Can child-focused sanitation and nutrition

messaging be effectively integrated into

CLTS programming? Evidence from an RCT in Kitui County, Kenya

Jeff McManus, IDinsight

University of North Carolina, Chapel Hill

Water & Health Conference 2018

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IDinsight partners with

clients to generate and

use rigorous evidence

to improve social

impact.

We offer a range of evaluation

services, including RCTs, tailored

to clients’ research needs.

We have conducted over 100

evaluations in Africa and Asia.

We have offices in 7 countries:

Kenya, Zambia, South Africa,

Senegal, India, Philippines, US.

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UNICEF-IDinsight learning partnership

Maps from https://www.worldatlas.com/

Goal: Generate evidence to inform decisions on

design and scale-up of WASH+nutrition interventions

IDinsight teams embedded in two UNICEF country

offices from 2016-18

Kenya Philippines

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• Child sanitation/nutrition outcomes are poor in rural

Kenya (Kenya DHS 2014):

o 15% of children had diarrhea in last 2 weeks

o 29% of children under 5 are stunted

• Kitui County has among the highest rates of stunting

in the country (46%)

Critical need for better child sanitation/nutrition

outcomes in rural Kenya

Research question: Does child-focused messaging

complement CLTS interventions, leading to better

sanitation and nutrition outcomes for children without

crowding out core CLTS objectives?

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• Kitui County Government implemented a CLTS

program across 2,100 non-ODF villages in 2016-17.

• Added Sanitation and Nutrition (“SanNut”) program

The SanNut Program in Kitui County

1. Pre-triggering

3. Caregiver Meeting 1:

Toddler Hygiene

6-9 months

2. Triggering Event

5. Household Visit with SanNutmessaging

4. Caregiver Meeting 2:

Toddler Nutrition

ADDED SANNUT ACTIVITIES

SanNut activities within CLTS in treatment villages, 2016-17

$34/

village

$2.30/

child

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Caregiver Session, Kitui, Kenya

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Evaluation design

CLTS intervention

2,100 villages

Sampling frame

724 villages

Evaluation sample

604 villages

CLTS + SanNut

(treatment)

317 villages

2,288 caregivers

CLTS only

(control)

287 villages

2,034 caregivers

Kitui County

Treatment/Control Villages

Supplemental process evaluation to examine implementation fidelity

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• Primary data collection: Survey of 4,322 caregivers

three months after implementation

Data collection

CLTS standard

sanitation metrics

• Latrine structure

• Latrine maintenance

• Latrine use

• Handwashing

infrastructure

• Knowledge of

sanitary practices

Non-CLTS child

sanitation metrics

• Disposal of child

feces

• Caregiver

handwashing

practices

• Child diarrhea

Non-CLTS child

nutrition metrics

• Proper breastfeeding

practices (exclusive

and complementary)

• Visits to health

facilities for

nutritional check-ups

• Vitamin A

supplementation

• Deworming

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Data challenge: False positives

What did we do?

1. Pre-specify analytical model and intended

hypothesis tests on a public registry

2. Adjust p-values to control for false discovery rate

(‘q-values’ up to 15x larger than p-values)

3. Larger sample to offset loss of power

4. Collapse related outcomes to indices

Many inference tests High chance of false positives

Bad recommendations to client

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Sanitation outcomes:

Proper disposal of toddler feces*

*Proper disposal is defined as disposal of feces or waste water (depending on type of

napkin/diapers used) in the latrine or in a hole in the ground.

68.1%63.0%

0

20

40

60

80

100

% o

f re

spo

nd

ents

Control TreatmentN = 1,951 households with a child between 6mo and 2yr

Avg Treat Effect

+5.1pp or 8%

q = 0.053

(p = 0.025)

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Sanitation outcomes:

Caregiver handwashing

Avg Treat

Effect

+5.8pp or

39%

q = 0.007

(p < 0.001)

Avg Treat

Effect

+1.9pp or

80%

q = 0.046

(p < 0.008)

20.6%

14.8%

0

6

12

18

24

30

% o

f re

spo

nd

ents

Control Treatment

Handwashing station

4.3%

2.4%

0

2

4

6

8

10

% o

f re

spo

nd

ents

Control Treatment

Station with soap

N = 4,322 households

Caregivers in treatment villages +32% likely to report handwashing

after cleaning child feces, +21% before feeding their child.

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Sanitation outcomes:

Child diarrhea (last two weeks)

Avg Treat Effect

-2.9pp or -16%

q = 0.053

(p = 0.021)

14.7%

17.6%

0

6

12

18

24

30

% o

f ch

ild

ren

Control TreatmentN = 5,481 children 6 months to 5 years

No differences in other traditional CLTS metrics: Latrine construction,

latrine functioning, latrine use

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Nutritional outcomes

Negligible change in child nutritional metrics:

• Exclusive/complementary breastfeeding

• Health facility visits for nutritional check-ups

• Vitamin A supplementation or deworming

Possible reasons for lack of impact:

• Lower attendance at nutrition-focused meeting

• Higher baseline knowledge of proper

breastfeeding practices

• Additional nutrition messaging more disparate

from CLTS than additional sanitation messaging

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Consequences for UNICEF policy

Findings: Modest but significant improvements in child-

related sanitary practices, no evidence of impact on

nutritional practices

Decisions

• Scale up in West Pokot County, over

100k children under 5, worst child

sanitation/nutritional outcomes in

the country.

• Refine nutrition component to (1)

increase caregiver attendance and

(2) make message more salient

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Caregiver Session, Kitui, Kenya

Acknowledgments:

Gerishom Gimaiyo (IDinsight)

Matt Yarri (IDinsight)

Shiva Singh (UNICEF, Kenya)

Andrew Trevett (UNICEF, Kenya)

Grainne Moloney (UNICEF, Kenya)

Ann Robins (UNICEF, Kenya)

Lilian Lehmann (IDinsight)

Contact info:

Jeff McManus (IDinsight)

jeffery.mcmanus@idinsight.org

Generous funding from