility Trial : Intervention Design & Findings Improving Handwashing with Soap and
Complementary Feeding
Brownbag , May 30, 2012FHI360
SUMITRO ROYDeputy Country Director, A&T Bangladesh
May 30, 2012
Jean Baker (Introduction)
Sumitro Roy(Presenter)
Overview
• Study timeline• Methodology• Intervention related findings from pre
assessment• Intervention • Results : TIPs• Timeline• Acknowledgement
3
Study timeline
Pre-assessment :
To inform integrated
intervention development
Designing of intervention:
Handwashing into Infant and Young Child
Feeding
Trials of Improved Practices (TIPs)
Qualitative Quantitative
Qualitative Quantitative
Dec 2010 to Feb 2011
March to June 2011
Sept 2011 to Jan 2012
4
Population for study
• Three pre-selected rural districts
• Representative sample from these districts
• Sampling method used for qualitative & quantitative study
5
MANIKGONJ
DINAJPUR
CHITTAGONG
Selecting communities
3 districts
5 Upazilas1 Manikgonj2 Dinajpur
2 Chittagong
10 unions (2 each upazila)
Exclude -A&T upazilas -<10 villages
6
Selecting Villages
10 unions (2 each upazila)
70 villages (7 each union)
50 villages- baseline15 villages- structure
obs.
20 villagesIntervention (TIPs)
7
Intervention related findings from pre assessment
8
Qualitative Findings:
• Child eats same family foods usually
• Mothers take the decision regarding child food
• Most respondents relate the child food contamination with the dust/dirt
• A good portion of people have handwashing knowledge, but this did not translate into practice
• Observed data showed that caregivers occasionally wash their hands before preparing food or feeding a child but with water only
9
• Lack of soap/soapy materials in a convenient place is a perceived barrier
• Participants ranked ‘Nurture’ as a best motivator and ‘Disgust’ as a second best motivator to wash hands with soap
• Community prefers visual actions like drama, video projection to promote hygiene behavior
• According community, along with doctors, community leaders could also be effective agents to promote positive behavior change
10
Factors Influencing HW Behavior
ICDDRB-A&T, Baseline
0
10
20
30
40
50
60
70
80
90
100
15
0
35
66 63
82
Social pressure
Belief in benefits & risks
Soap / HW Product
N= 350
Summary of Intervention related findings
Handwashing
1. Barriers• Convenience • Perception about illness• Social pressure2. Source of information3. Decision makers
Complementary feeding
1. Barriers• Knowledge
– Quantity– Frequency– Diversity (animal food)
• Convenience 2. Source of information3. Decision makers
12
Intervention
Behavioral Objectives
• Handwashing with soap & water before food preparation and feeding the child
– Maintaining handwashing station- Soap & water near to food preparation & child feeding area
• Complementary feeding : Correct quantity & frequency
• Complementary feeding: Four varieties including one animal food daily
14
Handwashing Food preparation
Feeding
15
Content & messages
Handwashing• Establish & maintain
HW station • Washing hand with
soap before food preparation of child by mother/caregiver
• Washing of child hands with soap before self feeding
Complementary feeding• Age specific quantity
and frequency • Diversity – 4 varieties
including one animal food daily
• Use of family food • Continue breast feeding
16
Materials used in Intervention
Reminder Sticker
HW Job Aid CF Job Aid 17
Channels of communication & intervention
Primary audienceMother : 6-24 m
• Setting up of HW station• Mass media-TV & radio• HH visit• Mothers Group
Meetings• Video show at village
meeting
Secondary audienceFather & Grandparents
• Mass media-TV & radio• Village Meetings with video
show
Community leaders
• CHWs, Religious leaders, • V.Doctors, School teachers • Union chairman & member
18
• Setting of Handwashing stations
• Counseling & Demo of CF
• Village meeting & video show
• Mothers group meeting• Social Influential-
Orientation
Community level intervention
• Establish handwashing station & reminder stickers• Each HH received four counseling visits by trained
Community volunteers/Community health workers• Mobile phone stickers at every target HH• Three village meetings for target audience with video show• Monthly mothers group meetings• Half day orientation of village doctors, imams, school
teachers & union leaders on Handwashing & complementary feeding
21
Mass media messages
Germ Ghost-HW
Diversity - CF
Intervention coverage
• Intervention across all 20 villages with total 834 HH of 6-24 m children
• Pre & Post HH survey done across 20 villages; randomly sampled 454 & 444 HH respectively
• TIPs assessment (quali) done in 80 HH from 4 villages Hardware & software
• 40 HH given HW stations & 40 HH encouraged to arrange their own
23
Steps of qualitative assessmentsImplement
Interventions
Assessment 1
Day 20
ImplementInterventions
Assessment 2
Day 58
Implement Interventions
Assessment 3
Day 83
Program Design
24
Data collection during the 3 assessments
25
Assessment1
Assessment2
Assessment3
Informal discussion with mothers
74 78 76
Unstructured observation 20 20 20
Video observation - - 12
GD: Family elders 4 4 4
GD: Influential villagers 4 4 4
Data collection : Pre & post intervention
26
Pre HH survey
Post HH survey
HH Survey (Randomly sampled each time)
454 444
Results: TIPs
27
Coverage/Participation in Interventions*
28* Reported by mothers during assessment # 3
Mothers Group Meeting
TV ads
Village meeting
HW stickers
Installation of HWS
Home visit
0 20 40 60 80 100 120
47
50
87
97
98
100
% of mothers
Inte
rven
tion
activ
ities
29
Hand washing with soap before food preparation & feeding child* (%)
* Reported by mothers
Understand risk & benefits
Has tried Currently practicing Intend to adopt & continue
0
20
40
60
80
100100 100
60
29
100 100
56
38
98 100
78 75
Assessment-1 Assessment-2 Asseessment-3
(of those who have tried)
(of those currently practicing)
30
Regular use & maintenance of HWS* (%)
* Reported by mothers
Understand risk & benefits
Has tried Currently practicing Intend to adopt & continue
0
20
40
60
80
100
72
90
50
16
85
96
54
37
9198
7365
Assessment-1 Assessment-2 Assessment-3(of those currently practicing)
(of those who have tried)
31
Quantity & Frequency of CF* (%)
Understand risk & benefits
Has tried Currently practicing Intend to adopt & continue
0
10
20
30
40
50
60
70
80
90
100
67 64
38
18
89
78
44
31
8882
43 42
Assessment-1 Assessment-2 Assessment-3
(of those who have tried)
(of those currently practicing)
* Reported by mothers
32
Four varieties of CF* (%)
Understand risk & benefits
Has tried Currently practicing Intend to adopt & continue
0
10
20
30
40
50
60
70
80
90
100
67
42
7 5
88
57
3327
90
74
1915
Assessment-1 Assessment-2 Assessment-3
* Reported by mothers
33
Mothers behavior on Handwashing in both categories of villages (%)
Hardware Software Hardware SoftwareAss-1 Ass-3
0
10
20
30
40
50
60
70
80
90
10080
28
86
6371
53
89
71
Regular use & maintenance of HWSHWWS before food preparation & feeding
Exposure to the intervention
Indicators
PreN=454%
PostN=444%
Health worker home visitAttended mothers’ group meeting
Attended video show in the communityRecalled TV message
Handwashing station with soap is near cooking/feeding area
17-- 26 -
98*676834*
65
* Statistically significant 34
Outcome Variables Results Indicators
PreN=454%
Post N=444%
HandwashingPerception that illness is caused by not
handwashing with soapHandwashing with soap at both key times
Acceptable complementary feeding Perception about correct quantity
Practice of acceptable complementary feeding
1412
59 32
75*
79*
93*
61*
* Statistically significant35
• Continue all activities until all mothers get habituated• Conduct inter-personal communication (IPC) with other
members of the household, including the male members
• Arrange more quiz session and prize giving in group meetings
• Involve students in this intervention• Arrange video show in public places such as school field
or local markets (bazaars)• Provide HWS to all households• Provide nutritious food to the children free of cost
36
Mothers suggestions
Timeline
Feasibility Trial: Timeline
Qualitative and quantitative assessment
2010
Trial start dateOct 2011
Trial end dateDec 2011
A-1 A-2 A-3
20th D 58th D 83th D
Pre HH Survey Post HH Survey
assessment qualitative
Intervention Trial HW+CF
Mass Media campaign
TV (BF, CF)
Mass Media campaign
TV (BF, CF)
Mass Media campaign
TV (BF, CF)
April 19
Mass Media campaign
TV (BF, CF, HW)
0 D
Next steps: Timeline
Launch of MMC HW linked to CF
National workshop
April 19
Core group meetingApril 30
July 2012
Community level implementation through water , sanitation & hygiene program
Scale up intervention in water, sanitation & hygiene program
Community level implementation through nutrition program
Scale up intervention in nutrition program
July/Aug 2012
June/July 2012
July/Aug 2012
2013
2013
National Dissemination
Acknowledgements
• Dr Stephan Luby1
• Dr Leanne Unicomb1
• Dr Nusrat Najnin1
• Gazi Salahuddin1
• Probir Kumar Ghosh1
• Field Research Officers and Assistants (N=14)1
• Fosiul Nizame1
• Debashish Biswas1
• Aasma Afroz1
• Dorothy Southern1 • Sumitro Roy A&T2
• Dr Tina Sanghvi A&T2
• Val Curtis/Robert Aunger, LSHTM
• Bill and Melinda Gates Foundation
• USAID 40
1= ICDDRB2= Alive & Thrive
Discussion
41