sumitro roy design and findings hq- edited version

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