Scaling Up a Water, Sanitation, and Hygiene Program in Rural Bangladesh: The Role of Program Implementation.
To evaluate whether the quality of implementation of a water, sanitation, and hygiene program called SHEWA-B and delivered by UNICEF to 20 million people in rural Bangladesh was associated with health behaviors and sanitation infrastructure access.



We surveyed 33 027 households targeted by SHEWA-B and 1110 SHEWA-B hygiene promoters in 2011 and 2012. We developed an implementation quality index and compared the probability of health behaviors and sanitation infrastructure access in counterfactual scenarios over the range of implementation quality.



Forty-seven percent of households (n = 14 622) had met a SHEWA-B hygiene promoter, and 47% of hygiene promoters (n = 527) could recall all key program messages. The frequency of hygiene promoter visits was not associated with improved outcomes. Higher implementation quality was not associated with better health behaviors or infrastructure access. Outcomes differed by only 1% to 3% in scenarios in which all clusters received low versus high implementation quality.



SHEWA-B did not meet UNICEF's ideal implementation quality in any area. Improved implementation quality would have resulted in marginal changes in health behaviors or infrastructure access. This suggests that SHEWA-B's design was suboptimal for improving these outcomes.
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Jade
J
Benjamin-Chung
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Sonia
S
Sultana
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Amal K
AK
Halder
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Mohammed Ali
MA
Ahsan
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Benjamin F
BF
Arnold
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Alan E
AE
Hubbard
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Leanne
L
Unicomb
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
Stephen P
SP
Luby
Jade Benjamin-Chung, Benjamin F. Arnold, and John M. Colford Jr are with the Division of Epidemiology, School of Public Health, University of California, Berkeley. Alan E. Hubbard is with the Division of Biostatistics, School of Public Health, University of California, Berkeley. Sonia Sultana, Amal K. Halder, Mohammed Ali Ahsan, and Leanne Unicomb are with the Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. Stephen P. Luby is with the Department of Medicine, Stanford University, Stanford, CA.
John M
JM
Colford
D001459:Bangladesh; D003430:Cross-Sectional Studies; D015438:Health Behavior; D006801:Humans; D006920:Hygiene / Q000592:standards*; D016730:Program Development; D011634:Public Health; D012424:Rural Population; D012499:Sanitation / Q000592:standards*; D011795:Surveys and Questionnaires; D014480:United Nations; D014881:Water Supply / Q000592:standards*